Clinical Assessment of the Cardiopulmonary System
I Clinical Assessment of the Cardiopulmonary System Requires a Number of Specific Steps.
A Review of the patient’s chart:
A Before entering a patient’s room his or her chart should be reviewed completely.
B This review should identify the reason for the patient’s admission and the type of therapy he or she is to receive.
C An initial review of the chart helps to outline areas where the clinician would ask the patient questions and to help focus the physical examination.
D This initial review also frequently provides insights into the patient’s history, his or her family history, and social and environmental issues that may affect his or her disease.
III The Patient Interview: Medical History
A The interview provides unique information because it is the patients’ prospective on their illness.
B The interview is designed to accomplish three related goals:
1. Establish a rapport between patient and clinician.
2. Obtain essential diagnostic information.
3. Monitor changes in the patient’s symptoms and response to therapy.
C Effective patient interviewing requires that the clinician pay attention to a number of professional issues as listed in Box 18-1.
D Questions during the interview can be structured in a number of different ways depending on the type of response the clinician desires. Table 18-1 lists a number of different types of questions.
TABLE 18-1
Types of Questions in Taking a Medical History
| Question Type | Description | Comments | Examples |
| Open-ended | Broad, general question about patient’s symptom or illness | Allows patients to give history spontaneously without bias or influence from interviewer; patients direct discussion to whatever they want to cover first; can provide greatest amount of information; should generally be used first in interview | “Tell me about your shortness of breath.” |
| “What brings you to the clinic today?” | |||
| Focused | Interviewer defines area of inquiry more than in open-ended question or statement | Directs discussion into more specific area but still gives patients latitude in answering | “What treatment have you had for this condition in the past?” |
| “What are the physical requirements of your job?” | |||
| Closed-ended | More specific question, which can generally be answered yes or no or by giving objective data such as dates, names, or numbers | Best way to obtain specific data but limits scope of information by restricting patients to individual items requested | “Have you ever had tuberculosis?” |
| “How may puffs from your inhaler do you use in a given day?” | |||
| Compound | Two or more separate questions asked at once, without giving patients chance to respond to them individually | May confuse patients; prevents patients from giving answers to all components; induces patients to focus on last question in series; should not be used | “Tell me about yourself—how old are you, where do you live, and what do you do for a living?” |
| “Have you ever smoked cigarettes, used drugs, worked with asbestos, or been exposed to tuberculosis?” | |||
| Leading | Interviewer phrases questions so as to lead patient in a particular direction in answering | Reflects interviewer’s bias; tends to produce inaccurate, unreliable answer; should not be used | “You’re feeling better today, aren’t you?” |
| “You’ve never used drugs, have you?” |
From Pierson DJ, Kacmarek RM: Foundations of Respiratory Care. New York, Churchill Livingstone, 1992. Churchill Livingstone
E Occupational or environmental exposures are a key aspect of a patient interview. Table 18-2 lists a number of common exposures associated with pulmonary disease.
TABLE 18-2
Common Occupational or Environmental Exposures Associated with Pulmonary Disease
| Occupation or Activity | Exposure | Disease |
| Asbestos mining/milling/manufacture; pipe fitting; shipbuilding/ship fitting; insulation, construction, demolition, living with someone employed in any of the above | Asbestos | Lung cancer, asbestosis, malignant mesothelioma, nonmalignant inflammatory pleural effusion |
| Hard-rock mining, quarrying, stone cutting, abrasive industries, foundry work, sandblasting | Crystalline quartz (silica) | Silicosis |
| Coal mining | Coal dust | Coal workers’ pneumoconiosis |
| Farming, grain handling | Grain dust | Chronic bronchitis, chronic obstructive pulmonary disease |
| Farming, animal attendants | Moldy hay (spores of thermophilic actinomycetes [fungus]) | Hypersensitivity pneumonitis (farmer’s lung) |
| Cotton/flax/hemp workers, textile industry | Cotton dust | Byssinosis |
| Pigeon breeding, bird handling | Proteins derived from parakeets, budgerigars, pigeons, chickens, turkeys (avian droppings or feathers) | Hypersensitivity pneumonitis (e.g., pigeon-breeders’ lung), bird-fanciers’ lung |
| Woodworking, lumber industry | Wood dust, Alternaria (fungus), Western red cedar, oak, others | Hypersensitivity pneumonitis, woodworker’s lung, occupational asthma |
From Pierson DJ, Kacmarek RM: Foundations of Respiratory Care. New York, Churchill Livingstone, 1992. Churchill Livingstone
F Symptoms expressed as a concern by patients should be explored in detail. Box 18-2 lists specific questions that should be asked regarding a specific symptom.
G All interviews of patients receiving respiratory care should focus on the following symptoms and signs.
a. The most common symptom of cardiopulmonary disease.
b. Is it dry or loose, productive or nonproductive?
c. A dry nonproductive cough is typical of congestive heart failure (CHF) or pulmonary fibrosis.
d. A loose, productive cough is often associated with bronchitis and asthma.
e. The most common cause of acute cough is viral infection.
f. Chronic coughing is associated with asthma, postnasal drip, chronic bronchitis, and gastroesophageal reflux.
a. Sputum containing pus is purulent.
b. Purulent sputum is thick, colored, and sticky.
c. Clear and thick sputum is mucoid.
d. Recent changes in the quantity, color, or viscosity of sputum are often signs of infection.
a. Defined as coughing up blood or blood-streaked sputum.
b. Hematemesis is vomiting of blood, blood from the gastrointestinal tract.
c. Massive hemoptysis is >300 ml.
d. Nonmassive hemoptysis is seen in tuberculosis, lung cancer, and pulmonary embolism.
e. Blood-streaked sputum is often associated with infection.
f. Massive hemoptysis is seen in lung abscess, bronchiectasis, and trauma.
a. Swelling of lower extremities
b. Normally associated with heart failure, usually right-sided failure.
c. May be severe enough to result in “pitting” when compressed.
a. With the head of the bed elevated 45 degrees, venous distention >3 to 4 cm above the sternal angle is abnormal.
a. Patient-perceived shortness of breath.
b. Occurs when the patient’s sense of the work of breathing exceeds that associated with the effort performed.
c. Orthopnea is dyspnea in the supine or lying position and is associated with heart failure.
d. Platypnea is dyspnea in the upright position seen in patients with right to left intracardiac shunts associated with congenital cardiac disease and venous to arterial shunts in the lung related to severe lung disease or chronic liver disease. Orthodeoxia is oxygen desaturation in the upright position.
a. Chest pain is usually classified as pleuritic or nonpleuritic.
b. Pleuritic chest pain is usually located laterally and posteriorly, worsens with a deep breath, and is described as sharp and stabbing.
c. Pleuritic pain is associated with inflammation of the pleura as a result of pneumonia or pulmonary embolism.
d. Nonpleuritic chest pain is located in the center of the chest and may radiate to the shoulder or back. It is not affected by breathing and is described as a dull ache or pressure.
e. The most common cause of nonpleuritic chest pain is angina, which is associated with coronary artery disease.
f. Nonpleuritic chest pain is also associated with gastroesophageal reflex, esophageal spasm, chest wall pain (costochondritis), and gallbladder disease.
a. A bluish discoloration of the skin and mucous membrane caused by the presence of at least 5 g of deoxygenated hemoglobin.
b. May be either peripheral or central.
c. Typically seen in association with hypoxemia in the absence of anemia.
a. Diffuse bulbous enlargement of terminal phalanges of the fingers and toes.
b. Occurs as a result of a buildup of fibroelastic soft tissue in the nail bed.
c. Clubbing is usually asymptomatic and of an unknown mechanism.
a. A high-pitched musical sound produced when a patient breathes.
a. Is the patient oriented to person, place, and time?
b. Box 18-3 lists the terms with their definition of various levels of consciousness.
