호흡기 질환은 대부분 coug h and/or dyspnea의 호소 major categories of respiratory disease(표 284-1)obstructive diseasemost common주로 airway diseases가 원인(asthma, COPD, bronchiectasis, bronchiolitis)restrictive diseaseparenchymal lung diseasesabnormalities of the chest wall&pleuraneuromuscular diseasevascular diseasepulmonary embolismpulmonary hypertensionpulmonary venoocclusive diseaseinfective and neoplastic diseases→ 위의 세 카테고리를 포함 여러 병리 소견을 일으키는 classification by gas exchange abnormalities→ hypoxemia, hypercarbia, combined impairment그러나 많은 호흡기 질환이 gas exchange abnormalities를 일으키지 않는지 evaluation of a patient with a respiratory system disorderthorough history&focused physical examinationpulmonary function testchest imagingblood&sputum analysisserologic or microbiologic studiesdiagnostic procedure(bronchoscopy)
HISTORYDyspnea&Coughtwo cardinal symptoms of respiratory diseasedyspnealung pathology가 아닌 경우도 많다 환자가 숨참을 표현하는데 사용되는 단어 자체가 etiology의 추정에 도움이 될 것 obstructive lung disease→”chest tightness”or”inability to get a deep breath”congestive heart failure→”air hunger”or”a sense of suffocation”tempo of onset&duration도 etiology의 추정에 도움 acute shortness of breathacute airway narrowing:laryngeal edema, bronchospasm, mucus pluggingacute hypoxemia:pulmonary edema, pneumonia, pulmonary embolismsudden changes in the work of breathing:pneumothoraxCOPD&idiopathic pulmonary fibrosis(IPF)gradual progression of dyspnea(지속적인 증상)+intermittent acute excerbations of dyspneaasthmaticsno daily symptoms+intermittent episodes of dyspnea, cough, and chest tightness usually associated with specific triggers(infection or allergens)호흡 곤란을 일으키는 요인뿐 아니라 호흡 곤란을 완화시키는 요인도 중요. dyspnea on exertionthe degree of activity that results in shortness of breath→ a gauge of the patient’s degree of disability의 환자가 현재 수행할 수 있는 활동 수준은 어느 정도이며 지난 시간 동안 어떻게 변화했는지 알아야만 햄 정전 underlying lung or heart disease의 조기 증상이므로 철저한 평가를 요하는 cough, 다음과 같은 사항을 질문 duration of coughany specific triggerssputum production동반할지+객담의양과 양상 acute cough productive of phlegm→ infection of the respiratory system의 시사 upper airway:sinusitis, tracheitislower airway:bronchitis, bronchiectasislung parenchyma:pneumoniachronic cough(>8 weeks에서 정의) 좋은 obstructive lung diseases(asthma, COPD, bronchiectasis)및”nonrespiratory”diseases(GERD, PND)와 관련 diffuse parenchymal lung diseases(IPF등)→ persistent, nonproductive cough모두 기침이 콜흡기의 원인이 아니므로 심질환, 위장관질환, 정신질환을 포함하여 종합적인 평가가 이루어져야 할 것
Additional Symptomswheezing→ airway diseasehemoptysis→ infections of the respiratory tract, bronchogenic carcinoma, pulmonary embolism등 chest pain→ parietal pleural diseases(eg.pneumothorax)or pulmonary vascular diseases(eg.pulmonary hypertension)lung parenchyma는 pain fiber innervation이 없음 symptoms of cor pulmonale(abdominal bloating or distension, pedal edema)→ d/t strain on the rightheart
Additional History, 철저한 사회력 문진은 필수 current or previous cigarette smokingassociated with COPD, bronchogenic lung cancer, and select parenchymal lung diseases(eg.desquamative interstitial pneumonitis, pulmonary Langerhans cell histocytosis)increased cigarette pack-years→ increased risk of disease, 전자 담배 → acute or subacute lung injury(E-cigarette or vaping use-associated lung injury[EVALI])간접흡연도 해로움 → 부모 배우자, 룸 메이트 중 흡연자가 있는지 물어봐야 할 일 inhalational exposuresat work(eg.asbestos, silica)at home(eg.wood smoke, excrement from pet birds)특정 지역에 요헹료크은 호흡기 감염을 유발할 수 있겠다고 most notably, tuberculosisexposure to fungi(eg.Histoplasma capsulatum)fever&chill→ infective etiologies의 의심.(both pulmonary&systemic)comprehensive review of systems for rheumatologic or autoimmune disease with respiratory manifestations focuses on joint pain or swelling, rashes, dry eyes, dry mouth, or constitutional symptoms 다른 곳 원발암의 폐 전이 가능성도 고려 therapy for other conditions(both radiation and medications)에 의한 폐질환 가능성도 고려
Physical Examination호흡기 질환에 대한 의심은 종종 vital signs에서 시작 respiratory rate→ elevated(tachypnea)or depressed(hypopnea)pulse oximetry→ hypoxemia(at rest or with exertion)the first step is inspection(차례 may be in distress and using accessory muscles of respiration to breathesevere kyphoscoliosis→ restrictive pathophysiology유발 inability to complete a sentence→ severeimpairment시사. 신속한 평가의 필요성 percussion of the Chestoestablish diaphragmexcursion and lungsizetodistinguishbetweenpleuraleffusion(dull) and pneumothorax(hyper-resonant) inthesetting of decreasedbreathsoundspalpation 호흡기 진찰에서는 사실상의 역할이 제한적 subcutaneous air inthesetting of barothorax(hyper-resonant) inthesetting of decreased breasedbreased breepinspiration→unilateraldisorders ofventilation의 부모 손가락을 lowerposteriorcest 가운데 모으고 나머지 손가락으로 lateralribcage를 움켜쥐는 auscultation 호흡기 질환은 대부분 청진 소견 이상을 나타내는 천성적인 abuction aobeverys를 유발하는 어떠한 질환도 유발 가능 eg.peribronchialedemain