Post on 16-Jul-2015
Female, 45 years, Nurse,
• Fever and weight loss X 2 months
• Productive cough X 2 months
• Blood in sputum X 2 days
Male, 18 year, Medical student
• Fever X 2 days
• Sore throat and running nose X 1 day
• Dry and painful cough X 1 day
55 year old soldier, Smoker
• Breathlessness and wheezing
• Productive Cough- more in the mornings
• Yellow sputum, approx 1 cupful X 1 week
• Similar problem every winter for over 15 years that takes months to clear up.
• Mild symptoms persist throughout the year
Female, 50 years, Army wife
• Dry, distressing cough X 15 days
• Recently started on treatment for high BP
Tab Indapamide and Tab Enalapril
1. Cough
• Explosive expiration against a closed glottis-
Purpose- clearance of airways
Protective Superficial Reflex
• Afferent- Trigeminal, Glossopharyngeal, Sup Laryngeal (Vagus)
• Efferent- Recurrent Laryngeal (Vagus) and Spinal nerves
Cough Triggers
• Exogenous- Fumes, smoke, dust, Foreign body
• Endogenous- Secretions, gastric contents
• Initiate inflammation- persistence of cough
• Constriction
• Infiltration
• Compression
Cough Causes
Inflammation Infections, Post nasal drip, GERD
Constriction Asthma, scarring, tumors
Infiltration Granulomatous diseases, Malignancy
Compression Lymph nodes, Mediastinaltumors, Aortic aneurysm
Other ACE Inhibitors
Cough AssociationsOrigin Common Cause Clinical Features
Pharynx Post nasal drip H/O chronic rhinitis
Larynx LaryngitisTumorWhooping coughCroup
Voice change, odynophagia, painful, harshLonger durationParoxysms of coughAssociated stridor
Trachea Tracheitis Retrosternal pain
Bronchi Acute BronchitisCOPDAsthmaCarcinoma
Dry/ productive; Associated fever; Short durationProductive; morning worsening ; long durationUsually dry, worse at nightPersistent (with hemoptysis)
Parenchyma TBPneumoniaBronchiectasis abscessPulmonary edemaInterstitial fibrosis
Productive (with hemoptysis)Initially dry, later productiveProductive (postural change)PosturalNocturnal (pink frothy sputum)Dry, irritant & distressing
Pleura Parietal pleura Pleurisy/ during aspiration
Questions ?
• Duration- Acute/ Chronic (3 weeks)
• Associated infection
• Seasonal
• Wheezing
• Post nasal drip/ GERD
• Sputum
• Associated conditions (smoking, HIV, occupation)
• Drug therapy
60 year old female in C4 ward
• Progressive neurological illness X 2 months
• Weakness all 4 limbs
• Difficulty in swallowing
• Weakness of trunkal muscles
• Ineffective cough
Baby boy, 2 years
• Breathlessness and cough 1 hour ago
• Loud and noisy breathing since then
• Blue discoloration of skin X 10 minutes
• Was playing with toys unattended when this happened
• Ineffective Cough- Muscle disease/ paralysis
• Bovine Cough -single vocal cord paralysis
Noisy Breathing
• Stridor- Inspiratory sound (partial obstruction of large airway) Laryngeal level
• Stertor- Oropharyngeal level
• Rattling – Tracheal level
• Wheezing – Bronchial level
Male, 35 years, Alcoholic
• Low grade fever and weight loss X 1 Month
• Cough X 1 month
• sputum production X 15 days
• Sputum is purulent, blood tinged, foul smelling. More while lying on the left side
2. Sputum Production
• Quantity- nil, scanty, moderate (qty) copious
• Quality-– Mucoid
– Muco-purulent
– Purulent
– Current Jelly
– Greenish
– Granules – yellow/ black
– Hydatid cysts
– Anchovy sauce (brown)
• Odour (smell)
45 year old diabetic
• Diarrheal illness 4 days ago
• Fever and chest pain X 2 days
• Cough X 1 day
• Current Jelly like blood in sputum
3. Hemoptysis
ALWAYS ALARMING
Differentiate from
• nasopharyngeal bleed
• Epistaxis
• Hematemesis
Quantity-
• Streaking
• Rusty, Mixed
• Massive (> 100 ml / > 600 ml/ 24 hrs)
45 year old male, Smoker
• Change of voice X 1 month
• Worsening cough X I month
• Blood in sputum X 2 days
Causes of HemoptysisSite Common Causes Rare Causes
Tracheo bronchial CarcinomaBronchitisBronchiectasis
AdenomaForeign body
Parenchyma TB & Chronic PneumoniaAcute PneumoniaLung abscess
ParasitesTraumaActinomycetesMycetoma
Lung Vasculature InfarctionPANGood Pasteur’s syndrome
Idiopathic pulmonary hemosiderosis
CVS Disease Ac LVFMS
Aortic Aneurysm
Blood Disorders LeukemiaHemophilia
Anticoagulants
Questions ?• Where from
• How much
• Single episode/ multiple
• Other sites
• Other complaints
• Pre existing disease
• Age group
• Occupation
• Injury
• Drugs
4. Breathlessness
Mechanism is complex
• Sensory endings stimulation
• Work of breathing (muscles)
• Small airway obstruction
• Chemoreceptor stimulation (acidosis)
70 year old male, non smoker
• Previously an employee of Union Carbide factory in Bhopal
• Progressively worsening breathlessness for 29 years
• Intermittent respiratory infections
30 year old HIV Positive,
• Dry Cough X 3 weeks
• Progressive Breathlessness X 2 weeks
• Moderate Fever and weight loss X 2 weeks
• Last CD4 200 cells
Chronic Exertional Breathlessness
• COPD
• Asthma
• Heart disease
• Interstitial or Alveolar disease
• Chest wall / Respiratory muscle disease
• Chronic Pulmonary Thrombo- embolism
• Psychogenic hyperventilation
Dry Cough
40 year old postman, cycling every day, non smoker
• Sudden onset and worsening by the minute-Breathlessness and Chest pain X 1 hour
• Cyanosed
• Percussion-
Acute Severe Breathlessness
• Pulmonary Edema
• Massive Pulmonary Embolism
• Acute Severe Asthma
• Acute Exacerbation of COPD
• Severe Pneumonia
• Tension Pneumothorax
• Foreign body/ mucous plug
• Epiglottitis (children)
• Metabolic Acidosis
• Psychogenic
Questions ?
• Symptom Scale
• Precipitating event
• Associated complaints
• Pre existing disease
• Age group
• Occupation
5. Chest PainCentral Peripheral
Cardiac Lungs
Aortic Pleura
Esophageal Muscular
Massive Pulmonary Embolism Skeletal
Tracheitis Neurological
Mediastinitis
Respiratory causes
• Raw upper sternal- Tracheitis
• Pleuritic- associated with breathing
• Shoulder - lower lobes/ diaphragm
• Neurologic- invasion of nerves
40 year old smoker
• Hoarseness of voice X 3 weeks
• Dry irritative cough X 3 weeks
• Blood in sputum X 1 day
6. Voice Change (Dysphonia)
Structural Problems
Neurological Problems
• Hoarseness
• Weakness
• Aphonia
CausesInflammatory Acute and chronic laryngitis
Smoke inhalation
Neoplastic CarcinomaLaryngeal Papillomatosis
Recurrent Laryngeal Nerve Post ThyroidectomyCarcinoma of lung/ breast
Neurological Myasthenia gravisHypothyroidism, Rheumatoid Arthritis
Habitual Dysphonias Renke’s Dysphonia, Singer’s nodulesVocal cord polyps,
GERD Reflux
Psychogenic Musculoskeletal tension,DysphoniaConversion Disorders
Questions
• Quality
• Time course
• Onset and other associations
• Other diseases
• Waxing and waning
• Level of discomfort
• Smoker