Respiratory Symptoms & Signs
description
Transcript of Respiratory Symptoms & Signs
Respiratory Symptoms & Respiratory Symptoms & SignsSigns
Chief complaints ( CC ): Presenting complaints and duration.
Present Illness ( PI ):
A : The immediate history that brought the patient to the hospital
B : Background history of disease leading to the immediate history
C : Significant positive and negative data that might give clues useful in differential diagnosis
Habits : A : Use alcohol , tobacco…… B : Sexual habits
Allergies : Hay fever , asthma , drugs
Common symptomsCommon symptoms
Cough Expectoration Hemoptysis Chest pain Cyanosis Dyspnea
What is cough?
• A complex reflex arc.• A defense mechanism.• A factor in the spread of
infection.• A common symptom.• A means of providing
cardiopulmonary resuscitation.
Cough Cough ((a protective reflexa protective reflex): ): causescauses
Respiratory diseases___ the most common causes Airway agents
Bronchitis, bronchiectasis, asthma, endobronchial tuberculosis, tumor, pharyngitis
Lung agentsInfection, edema, fibrosis, tumor
Cardiovascular diseases pulmonary edema, pulmonary embolism
Cough : Cough : manifestationsmanifestations
Characteristics Dry cough (non-sputum: non-infectious) Productive cough (sputum: infectious, edema)
Attack Time season
Tone Hoarseness Brassy
Cough: Cough: accompany symptomsaccompany symptoms
Fever (infection) Chest pain (infection, tumor, pleurisy,
pneumothorax, pulmo embolism) Dyspnea Hemoptysis (bronchietasis, tuberculosis, tumor) Bulk pus sputum (bronchietasis, lung abscess) Wheezing (asthma, foreign body) Clubbing fingers (bronchietasis, lung cancer,
chronic lung abscess)
The Duration of Cough
• Cough can be divided into 3 categories
- Acute (<3 weeks)
- Subacute (3-8 weeks)
- Chronic (>8 weeks)
• Estimating the duration is the 1st step in narrowing the list of potential causes.
Most Common Causes of Acute Cough• URT Infections
- Common Colds• “Acute bronchitis”• Acute Bacterial Sinusitis• Bordetella pertussis Infection in
Selected Communities• Exacerbations of Chronic
Bronchitis• Allergic Rhinitis• Environmental Irritant Rhinitis
Commonest Causes of Subacute Cough After a Respiratory Infection
• Postinfectious Cough- B. pertussis infection
• Bacterial sinusitis• Exacerbation of a pre-existing disease
- Asthma- Chronic Bronchitis
Helpful Hints:
1. Pertussis is likely with cough-vomit syndrome with or without whoop
2. Consider all 3 when cough has a biphasic
course
Summary of Results of the Diagnostic Evaluation of Chronic Cough
• Chronic cough is often simultaneously due to more than 1 condition (18-93% of the time).
- It has been due to 3 diseases up to 42% of the time. - Up to 4% of the time, it can be due to 5 conditions.
Summary of Results of the Diagnostic Evaluation of Chronic Cough
• In prospective studies in adults, chronic cough is most commonly due to 6 disorders: - Upper airway cough syndrome (UACS)
• Previously referred to as postnasal drip syndrome
- Asthma- GERD- Chronic bronchitis- Bronchiectasis- Non-asthmatic esosinophilic bronchitis
Sputum: Sputum: amountamount
Bulk frothy sputum Pulmo edema
Bulk pus sputum Bronchiectasis Lung abscess
Sputum: Sputum: consistencyconsistency
Mucoid sputum Bronchitis (without bacterial infection) Asthma
Pus sputum Any bacterial infection
Bloody sputum
Sputum: Sputum: colorcolor
White mucoid or serofluid sputum
Yellow general bacterial infection
Green aeruginosus Bacillus infection
Pink cardiac edema
Red hemoptysis
Sputum: Sputum: foul odorfoul odor
anaerobic bacterium infection
Hemoptysis Hemoptysis
Bleeding from lower respiratory tract
The amount varies from blood-stained sputum to several
hundreds ml pure blood
Mild: 100ml/d
Moderate: 100-500/d
Severe: >500ml/d, or 100-500/time
Differential diagnosis
Bleeding from upper respiratory tract
Hematemesis
Distinguished hemoptysis from Distinguished hemoptysis from hematemesishematemesis
Hemoptysis Hematemesis
Causes Pulmo or cardiac digestive system
Previous symptoms Cough, chest tightness Nausea, vomiting
Spit up Cough up Vomited
Color Bright red Dark red
Mixture Sputum, frothy Gastric contents
Tarry stools + +
Post-bleeding Sputum with blood No sputum
Hemoptysis: Hemoptysis: causescauses
Bronchial disorders Bronchiectasis Bronchogenic carcinoma Chronic bronchitis
Pulmo Disorders Pulmo TB Pulmo embolism
Cardiovascular disorders Acute left heart failure Mitral stenosis
Others Hematologic disease,
Hemoptysis: Hemoptysis: accompany symptomsaccompany symptoms
Fever Infection or carcinoma
Chest pain Infection , Pulmo Embolism , Carcinoma
Pusy sputum Bronchiectasis , Lung abscess
Clubbing of fingers Bronchiectasis , Lung abscess , Carcinoma
Diagnostic Caveats to Consider in Diagnosing
Hemoptysis
• Lack of hemoptysis does not rule out a substantial intrapulmonary bleed.
• It is not uncommon for bronchoscopy to establish sites of bleeding different from those suggested by chest radiograph.
• Although as many as 30% of patients with hemoptysis will have normal chest radiographs, routine films may be diagnostically valuable.
Chest pain: Chest pain: causescauses
Chest wall herpes zoster, rib fracture
Cardiovascular angina pectoris, myocardial infarction, pericarditis, dissecting
aneurysm Respiratory
Pleural disorders, pneumothorax, carcinoma
Chest pain: Chest pain: characteristicscharacteristics
Location Radiation Level or feature
Burning pain, pressing pain, pricking pain Duration Influential factors
Exertional, respiration, food intake, administration
Chest pain: Chest pain: accompany symptomsaccompany symptoms
Cough, sputum and/or fever Respiratory disease
Dyspnea Severe pneumonia, pneumothorax, pleurisy, pulmo embolism
Hemoptysis Carcinoma, pulmo embolism
Shock myocardial infarction, dissecting aneurysm (rupture ),
large area pulmo embolism Dysphagia
Esophageal disease
What Is Dyspnea?
Dyspnea is a distressing sensation of difficult,
labored, or unpleasant breathing.
What Is the Differential Diagnosis of Dyspnea?
• There are a multiplicity of causes located in a variety of anatomic locations.
• While the list of causes is nearly endless, 5 major causes account for ~94% of cases:- Cardiac- Respiratory- Psychogenic/hyperventilation syndrome- Deconditioning- GERD
Class Patient Symptoms
Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue symptoms
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, ordinary physical activity results in symptoms.
Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.
Class IV (Severe) Symptoms of cardiac insufficiency at rest.
If any physical activity is undertaken, discomfort is increased.
Classification of Dyspnea Classification of Dyspnea
Dyspnea: Dyspnea: causescauses
Respiratory system Obstruction: asthma, COPD, tumor Pulmo Diseases: pneumonia, interstitial lung disease, Pleura: pneumothorax, effusion Diaphragma movement disorder: tense ascites
Cardiovascular system Heart failure Pulmo embolism
Features of left heart failureFeatures of left heart failure
Underlying diseases
Position related dyspnea
Crackles or rhonchi in both lungs
PND
Nocturnal paroxysmal dyspnea Nocturnal paroxysmal dyspnea
Characteristics
Awoken due to chest tightness or dyspnea
Forced sitting position or orthopnea
Tachycardia
crackles or rhonchi in both lungs
Pink frothy sputum
Nocturnal paroxysmal dyspneaNocturnal paroxysmal dyspnea
Mechanism Vital capacity decreased in supine position
Returned blood volume increased pulmo edema
Dyspnea: Dyspnea: accompany signs (1)accompany signs (1)
Rhonchi Asthma Acute left heart failure (cardiac asthma) Acute laryngeal edema
Chest pain Infection Pneumothorax Pulmo embolism Acute myocardial infarct
Dyspnea: Dyspnea: accompany signs (2)accompany signs (2)
Fever Infection
Cough and sputum COPD Infection Left heart failure
Unconsciousness CNS disorder Uremia diabetic ketoacidosis
What is the Value of History for Diagnosing the Etiology of Wheeze?
While wheezing is indicative of obstruction of airways, it is insensitive and nonspecific in diagnosing the specific location and cause of the obstruction.- Expiratory wheezing by history may
be predictive of asthma no more than 35% of the time; past history of asthma, no more than 62%; monophonic expiratory wheezing by physical, no more than 43% of the time.
47%
35%
12%
3% 3%
0
10
20
30
40
50
60
70
80
90
100
Postnasaldrip
syndrome
Asthma Psychogenicillness
Industrialbronchitis
Unknown
%
Spectrum and Frequency of Causes of Wheeze
An Approach to the Diagnosis of Wheeze
Be aware that:“All that wheezes is not asthma;
All that wheezes is obstruction.”
Differential Diagnosis of Wheeze According to Anatomic Area
UPPER AIRWAY OBSTRUCTION
Extrathoracic Causes Intrathoracic Causes
PNDS Tracheal stenosis
Vocal cord dysfunction Goiter
Syndrome
Epiglottitis Malignancies
Laryngeal edema Benign tumors
Postextubation granuloma
Anaphylaxis
Differential Diagnosis of Wheeze According to Anatomic Area
LOWER AIRWAY OBSTRUCTION
Asthma Bronchiolitis
COPDBronchiectasis
Pulmonary edema Carcinoid syndrome
Pulmonary embolism Parasitic infections
Cystic fibrosis Lymphangitic carcinomatosis
Cyanosis Cyanosis
An excess of desaturated hemoglobin causes a
blue coloration of the skin or mucosae.
Cyanosis: Cyanosis: classificationclassification
Central (warm) Deficient oxygenation Right-to-left shunt
Peripheral (cold) Reduced cardiac output Local vasoconstriction
Mixed Heart failure
Cyanosis: Cyanosis: accompany signsaccompany signs
Dyspnea Severe cardiac or respiratory disorder
Clubbing fingers Congenital heart disease Chronic respiratory disease
Physical Examination Physical Examination of Respiratory Systemof Respiratory System
Anterior imaginary lines and Anterior imaginary lines and landmarkslandmarks
epigastric angle
Infraclavicular fossa
Suprasternal fossa Supraclavicular fossa
Midclavicular line
Lateral imaginary lines Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line
Posterior imaginary lines and Posterior imaginary lines and landmarkslandmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region
Left lateral view of lobesLeft lateral view of lobes
Right lateral view of lobesRight lateral view of lobes
Anterior view of lobesAnterior view of lobes
Posterior view of lobesPosterior view of lobes
Thoracic deformity Thoracic deformity
Pectus excavatumBarrel chest
Kyphosis
Inspection Inspection
1. Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult
2. Respiratory rate: 16-18 f/min Tachypnea: >20 f/min Bradypnea: <12 f/min Shallow and fast
respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy
Deep and fast Agitation, intension
Deep and slow Severe metabolic acidosis (Kussmaul’s breathing)
Inspection Inspection
Abnormalities in Rate and Rhythm of Breathing
NormalRapid Shallow Breathing
(Tachypnea)
Rapid Deep Breathing
(Hyperpnea, Hypeventilation) Slow Breathing (Bradypnea)
The respiratory rate is about 14-20 per min in normal
adults and up to 44 per min in infants.
Rapid shallow breathing has a number of causes, including
restrictive lung disease, pleuritic chest pain, and an
elevated diaphragm.
Rapid deep breathing has several causes, including exercise, anxiety,
and metabolic acidoses. In the comatose patient, consider
infarction, hypoxia, or phypoglycemia affecting the midbrain or pons. Kussmaul
breathing is deep breathing due to metabolic acidosis. It may be fast,
normal in rate, or slow.
Slow breathing may be secondary to such causes as diabetic coma, drug induced respiratory depression, and
increased intracranial pressure.
Cheyne-Strokes BreathingAtaxic Breathing
(Biot’s Breathing) Sighing Respiration Obstructive Breathing
Periods of deep breathing alternate with periods of apnea (no breathing). Children and aging people normally
may show this pattern in sleep. Other causes include heart failure, uremia, drug-induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or
diencephalon.
Ataxic breathing is characterized by unpredicted irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include
respiratory depression and brain damage, typically at the
medullary level.
Breathing punctuated by frequent sighs should alert you to the
possibility of hyperventilation syndrome – a common cause of
dyspnea and dizziness. Occasional sighs are normal.
In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to airflow. Causes
include asthma, chronic bronchitis, and COPD.
Palpation Palpation
Thoracic expansion
Massive hydrothorax,
pneumonia, pleural
thickening, atelectasis
Vocal fremitus (tactil fremitus)
PercussionPercussion
ClassificationClassification
Resonance Normal
Hyperresonance Emphysema Cavity or pneumothorax
Dullness Hydrothorax, atelectasis
4. Normal sound4. Normal sound
Shifting range of bottom of lung
6-8 cm
5. Abnormal sound5. Abnormal sound
Dullness, flatness, hyperresonance or tympany appear in the area of supposed resonance.
Unchanged sound (resonance) The depth of the lesion > 5 cm The diameter of the lesion 3 cm Mild hydrothorax
5. Abnormal sound5. Abnormal sound
Dullness or flatness Decreased containing gas in alveoli
Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis
No gas in alveoli Tumor Pulmo. Hydatid Pneumocystis Non-liquefied lung abscess
Others Hydrothorax Pleural thickness
5. Abnormal sound5. Abnormal sound
Hyperresonance Emphysema
Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)
AuscultationAuscultation
Order of auscultation Order of auscultation
Sound of auscultationSound of auscultation
1. Normal breath sound
2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance
1. Normal breath sound1. Normal breath sound
Tracheal breath sound Bronchial breath sound
Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra
Bronchovesicular breath sound 1st, 2nd intercostal space
beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung
Vesicular breath sound Most area of lungs Bronchovesicular
Bronchial
Bronchial
Bronchovesicular
Characteristics of Breath Sounds
Duration of Sounds
Inspiratory sounds last longer than expiratory ones.
Inspiratory and expiratory sounds are about equal.
Expiratory sounds last longer than
inspiratory ones.
Inspiratory and expiratory sounds are about equal.
Intensity of Expiratory Sound
Soft
Intermediate
Loud
Very Loud
Pitch of Expiratory
Sound
Relatively low
Intermediate
Relatively high
Relatively high
Locations Where Heard Normally
Over most of both lungs
Often in the 1st and 2nd interspaces anteriorly
and between the scapulae
Over the manubrium, if heard at all
Over the trachea in the neck
Vesicular*
Broncho-vesicular
Bronchial
Tracheal
2. Abnormal breath sound2. Abnormal breath sound
Abnormal vesicular breath sound
Abnormal bronchial breath sound
Abnormal bronchovesicular breath sound
Abnormal vesicular breath Abnormal vesicular breath soundsound(1)(1)
1) Decreased or disappeared Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor
2) Increased Movement of respiration
Abnormal vesicular breath sound Abnormal vesicular breath sound (2)(2)
3) Prolonged expiration Bronchitis Asthma emphysema
Abnormal bronchial breath soundAbnormal bronchial breath sound
Bronchial breath sound appears in supposed vesicular breath sound area
Consolidation: lobar pneumonia (consolidation stage)
Large cavity: TB, lung abscess
Compressed atelectasis: hydrothorax, pneumothorax
Abnormal bronchovesicular Abnormal bronchovesicular breath soundbreath sound
Bronchovesicular breath sound appears in supposed vesicular breath sound area
The lesion is relatively smaller or mixed with normal lung tissue
3. Adventitious sound3. Adventitious sound
Adventitious Lung Sounds
DISCONTINUOUS SOUNDS (CRACKLES OR RALES) are intermittent, nonmusical, and brief – like dots in time
Fine crackles (. . . . . ) are soft, high pitched, and very brief (5 – 10 msec).
Coarse crackles (• • • • • ) are somewhat louder, lower in pitch, and not quite so brief (20-30 msec).
CONTINUOUS SOUNDS are > 250 msec, notably longer than crackles – like dashes in time – but do not necessarily persist throughout the respiratory cycle. Unlike crackles, they are musical.
Wheezes ( ) are relatively high pitched (around 400 Hz or higher) and have a hissing or shrill quality.
Rhounchi ( ) are relatively low pitched (around 200 Hz or lower and have a snoring quality.
Vocal resonanceVocal resonance
Bronchophony Consolidation
Egophony Upper area of hydrothorax
Whispered Pectoriloqny Consolidation
Main symptoms and signs in Main symptoms and signs in common respiratory diseasescommon respiratory diseases
Labor pneumoniaLabor pneumonia
Symptoms Symptoms
Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum
Signs (1)Signs (1)
General signs Acute facial features, dyspnea Cyanosis Tachycardia Simple herpes around lips
Signs (2)Signs (2)
Inspection Decreased respiratory movement Palpation Increased vocal r
Chronic bronchitis with Chronic bronchitis with emphysemaemphysema
Symptoms Symptoms
Chronic productive cough White mucous sputum or pus sputum (infection) Exertional dyspnea Breathlessness (dyspnea) Chest depression
Signs Signs
Barrel chest Movement of respiratory Vocal fremitus HyperresonanceCardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)
Bronchial asthmaBronchial asthma
Symptom Symptom
Expiratory dyspnea with wheezing
Signs Signs
Expiratory dyspnea with wheezing Orthopnea Cyanosis Decreased movement of respiration Hyperresonance Rhonchi in full fields of lungs
HydrothoraxHydrothorax(pleural effusion)(pleural effusion)
Symptoms Symptoms
Dry cough Chest pain
Disappeared with growing of pleural effusion Reappeared with the fluid decreasing
Affected side lying Dyspnea, orthopnea The symptoms of underlying disease
Signs Signs (Moderate to massive effusion)(Moderate to massive effusion)
Tachypnea Limited movement of affected side Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Pleural friction rub Abnormal bronchial breath sound in upper area of the
fluid
Pneumothorax Pneumothorax
Symptoms Symptoms
Sudden chest pain Dyspnea Forced sitting position Dry cough
Tension pneumonia Progressive dyspnea Tyckycardia Cyanosis Respiratory failure
Signs Signs
Limited movement of affected side Decreased vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or
disappeared