Symptomatology of Respiratory Disorders

Department ofMedicine

ACMS

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

Why do patients consult ?

–Discomfort

– Interference with normal life

– Fear/ concern

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

A R Rehman, Musician

• Weakness of voice after tour 10 concerts in 2 weeks

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

7. Hiccups

• Diaphragmatic irritation

Causes

• Respiratory- Basal pneumonia, Pleurisy

• CVS

• Upper GI

• Metabolic