Transcript Symptoms and Signs in Respiratory System

Symptoms and Signs in
Respiratory System
Dr. Nawal N Binhasher
Assistant professor, Medical Consultant
department of medicine
History:
Symptoms:
Cough
Sputum
Hemoptysis
Dyspnea
Chest pain (chest tightness)
Wheezing
cough
Definition: cough reflex arc
Types:
1. Acute (< 3 wks) ex: RTI
2. Subacute (3-8 wks) ex: post RTI
3. Chronic (>8 wks) ex: bronchiectasis
Causes of acute cough:
1. Acute upper respiratory tract infection.
2. Acute lower respiratory tract infection
(pneumonia).
3. Acute exacerbation of underlying chronic
pulmonary disease.
4. Pulmonary Embolism (PE).
Causes of subacute cough:
1. Post-infection of upper or lower respiratory
tract.
2. Angiotensin Converting Enzyme Inhibitors
(ACE-I) medication.
Common causes of chronic cough
usually with a normal CXR:
1. Upper airway cough syndrome (it is related to
allergic, non-allergic or vasomotor rhinitis, nasopharyngitis, & sinusitis. i.e postnasal drip «PND»)
2. Bronchial Asthma
3. Gastroesophageal reflux disease
Other Respiratory Causes:
1.
2.
3.
4.
5.
6.
7.
8.
Chronic bronchitis (COPD, eosinophilic)
Bronchiectasis
Neoplasm
Interstitial lung disease (ILD)
Lung abscess
Obstructive sleep apnea (OSA)
Tracheobronchial foreign body or mass
Nasal polyps & others……
Non-Respiratory Causes:
Mediastinal:
• external tracheal compression ex: enlarged LN
• Tumors, cysts, masses
Cardiac:
• LVF
• Severe MS
ENT:
• Acute/chronic sinusitis
• PND (perennial, allergic, or vasomotor rhinitis)
Cont’n:
GI:
• GERD
• Esophageal dysmotility, stricture, or pouch
• Esophago-bronchial fistula
CNS:
• CVA
• MS
• MND
• Parkinson’s disease
Cont’n
Drugs:
• ACE-Inhibitors
• Some inhaler preparations can cause cough
Others:
• Idiopathic
• Ear wax (vagal nerve stimulation)
• Psychogenic
Sputum:
• Amount: N amount < 100mls of mucus/day
• Color: N, clear & white mucus
• Smell: N, not smelly
Ex: chronic large amount of purulent sputum may
suggest bronchiectasis while acute one may indicate
lobar pneumonia.
Ex: foul-smelling purulent sputum may indicate lung
abscess with anaerobic infection
Ex: pink frothy secretions occurs in pulmonary edema
Hemoptysis:
• It’s a blood-stained sputum
• Varies from streaks of blood to massive
bleeding (>100 - 600mls /24 hrs)
• It should be investigated thoroughly
• Commonest cause is acute infection like
exacerbation of copd but other serious causes
should be rolled out
• Other causes: PE, Bronchogenic ca., pul TB,
bronchiectasis, lung abscess,
Cont’n
• Pulmonary hemorrhage from any cause like:
Goodpasture’s syndrome or rupture of a
mucosal blood vessel after a vigorous
coughing
• Non-respiratory causes: CVS: severe MS, &
acute LVF. Bleeding Diathesis should be
excluded.
• Rusty sputum (when purulent sputum is mixed
with blood) eg: lobar pneumonia
Dyspnoea:
•
•
1.
2.
Defined as: experience of discomfort in breathing or an
awareness of respiratory distress & physiologically its an ↑
in the level & work of breathing.
Onset:
Instantaneous: pneumothorax, PE
Min.s – hrs:
* Aw disease: (BA, copd exacerbʼn, UAW obstrcʼn)
* parenchymal disease: (pneumonia, pul hage, pul edema..)
* pul vascular disease: (PE)
* cardiac disease: ( MI,……. )
* metabolic acidosis
* hyperventilation syndrome.
Cont’n:
3. Subacute (days):
* Many of the above plus:
* Pl. effusion
* lobar collapse
* Acute Interstitial pneumonia
* SVC obstruct’n
* Pul vasculitis
4. Chronic (months-years):
* COPD & BA
* Diffuse parenchymal dis: (IPF, sarcoidosis, bronchiectasis)
* Hypoventilat’n:(neuromuscular weakness, chest wall defor)
* Anemia
* Thyrotoxicosis
Cont’n:
•
Severity (grading):
Dyspnea can be graded from І – IV based on the NYHA
classification.
Chest pain:
Pul causes of CP:
1. pul vasculature:
•
Acute PE
•
Pul HTN & Corpulmonale
2. Lung parenchyma:
•
Pneumonia
•
Cancer
•
sarcoidosis
Cont’n:
3. Pleura & plural spaces:
• Pneumothorax
• Pleuritis & serositis
• Pleural effusion
4. psychogenic/psychosomatic
Wheezing:
It’s a continuous whistling, not diagnostic for
asthma & can occur in other resp diseases like copd.
Other symptoms:
1. Runny, blocked nose & sneezing: may occur in both
common cold & allergic rhinitis (loss of smell =
inosmia, runny nose = rhinorrhea)
2. Nocturnal fever may accompany TB, pneumonia, &
mesothelioma.
3. Nocturnal sweating can occur in TB, lymphoma, &
lung abscess.
4. Hoarseness may be secondary to laryngitis, VC
tumor, & RLN palsy in apical lung CA.
5. Symptoms of corpulmonale (abd & ankle swelling,
….)
Other aspects of history:
• Details of the respiratory system symptom should be
inquired such as; onset, duration, character,
radiation/severity/grading, frequency, aggravating &
relieving factors, & associated symptoms.
• PMH of a respiratory disease
• Smoking history in details
• Drug history including IV drug abuser (lung abscess)
& alcohol consumption (aspiration pneumonia)
• Inquiry about occupat’n & or previous jobs
• Pets history
Clinical examination (signs):
* General appearance
* General system
* Chest examination
In general appearance, look for:
• Respiratory distress {count RR, normal 14-20bpm
Tachypnea = ↑ rate of breathing
Hyperapnea = ↑ level of ventilation, and
look to the accessory muscles; sternomastoids,
scalene, platysma & strap muscles of neck &
abdominal muscles, if they are in use?}
Cont’n
• Coughing; character (bovine cough…)
• Sputum;
• Abnormal sound; stridor (croaking noise,
loudest on inspiration 2° to larynx, trachea or large
airways obstruction), or wheezing.
• Abnormal voice; hoarseness
• Surroundings; like containers of sputum, O2 mask,
IV lines or medications respiratory aids or machines..
General system examination:
•
Hands:
1. Clubbing (check respiratory causes)
2. Tar staining
3. Weakness of hand’s small muscles (abduction)
•
Wrist:
1. Pulse: rate & character
2. Flapping tremors (asterixis)
•
BP: pulsus paradoxux (asthma), hypotension
Cont’n
• Neck:
1. JVP: ↑ in corpulmonale & SVC obstruct’n but not
pulsatile.
2. LN: enlargement in CA bronchus or mets
•
1.
2.
3.
Face:
Eye: Horner’s syndrome in CA bronchus
Tongue: central cyanosis
SVC obstruction: plethoric & cyanosed,
periorbital edema, injected conjuctvae & +ve
Pemberton’s sign
Chest examination:
• Inspection:
1. Shape: AP diameter compared to transverse
(barrel-chest), pectus excavatum, pectus carinatum,
kyphoscoliosis,…. others
2. Symmetry: assessment of upper & lower lobes
should be done posteriorly looking for ↓ or delayed
chest movement during moderate respirat’n.
3. Scars: from previous operat’n or chest drains or
cautery marks or radiotherapy markings.
4. Prominent veins: in case of SVC obstruct’n
Palpation:
1. Trachea: normally central, slight Rt displacement
could be N. Check for gross displacement. Tracheal
tug means the N distance bet sternal notch &
cricoid cartilage is < 3-4 finger breadths & occurs
in chest overexpansion as copd.
2. Apex beat & mediastinum: Check for
displacement.
3. Chest expansion: N expansion ≥ 5cm
4. Tactile vocal fremitus (TVF): can be done with
the palm of one hand.
Percussion:
• Should be done symmetrically (Lt compared with the
Rt), posteriorly (the back), anteriorly (the front) &
laterally (the sides).
• Supraclavicular area, then clavicles should be
percussed directly to evaluate the upper lobes.
• Liver dullness: of the upper edge starting at the 6th rib
MCL, resonant note below this area indicates hyperinflation (copd, severe asthma)
• Cardiac dullness: may be ↓ in hyperinfated chest.
Auscultation:
Using the diaphragm of a stethoscope & comment
on the following:
1. Breath sounds (BS):
• Intensity: N or ↓ as in (consolidation, collapse, pl effusion,
•
•
pneumothorax, lung fibrosis)
Quality: Vesicular or bronchial in consolidation
Differentiation between vesicular & bronchial BS:
Vesicular: louder &longer on inspiration than expiratory phase
& has no gap between the 2 phases
Bronchial: louder &longer on exp phase & has a gap between
the 2 phases
2. Added Sounds:
•
•
•
•
•
Type: Wheezes or Crackles or friction rub
Timing: inspiratory or expiratory
Wheezes: are continuous musical polyphonic sound, heard
louder on expiration & can be heard on inspiration which
may imply severe AW narrowing. High pitched- wheezes are
found in BA due to acute/chronic airflow limitation & low
pitched in copd. Localized monophonic wheeze due to fixed
AW obstruct’n in CA bronchus.
Crackles: interrupted non-musical inspiratory sound
Crackles may be early, late or pan-inspiratory & fine,
medium or coarse. Ex: late/pan-insp coarse crackles in
bronchiectasis, late/pan-insp medium crackles in pul edema ,
late/pan-insp fine crackles in pul fibrosis
• friction rub:
It’s due to thickened or roughened pl surfaces rub
together as lungs expand & contract & give off a
continuous or intermittent grating sound. It
indicates pleurisy & may be heard in pneumonia or
pul infarction.
3. Vocal Resonance:
•
•
It’s the ability to transmit sounds.
Ask patients to say 44 (Arabic) or 99 (English) &
listen for the transmitted sound which may be ↓ or ↑
or N (low pitched component of speech heard with
booming & high pitched become attenuated).
4. Egophony:
When the patient with consolidation is asked to say ‘e’ it
sounds like ‘a’
5. Whispering pectoriloquy:
The whispered speech is heard very loudly over the
consolidated area.
Other signs should be looked for to complete the respiratory
system examination “signs of complications”
1. Signs of pul HTN or corpulmonale.
2. Signs of SVC obstruction.
3.
Signs of CA bronchus mets, or extension
Secondary pul HTN or corpulmonale:
• Should be suspected in:
1. Chronic airflow limitation such as copd
2. Pulmonary fibrosis
3. Chronic pul thromboembolism
4. OSA
5. Severe kyphoscoliosis/marked obesity
• Signs:
loud P2 of S2 + signs of RHF
Thank you
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