11.2 Signs And Symptoms Of Respiratory Disease Flashcards
How do we approach a patient presenting with respiratory problems in primary consultation?
Full history - symptoms/signs/onset/duration/exacerbating and alleviating factors
Clinical examination
Further investigations
What are the cardinal signs that indicate respiratory disease?
Breathlessness Coughing (productive/non-productive) Production of sputum (colour/amount) Haemoptysis Added sounds - wheeze/stridor
What is dyspnoea?
Subjective awareness of increased effort of breathing
Symptom rather than a sign, but may be objective evidence i.e. raised RR, accessory muscle use
What non-respiratory conditions can cause breathlessness?
Anaemia
HF
obesity
What questions should be asked about dyspnoea?
Progression
Onset, timing and duration
Precipitating factors
Severity ( what has it affected - walking/talking)
What might cause chest pain?
Mediastinal structures (ACS - acute coronary syndrome/Pericarditis/Oesophagitis/GORD/Aortic dissection)
Pleura (Infection (causing pleurisy)/ Pneumothorax/ Pulmonary embolism (causing infarct))
Chest wall (Rib fracture/ Costochondritis/ Shingles (varicella zoster))
What might cause sudden onset dyspnoea?
Pneumothorax
PE
What might cause dyspnoea that develop over hours to days?
Infection
Pneumonia
Deterioration of Chronic lung disease
What might cause dyspnoea that comes and goes?
Asthma
What should be asked about chest pain?
Location
Character
Exacerbating
Relieving
What is orthopnoea
Shortness of breath that occurs when lying flat
What is pleurisy?
Inflammation of the pleura
Also called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing
How is cardiac pain described?
Central, dull, poorly localised, tight, crushing, heavy, may radiate to neck/jaw/shoulders
How is pleuritic pain described?
Thoracic wall or shoulder tip (referred - intercostal n/phrenic nerve)
Sharp, well localised. Worse with coughing and breathing in.
Doesn’t necessarily mean the pleura is definitely involved.
How is a cough triggered?
Triggered by stimulation of mechano- and/or chemo-receptors within airway. Any source of inflammation (foreign body/acute or chronic inflammation/cancer)
Describe the mechanism of a cough
Deep breath in
Adduction of VC, closing off the glottis
Contraction of internal ICs and abdominal muscles increasing the intrathoracic pressure.
Followed by abduction of the vocal cords
What do we need to know about a cough?
Productive cough? Type of sputum?
Character? E.g. bovine cough/croup cough
Timing e.g worse at night? In the winter?
What is a bovine cough?
A cough that isnt explosive. Less effective cough as cant close glottis.
What is the commonest cause of a cough?
URTI
What might cause clear sputum with a cough?
Chronic bronchitis
COPD
What might cause yellow/green sputum?
Infection
Pneumonia
What might large volumes of yellow/green sputum suggest?
Bronchiectasis
Why might haemoptysis be concerning?
Red flag sign for lung cancer
What are the non-respiratory causes of a cough?
- LV heart failure (“pink frothy sputum”)
- GORD
- Drugs e.g. ACE-inhibitors (dry irritating cough)
What causes additional breath sounds?
Abnormal breath sounds indicating narrowing within the airway causing turbulent air flow
What is a wheeze?
A high pitched ‘musical’ breath sound. Mostly on expiration. May only be audible with stethoscope
What causes a wheeze?
Narrowing in intrathoracic airways E.g. from bronchial smooth muscle contraction, oedema, mucous
Narrowing exacerbated during expiration
What is stridor?
High pitch, constant, loud, audible without stethoscope. Mostly heard on inspiration.
What causes stridor?
Indicates narrowing in extrathoracic airway (Upper respiratory tract)
• Supraglottis, glottis, infraglottis or trachea
• Narrowing exacerbated during inspiration
During clinical examination, what do we inspect?
Respiratory rate
Look at hands (clubbing/ peripheral cyanosis)
Look at face (central cyanosis/pursed lip breathing)
Chest (accessory muscle use/abnormal shape of chest)
What is peripheral cyanosis?
Peripheral (skin of feet, hands, nose and tips of ears)
• Cold exposure and decreased cardiac output
• Slowing of blood to peripheries (due to vasoconstriction)
• Increased oxygen extraction
• More deoxygenated blood present in that area
What is central cyanosis?
Central cyanosis: lips and tongue (mucous membranes)
• Significant cardiac or respiratory cause
• Caused by increase in amount of deoxygenated Hb in
blood arriving at tissues [deoxygenated blood is leaving the heart]
What are signs that may be seen on inspection in respiratory examination?
Clubbing
Accessory muscle use
Barrel chest
Why is pursed lip breathing an important clinical sign?
- Commonly seen in COPD
- Pursing lips increases resistance to outflow on expiration
- Maintains intrathoracic airway pressures allowing for small airways to remain open for longer
- prolonging period for gas exchange to occur • and to allowing more air to empty (rather than trap)
What is barrel chest?
Increased A-P diameter of chest / hyper expansion
• Associated with lung hyperinflation
• Seen in severe COPD (especially emphysema)
• AP diameter > lateral diameter
• Chronic over-inflation of lungs (due to air trapping)
• Hyperexpands the chest wall over time
What are we assessing of clinical examination?
Trachea position Chest expansion (symmetrical/asymmetrical/reduced)
What are we assessing on percussion?
- Resonant?
- Normal • Hyper-resonant
- Increased air • Dull
- Consolidation
- Stony-dull (pneuomthorax)
What is normal lung sounds on auscultation?
Normal (vesicular) • ‘Rustling leaves’ • Inspiration and first part of expiration • No gap between inspiratory and expiratory components
What is bronchial breath sound?
- ‘Blowing’ harsh sound
- Inspiration and expiration
- Gap between
Where do we hear bronchial breath sounds?
Over an area of pneumonia
Consolidated alveoli act like a solid
Conduct the breath sounds from the larger airways more readily
What breath sounds might be auscultated?
Vesicular Bronchial Reduced/absent Wheeze Stridor Crackles Pleural rub
