ALS Lecture 1 - Respiratory Symptoms and Signs DONE Flashcards
symptom
what pt complains of
sign
abnormality O/E
history
time course, relationship of symptoms
diagnostic process (3 steps)
- history
- physical examination
- investigations
6 common respiratory symptoms
breathlessness, cough, sputum, haemoptysis, wheeze, chest pain
other symptoms relevant to respiratory disease (8)
peripheral oedema, nighttime wakening, swelling of face or arms, nasal obstruction/discharge/sneezing, voice alteration, night sweats, fevers, weight loss
peripheral oedema may be due to…
right heart failure, CHF, lung disease
nighttime wakening/paroxysmal nocturnal dyspnoea may be due to…
heart failure, asthma
swelling of the face/arms may be due to…
blocked SVC due to tumour on right lung apex (cancer)
voice alteration may be due to…
larynx problems
weight loss/anorexia may be due to…
malignancy
breathlessness
unpleasant sensation of increased demand for breathing
is breathlessness a symptom or sign?
symptom
tachypnoea, hypoxaemia or hypercapnia have a poor correlation with
breathlessness
breathlessness is related to work of breathing (3 points)
- increased ventilation
- respiratory muscle weakness
- often multiple factors
with breathlessness we must
quantify exercise capacity (walking distance, flights of stairs, ADLs, work, etc.)
sudden (minutes) causes of breathlessness (5)
pulmonary oedema, pneumothorax, PE, anaphylaxis, foreign body inhalation
rapid (hours) causes of breathlessness (4)
acute asthma, pneumonia, pulmonary oedema, acute hypersensitivity pneumonitis
subacute (weeks) causes of breathlessness (4)
heart failure, anaemia, pleural effusion, lung cancer
slow (months/years) causes of breathlessness (4)
chronic bronchitis and emphysema (COPD), interstitial lung disease (e.g. idiopathic pulmonary fibrosis), pneumoconiosis, pulmonary arterial hypertension
cough acts as a
defence system, prevent inhalation of foreign objects
upper and lower respiratory tract are innervated by
sensory nerve endings to detect irritation
irritation leads to
cough reflex to clear airway
if cough reflex is heightened then…
airway nerves are hypersensitive
causes of cough hypersensitivity (10)
infection, left heart failure, lung cancer, foreign body inhalation, interstitial lung disease, tracheal compression (by lymph nodes, tumour, AA), ACE inhibitors, asthma, COPD, acid reflux
which 2 diseases come under COPD?
chronic bronchitis, emphysema
why do ACE inhibitors cause cough? (2 steps)
- metabolise bradykinin (as well as angiotensin), 2. accumulation increases sensitivity of airway nerve
label the diagram of the airway nerves
done
types of sputum colour (3)
mucoid, purulent, bloodstained
mucoid sputum
clear/creamy
purulent sputum
yellow/green
why is purulent sputum yellow/green?
myeloperoxidase from granulocytes (eosinophils/neutrophils)
in bacterial infection, sputum is green because of the
neutrophilic reaction
in asthma (allergic) cough, sputum is green because of the
eosinophilic reaction
bloodstained sputum
haemoptysis
when investigating cough we must ask what 4 things about sputum?
colour, volume (how much, how often), taste, odour
when taking a respiratory history, we must always ask
have you ever coughed up blood?
causes of haemoptysis (6)
lung cancer, TB, bronchiectasis, pulmonary oedema, PE, pneumonia
sputum in pulmonary oedema
pink, frothy
sputum in pneumonia
rusty, blood mixed through purulent
wheeze
musical noise due to narrowed airways
wheeze happens upon
expiration
why does wheeze happen upon expiration?
airways narrow as lungs get smaller
what is stridor?
wheeze sound on inspiration
stridor tends to indicate
upper airway issues, e.g. epiglottis, larynx, trachea
give 4 causes of wheeze
acute bronchitis, asthma, COPD, large airway obstruction (tracheal/laryngeal tumour)
in asthma airway obstruction we see (5)
- eosinophils
- basement membrane thickening
- smooth muscle hypertrophy
- goblet cell hyperplasia
- mucus plugging
chest pain important question
show me where it is
pleurisy
pleuritic pain
what causes pleuritic pain?
injured/inflamed pleura
what kind of pain is pleuritic pain?
sharp, stabbing, worse on inspiration
causes of pleuritic pain (3)
pneumonia, PE, pneumothorax
we need to distinguish pleuritic pain from (6)
upper retrosternal pain, musculoskeletal pain, retrosternal pain, bony pain, spinal root pain, shingles (before rash)
retrosternal pain could be due to
mediastinal tumour, constant/progressive, unrelated to exertion
bony pain could be due to
rib metastases
4 parts of respiratory exam
inspection, palpation, percussion, auscultation
2 main features to look for upon inspection
central cyanosis, finger clubbing
central cyanosis
lips, tongue, 20-30% of Hb deoxygenated
peripheral cyanosis
fingers, toes
give 4 features of finger clubbing
loss of angle between nail and nail bed, more spongy nail bed, curved nails, swollen end of fingers
asterexis
flapping tremor, type 2 respiratory failure with CO2 retention
respiratory distress can be indicated by
use of accessory muscles
patients with apical lung tumour can develop
muscle wasting (hands, brachial plexus), Horner’s syndrome
give 3 types of chest deformities
kyphoscoliosis, pectus carinatum (pigeon), pectus excavatum (funnel)
label the chest wall deformities
done
expansion (2 points)
- compare sides
- reduced expansion always on side with pathology
position of trachea to
assess mediastinal shift
the trachea is pushed way by (2)
pleural effusion, pneumothorax
the trachea is pulled towards (2)
collapse, fibrosis
cricosternal distance
how many fingers can we get between cricoid cartilage and suprasternal notch
normal cricosternal distance
3-4 fingers
types of sound on percussion
resonant, dull, stony dull, hyperresonant
normal percussion should be
resonant
dull percussion can mean
consolidation (pneumonia) collapse, dense fibrosis
stony dull percussion can mean
pleural effusion
hyperresonant percussion can mean
pneumothorax, bulla
normal breath sounds should be
vesicular
types of breath sounds
vesicular, diminished vesicular, absent, bronchial
breath sounds may be diminished vesicular in (2)
pneumothorax, collapse, effusion
breath sounds may be absent in (2)
big effusion, big pneumothorax
breath sounds may be bronchial in (1)
consolidation
added sounds on auscultation may be (2)
wheeze, crackles
crackles/crepitations are
explosive opening of multiple occluded small airways
coarse crackles may be seen in (2)
pneumonia, bronchiecstasis
pleural rub
creaking sound (like walking in fresh snow)
vocal resonance/tactile vocal fremitus (1)
ask pt to say 99
increased vocal resonance
bronchophony, sign of consolidation
reduced vocal resonance
collapse, pneumothorax, effusion
whispering pectoriloquy
whisper heard clearly through stethoscope, consolidation
fill in the blanked out table
done
