Lecture 9 - Respiratory Symptoms And Signs Flashcards
Respiratory symptoms
- dyspnoea
- cough
- haemoptysis
- Chest pain
Respiratory signs
- Clubbing
- Percussion
- Auscultation
- Vocal resonance and Fremitus
Symptom definition
- any sensation or change in bodily function experienced by a patient that is associated with a particular disease
- subjective sensation
Sign Definition
- evidence of disease pereceptible to the examining physician
- objective observations
Differentiatl diagnosis
- a list of two or more conditions which may share clinical symptoms or signs
The diagnostic method:
- 1) list a set of all possibilities of diagnosis
2) Reorder these based on probability, incorporating your history and exam findings
3) Test these differential diagnoses with further enquiry or investigations
4) Re-evaluate your list of differentials
Creating a differential diagnosis list - by types of pathology : I VINDICATE AIDS
- Idiopathic
- Vascular: Pulmonaru Embolus
- infectious: Pneumonia
- neoplastic: Lung Cancer
- degenerative: COPD
- inflammatory: Pleurisy
- Congenital: Cyanotic heart disease
- Autoimmune: Vasculitis
- Traumatic: Pneumothorax
- Endocrine and metabolic: Acidosis
- Allergic: Asthma
- Iatrogenic
- Drugs: Methotrexate
- Social: Anxiety
Creating a differential diagnosis list - by systems review
- Neurological: Neuromuscular disease
- Endocrine/ Metabolic: Acidosis
- Cardiovascular: AMI, APO, Valvular
- Respiratory: a lot
- Hematological: Anemia, Coagulopathy
- Gastrointestinal: Reflux
- Genitourinary: None
- Reproductive: None
- Musculoskeletal: Deconditioning
Creating and prioritising a differential diagnosis list - by time course
- suddon onset: Pulmonary embolism
- Rapid onset - Asthma
- Acute onset - Pneumonia
- Sub-acute onset: TB
- Chronic : neuromuscular disease
Creating and prioritising a differential diagnosis list - as per John Murtagh
1) The probability diagnosis
2) The serious disorders not to be missed
3) The conditions which are often missed
4) The seven masquerade: Depression, diabetes, drugs, anemia, thyroid, spinal, UTI
5) Is the patient trying to tell me something: interpersonal conflicts, financial, drugs, fears, family
Dyspnoea
- subjective awareness of discomfort related to breathing
Dyspnoea - DDx: Sudden
- Pneumothorax
- pulmonary embolism
- Myocardial infarct
- Arrythmias
- Aspiration
- Anaphylaxis
- Anxiety/psychogenic
- Trauma
Dyspnoea - DDx - Acute
- Asthma
- pneumonia
- pulmonary oedema
- respiratory tract infection
- lung tumour
- Pleural effusion
- Metabolic acidosis
- Renal failure
Dyspnoae - DDx - Chronic
- COPD
- heart failure
- arrhythmia
- anemia
- bronchiectasis
- cystic fibrosis
- Pulmonary hypertension
- Pulmonary fibrosis
- Neuromuscular
Variations of dyspnoea
- Tachypnoea - rapid breathing
- Hyperpnoea - increased volume breathing
- Orthopneoa - Dyspnoea when lying supine
- Paroxysmal noctunarl dyspnoae - waking with dyspnoae in the middle of the night (often associated with heart failure)
- Platypnoea - Dyspnoea when sitting erect
Mechanism of dyspnoea can be divided into
- increased central respiratory drive
- increase respiratory load
- lung irritation
Dyspnoea - mechanisms
- afferent signal: Mechanoreceptors/chemoreceptors/ lung receptors
- Efferent smuscle fibres
Assessing/Measuring dyspnoea
- MMRC
- Modified Borg scale
Cough receptors
1) lung receptors: Type 1 receptors
- rapidly adapting (myelinated)
- found in airway epithelium
- stimulated by exogenous and endogenous substances
- cough
2) Larynx and Carina - Very sensitive to foreign bodies/vapors
3) Terminal bronchiole and alveoli - sensitive to chemical stimuli
Cough DDx - Acute
- inhaled foreign body
- aspiration
- Respiratory infection
- inhaled irritiants
- Left ventricular failure
- Cough DDx- Chronic
- COPD
- Bronchiectasis/CF
- Pulmonary Oedema
- Tuberculosis
- Smoking
Cough - DDx - Chronic, non productive
- Asthma
- Post nasal drip
- Gastro-oesophagal reflux
- Drugs
- Lung Cancer
- Pulmonary Fibrosis
- TB
- whooping cough (pertussis)
Cough types
- Barking
- Honking
- Paroxysmal
- Stacatto
- Wet cough
Sputum
- Fairly non-specific sign
- Sputum is mucous secretion from glands in the tracheobronchial tree: any irrititant increases sputum production
- green colour more likely to be bacterial infection
- change in colour or volume usually indicates infection, particularly in COPD
Sputum investigations
- Examine appearance and odour
- Microscopy, Gram stain and culture
- Cytology: Makignancy, cell count
Hemoptysis
- coughing up blood or blood stained sputum
1) Volume and type
- blood flecks in sputum
- blood stained/streaked sputum
- old clots vs Fresh
- Frank Hemoptysis
Chest pain
- relatively non-specific and carries a long differential diagnosis list
- pleuritic chet pain: pain on inspiration/breathing. More specific for respiratory problems
4 steps to a resp exam
- inspect
- palpate
- percuss
- auscultate
Clubbing
- characteristic bulging of the distal finger and nail bed
Develops in 5 stages
Dyspnoea - DDx: Sudden
- Pneumothorax
- pulmonary embolism
- Myocardial infarct
- Arrythmias
- Aspiration
- Anaphylaxis
- Anxiety/psychogenic
- Trauma
Dyspnoea - DDx - Acute
- Asthma
- pneumonia
- pulmonary oedema
- respiratory tract infection
- lung tumour
- Pleural effusion
- Metabolic acidosis
- Renal failure
Dyspnoae - DDx - Chronic
- COPD
- heart failure
- arrhythmia
- anemia
- bronchiectasis
- cystic fibrosis
- Pulmonary hypertension
- Pulmonary fibrosis
- Neuromuscular
Variations of dyspnoea
- Tachypnoea - rapid breathing
- Hyperpnoea - increased volume breathing
- Orthopneoa - Dyspnoea when lying supine
- Paroxysmal noctunarl dyspnoae - waking with dyspnoae in the middle of the night (often associated with heart failure)
- Platypnoea - Dyspnoea when sitting erect
Mechanism of dyspnoea can be divided into
- increased central respiratory drive
- increase respiratory load
- lung irritation
Dyspnoea - mechanisms
- afferent signal: Mechanoreceptors/chemoreceptors/ lung receptors
- Efferent smuscle fibres
Assessing/Measuring dyspnoea
- MMRC
- Modified Borg scale
Cough receptors
1) lung receptors: Type 1 receptors
- rapidly adapting (myelinated)
- found in airway epithelium
- stimulated by exogenous and endogenous substances
- cough
2) Larynx and Carina - Very sensitive to foreign bodies/vapors
3) Terminal bronchiole and alveoli - sensitive to chemical stimuli
Cough DDx - Acute
- inhaled foreign body
- aspiration
- Respiratory infection
- inhaled irritiants
- Left ventricular failure
- Cough DDx- Chronic
- COPD
- Bronchiectasis/CF
- Pulmonary Oedema
- Tuberculosis
- Smoking
Cough - DDx - Chronic, non productive
- Asthma
- Post nasal drip
- Gastro-oesophagal reflux
- Drugs
- Lung Cancer
- Pulmonary Fibrosis
- TB
- whooping cough (pertussis)
Cough types
- Barking
- Honking
- Paroxysmal
- Stacatto
- Wet cough
Sputum
- Fairly non-specific sign
- Sputum is mucous secretion from glands in the tracheobronchial tree: any irrititant increases sputum production
- green colour more likely to be bacterial infection
- change in colour or volume usually indicates infection, particularly in COPD
Sputum investigations
- Examine appearance and odour
- Microscopy, Gram stain and culture
- Cytology: Makignancy, cell count
Hemoptysis
- coughing up blood or blood stained sputum
1) Volume and type
- blood flecks in sputum
- blood stained/streaked sputum
- old clots vs Fresh
- Frank Hemoptysis
Chest pain
- relatively non-specific and carries a long differential diagnosis list
- pleuritic chet pain: pain on inspiration/breathing. More specific for respiratory problems
4 steps to a resp exam
- inspect
- palpate
- percuss
- auscultate
Clubbing
- characteristic bulging of the nail bed
May develop in 5 stages
1) Softening of the nail bed
2) Loss of the normal
Clubbing mechanism
- not very understood
- Normal pulmonary circulation disruption -> megakaryocyte not broken into fragments -> deposition in circulation of extremities -> platelet growth factors released -> proliferation of muscle cells and fibroblasts -> clubbing
Clubbing DDx
- Respiratory: suppuratie lung disease, idiopathic pulmonary fibrosis
- Malignancy: Lung cancer, lymphoma
- CardiacL congenital cyanotic heart disease, infective endocarditis
- Gastrointestinal: Liver cirrhosis, inflammatory bowel disease
COPD alone is not a cause of clubbing - think lung cancewr
Percussion notes
- air : hyperresonant
- Infiltrate: Dull, Percussion, note
- normal lung: resonant (normal)
- effusion: stony dull
How sound travels
- Air: 343 m/s
- Water: 1484m/s
- Normal lung parenchyma: 70m/s
- sound generally does not like interfaces
Adventitious sounds
- Wheeze
- Crackles
- Stridor
- Rubs
Crackles
- inspiratory
- non-continuous, popping sounds
- caused by opening of obstructed airways
- course crackles: wet - low pitched: sound made by fluid secretion in airway (Pneumonia, COPD, Pulmonary oedema, IPF)
- Fine crackles: dry, velcro-like sounds. Sounds made by stiff alveoli popping open (DDx: pulmonary fibrosis, radiation pneumonitis)
Auscultation sounds
- air: absent breath sounds
- Infiltrate: reduced breath sounds/coarse crackles
- normal lung: normal vesicular breath sounds
- effusion: absent breath sounds
Wheeze
- expiratory
- continuous, high-pitched
- polyphonic, musical sounds
- occurs in multiple airways simultaneously
DDx:
- asthma
- pulmonary oedema - cardiac wheeze
- small airway trauma
Stridor
- inspiratory: above the glottis
- expiratory: below the thoracic inlet
- Biphasic: fixed obstruction in either constant location
- Loud, monophonic with constant pitch
- cause: any large airway obstruciton
- DDx: tumours, croup, foreign bodies, aspiration, vocal cord dysfunction, sub-glottic stenosis, laryngomalacia
Pleural rubs
- rubbing.scratiching sound heard over inflammed pleura
- can be heard in both inspiration and expiration
- not to be confused with pericardial rib, which is independent of respiration
- Mechanism: inflammation of the pleura and loss of the normal pleural lubrication
- DDx: pleurisy, PE, Pneumonia, TB, Serositis
Bronchial breath sounds
- increased clarity and loudness of breath sounds
- soft/non-musical
- same sound as that heard when listening over the trachea with your stethoscope
- indicates that patient airway is surrounded by consolidated lung tissue
- DDx: Consolidation
Cocal resonance
- normal lung tissue only transmits higher pitched sounds
- consolidated lung tissue transmits both high and low pitched sounds
- more difficult to hear in woman
- normal vocal resonance: muffled sounds
- consolidated lung: sounds more clear
- Pleural effusion: decreased/absent vocal resonance
Signs of consolidation
- bronchophony: voice is louder than normal and higher vocal resonance
- whispering pectoriloquy: whispered words are clearly heard
- Aegophony: nasal, bleating quality to the sound
Vocal fremitus
- the vibration felt when placing the hands on the back of a patient and asing them to speak
- similar findings to that found in vocal resonance
Vocal resonance sounds
- air: absent
- infiltate: increased vocal resonance/fremitus
- normal lung: normal vocal resonance
- Effusion: absent/reduced vocal resonance
Signs of pulmonary consolidation
- decreased chest expansion on affected side
- dull to percussion
- decreased breath sounds, with inspiratory crackles
- bronchial breath sounds
- increased vocal resonance with: bronchophony, whispering pectoriloquy, aegophony
