Session 11 - Lecture 1 - Signs and Symptoms of Respiratory Disease Flashcards
1 - Title
Signs and Symptoms of Respiratory Disease
“This session going to pick up on quite a few bits of pieces that you probs already know, throughout Resp, but also CHDD module – steps of Resp exam and taking a hx of someone with an underlying resp problem.”
2 - Diseases Involving the Respiratory System
Many Diseases Involving the Respiratory System
- Airways • Asthma • COPD • Bronchiectasis • Cystic Fibrosis
- Lung parenchyma
• Pulmonary fibrosis
• Pneumonia
• TB - Pulmonary circulation
• Pulmonary embolism - Pleura (between)
• Pneumothorax
• Pleural effusion - Chest wall shape and neuromuscular
• e.g. kyphoscoliosis, myasthenia gravis
[scoliosis]
“So, these are all the diseases, had a quick look through your WB, had various lectures, GW sessions etc. – that can affect the resp system – think about how you can frame these conditions, help you to understand signs and symptoms you can get with symptoms – which part of resp system as a whole are these diseases affecting.
1b. Elements of COPD
2. Lung parenchyma or lung tissue affected – COPD has an element of pathophysiology here
2b. infections like TB and pneumonia.
4a. too much air
b. or fluid
5. chest wall itself for mechanics of ventilation – how you can expand the chest wall and increase thoracic volume – so any problems with shape of chest wall, also potentially cause problems with breathing, even though lung tissues and airways themselves may be perfectly healthy. Picture of someone with scoliosis”
3 - How do you make a differential diagnosis?
What symptoms and signs does the patient have?
Do they point to disease in a specific body ‘system’ or systems?
If so, what IS the underlying disease affecting that body ‘system(s)’?
History –> Clinical Examination –> +/- further investigations
“Okay, so now you’ve got those sorts of things in mind, so there’s lots of things so you have this build up of illness scripts in your head e.g. what does a asthmatic pt present like, what does a COPD pt present like etc? So tease out hx, what are the signs and symptoms they are describing, do they fit to a disease that affects a specific body system etc. And once you have an idea as to which system and which systems you think by what disease processes you have, next step is to think what is my differential? Many signs and symptoms overlap between CV and Resp so sometimes the DDx can affect umerous systems, so your hx and clinical exam complemented by some further investigations really going to help you tease out the significance of it, to get a diagnosis, therefore help you to manage the pt.”
4 - Cardinal Signs and Symptoms of Respiratory Disease
Cardinal* Signs and Symptoms of Respiratory Disease
[breathlessness chest pain cough haemoptysis sputum wheeze/stridor]
…some of these signs/symptoms are not necessarily ‘specific’ to the respiratory system
* Key/main symptoms and signs..
“So, there are a few symptoms or signs that we say are sort of key, highly suggestive of there being a problem in the resp system.
- Breathlessness. And v v frightening to experience.
- Chest pain.
- Cough.
- Haemoptysis – blood in sputum. It’s something they have coughed up and it is coming from their resp system – not something they have vomited up or blood that has trickled down from their nose from a nosebleed, somewhere from inside resp system.
- Sputum – coughing up stuff with a colour.
- Musical notes denote wheeze and stridor.
So if a resp problem, see if pts are presenting with cardinal signs or symptoms, and ask about them – sometimes pts don’t know significance of their signs and symptoms – these 6 things you should always explore when you think could this be a resp disease in complaint. These signs and symptoms are not necessarily specific to resp system. What other system can cause breathlessness? CV, HF can cause breathlessness. Another cause that’s not in resp system? Quite severe anaemia can sometimes cause someone to become breathless, particularly on exertion, other things that aren’t resp that may cause some of these signs, and we certainly know from 1st year, varied DDx for chest pain – hx is critical for teasing out features for resp or CV or perhaps somewhere else.”
5 - Breathlessness
Breathlessness (dyspnoea)
Can be very distressing!
• SUBJECTIVE awareness of INCREASED EFFORT required for breathing
• Symptom rather than a sign
• …but objective evidence of breathlessness may be present (e.g. raised RR)
- VERY COMMON (often variably described)
- Common to all respiratory conditions
- ..But not specific to respiratory conditions (e.g. anaemia, heart failure, obesity)
“Difficulty getting enough air”
“short of breath..”
“can’t catch my breath”
“chest feels tight”
“Breathlessness – dyspnoea, v distressing, can feel like you’re drowning, suffocated – can make pts v distressed & anxious which often compounds the issue.
So normally you’re not rly conscious of the need to breathe, it just happens, but if you have some sort of disease process, if that’s not adequate, breathing O2 to blood and tissues, get awareness what you’re doing is insufficient – symptom, pt tells you what they feel – tease out what they rly mean e.g. “chest feels tight” could also mean chest pain; what do they mean by can’t get a deep breath in.
But also could see raised RR or using accessory muscles – objective signs.
So really really common symptom, and other things, outside resp system can cause it, always bear that in mind when taking hx, but pretty much all resp conditions will have had breathlessness as one of their presenting features, so v common to all of them”
6 - Breathlessness Questions (1)
Breathlessness (dyspnoea)
…explore with further questions
Onset, timing and duration • Instant- Minutes • Hours to Days • Weeks to months • Months to years
• Intermittent or constant?
Progression
• Stable
• Worsening over time
“Onset/timing - how quickly the breathlessness started
Duration - how long it lasted
Progression - how it’s changed over time
So of all theresp conditions you know of, pull out some things that will present almost instantaneously or within a matter of mins – PE. Just gonna put PE. Something else might be sudden, e.g. asthma, an acute asthma attack, anything else? Pneumothorax, so something that some sudden change in the system, something that suddenly changes will often cause a symptom to present suddenly unwell. Any other things? Whast about kiddies, children? Likelihood – foreign body, like to put places they shouldn’t- swallow something, lodge itself in various places within the body. What about hrs to days, a bit slower, in sort of coming on, what condition might someone say, get increasingly breathless over the last 24h – infection e.g. pneumonia. So that could be a pneumonia is someone who doesn’t; have an underlying lung disease, or an acute exacerbation of COPD – usually triggered by viral infection rather than bacterial but they are susceptible to obviously pneumonia. ANyhting else, hrs to days? Pleural effusion, yeah potetnailly, perhaps a bit more days to weeks to between hrs to days and weeks to months, usually a few days where we notice their breathlessness has become problematic. What about wks to months? We’ve put pleural effusion under that, obvs depends on underlyting pathology, anything else, weeks to months that might cause someone to develop breathlessness, not necessarily resp perspective? HF – sometimes if you have acute left ventricular HF that might be instant, perhaps mins, but there could be a lil more chronicity, these ones are sort of more slow/gradual onset, and these are a lil bit more acute. Okay. So underlying lung cancer. What about months to years? Breathlessness for years – COPD, chronic lung diseases, that sort of progressively get worse over time, pulmonary fibrosis. Put anaemia under here as well, might be something if someone is just losign blood over time, slowly start feelings of breathlessness. Think about how quickly something comes up can help direct your differentials. What about this intermittent vs constant – i.e. is that breathlessness there all the time or does it come and go, how might that be helpful? What of these chronic lung conditions is intermittent? Asthma. COPD, they’re never q fully right, will have periods where they’re a lot worse, but theyre never q right, breathing is never q right – asthmatic, breathing can be perfectly normal even between exacerbations, so asking about whether breathlessness comes and goes is q helpful. Worsening over time, again that’s helpul, COPD we know is progressive, chronic but progressive lugn disease – slowly over months and years, symptoms and signs will start to deteriorate – variable rates of progression, but still a deterioration over time.”
7 - Breathlessness Questions (2)
Breathlessness (dyspnoea)
…explore with further questions
Precipitating factors
• Specific trigger(s)?
• Factors exacerbating or relieving it? E.g. position, cold weather, pets
Severity [very high, severe, extreme, catastrophic]
• Impact of breathlessness e.g. at rest, on exertion [how much exertion?]
• What does it stop you doing?
“So things that trigger the breathlessness will be helpful, so what sort of triggers might you ask about? Allergies – pets, breathlessness came on quite quickly when stroking neighbour’s dog, is it worse around summer period when pollen is high, cold weather can often exacerbate symptosm of breathlessness in pts with primary lung cinditions. What if it were cardiac, what might they say about position, in terms of what position helps or makes worse – lying flat – sometimes pts with breathlessness bc of cardiac problem, find that lying rly makes it worse – so do bear in mind if u have rly crappy lugns from resp disease, abdo contents going to splinch your diaphragm – so sometimes lying flat makes breathing more difficult bc of diaphragm pushing up, so not a hard and fast rule, but if someone breathes more difficult lying flat, may be a CV cause but there may be other reasons why challenging such as pts with COPD. Severity can be a clue for what’s going on – limited of breathlessness, functional limititaion as a result of this breathlessness. May have breathlessness as rest as well, and that would be a particular concern, so lots of things you would explore, teasing out diff features that might make you think one thing vs another.”
8 - Chest Pain causes
Chest Pain
Many potential causes!
- Pleura
• Infection (causing pleurisy)
• Pneumothorax
• Pulmonary embolism (causing infarct) - Chest wall
• Rib fracture
• Costochondritis
• Shingles (varicella zoster)
- Mediastinal structures • Myocardial infarction • Pericarditis • Oesphagitis/GORD • Aortic dissection
“tHE CHEST PAIN side of things, probs gone over this a million times before in CHDD, in CV in Year 1, these are, kind of non respiratory things, mediastinal structures, your heart stuff, MI, pericarditis, there are things here centrally that may cause chest pain, but also a lot going on from resp perspective accounting for pts presenting with chest pain. Problem could be inside lung itself – if inside lung itself needs to cause irritation to pleura, particularly parietal pleura, for it to cause chest pain – so not all pneumonia will cause chest pain unless there’s some involvement/irritation of chest pain. So disease doesn’t necessarily have to be in pleura, but pleura has to be involved for pt to describe pain as coming from resp system. CHest wall – lots of things there that ociuld cause problems, cause pain, rib fracture, elderly people, sometimes can have a v violent coughing fit, can actually fracture a rib, and there’s some other bits and pieces on there to consider – so the DDx is v v wide for chest pain.”
9 - Chest Pain
Chest Pain
Location, Character and Exacerbating or Relieving Factors Important
• Central vs non-central
• Cardiac vs “pleuritic”?
Irritation of PARIETAL PLEURA causes pain that is sharp, localised and referred to thoracic wall (intercostal n) or shoulder tip (phrenic nerve)
“so if we’re thinking about, well what about chest pain makes me think it’s resp So we’ve talked about diff in cardiac, pleuritic, a lot about characteristics of pain and location. Obvs where central or lateral – lung more likely to be laterally around lung fields causing pain rather than middle where mediastinal structures are. What are the features of pleuritic type chest pain? It’s sharp – it’s made worse on inspiration and coughing, something else, it’s localisednot going to say crushing chest pain, they’re going to say rly sharp pain here – may be constant, may be worse on cough or breathing but only made apparent then. What makes it better or worse rly helpful. Irritation of the pleura can either refer directly to the chest, can feel it directly on chest, but involving parts of pleura on your diagram, then often that’s referred to shoulder, so depends on which bits of pleura being irritated depens on where referred ot. Intercostal nerves on lateral sides, diaphragmatic and mediastinal surfaces on front. “
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