Medical Semiology Lecture 6 PDF

MEDICAL SEMIOLOGY Course 6  ANAMNESIS Age, ethnic origin Presenting symptoms: cough, sputum, hemoptysis, dyspnea, wheeze, chest pain, sinusitis, night sweats, hoarseness Family history: pulmonary disease (ex. TB, emphysema, atopy) Past history: pulmonary di...

MEDICAL SEMIOLOGY Course 6  ANAMNESIS Age, ethnic origin Presenting symptoms: cough, sputum, hemoptysis, dyspnea, wheeze, chest pain, sinusitis, night sweats, hoarseness Family history: pulmonary disease (ex. TB, emphysema, atopy) Past history: pulmonary disorder, chest pain, allergies, previous CXR abnormalities Social history:- work conditions (toxic environment) - smoking (how much and for how long)  SYMPTOMS The seven principal symptomes of the respiratory tract: Cough Sputum Haemoptysis Dyspnea Chest pain Wheeze Stridor  COUGH is an explosive expiration required for the self- cleaning of the lungs and is a nonspecific reaction to irritation anywhere from the pharynx to the lungs Three Categories of Cough Acute Cough = < 3 Weeks Duration Subacute Cough = 3 – 8 Weeks Duration Chronic Cough = > 8 Weeks Duration  Characteristics : -Dry cough (ex. pleuritis) -Productive cough (ex. Bronchiectasis) -Brassy cough (ex. Laryngitis, Tracheitis) -Barking cough (Hysterical ) -Bovine cough ( ex.Recurrent laryngeal nerve paralysis ) -Whooping cough (ex. Pertussis ) -Night cough (Acute exacerbation of bronchial asthma and heart failure ) -Early morning cough (smokers)  SPUTUM represents the elimination of the secretions from the airways by the act of coughing. Quantity of sputum often suggest the etiology: -50-100 ml (in chronic bronchitis, asthma) -100-300 ml ( in bronchiectasis, caverns) -more than 300 ml (pulmonary abscess)  Sputum types: - serous sputum (clear, frothy) - in acute pulmonary edema (pink) and alveolar cell carcinoma - Mucoid sputum: in traheobronchitis and asthma - Mucopurulent sputum (yellow or greenish sputum) - in chronic bronchitis, in bronchiectasis, tuberculosis - Purulent sputum (with puss) - in pulmonary abscess, bronchiectasis - Blood staines sputum (hemoptysis) - Streaking of sputum with a little blood (mitral stenosis), rusty sputum (bloody, inflammatory exudates coughed up typically in pneumococcal pneumonia), Coughing up fresh blood (ex. pulmonary tumours) - Smoking is the commonest cause of increased sputum production and it may have black specks from inhaled carbon.  HAEMOPTYSIS is the expectoration (coughing up) of blood or of blood- stained sputum from the respiratory tract. Causes: 1. respiratory: tumors (primary or secondary), tuberculosis, bronchiectasis, pneumonia, lung abscess, pulmonary infarction, acute bronchitis 2. cardiovascular: pulmonary edema, mitral stenosis, aortic aneurysm 3. bleeding diatheses (coagulopathy) False hemoptysis: Blood also may come from the nose, the back of the throat, or part of the gastrointestinal tract.  DYSPNEA is the subjective sensation of shortness of breath Etiology: - pleuropulmonary causes: pleurisy, pneumothorax, hidropneumothorax, pneumonies, pahipleurites, tuberculosis, pulmonary infarction, restrictive diseases (pulmonary fibrosis), obstruction of the large airways (foreign body, laryngeal neoplasm) and of the small airways (bronchial asthma) - cardiac causes- that induced retrograde stasis in pulmonary circulation: ex. mitral stenosis, cor pulmonare, aortic stenosis, aortic valve insufficiency. - anatomical: disease of the chest wall, muscle - abdominal disease - that determine ascension of the diaphragm: ex. ascites, tumors - other disease: thyrotoxicosis, ketoacidosis, anemia, psychogenic.  CHARACTERISTICS OF DYSPNEA Dyspnea with regular rhythm 1. Tachypnea - acceleration of respiratory rate more than 30/min. 2. Bradypnea - decreasing of respiratory frequence less than 16/min: - inspiratory bradypnea: in large airways obstruction (associated with stridor) - expiratory bradypnea: in small airways obstruction (associated with wheeze)  Dyspnea with irregular rhythm 1. Cheyne-Stokes dyspnea - periods of hyperventilation (crescendo-decrescendo) alternating with periods of apnea. The apneic spells can last as long as 45 seconds. Etiology: in left heart failure, severe neurological disease. 2. Biot respiration - irregular breaths (without crescendo–decrescendo pattern seen in Cheyne– Stokes respiration) irregular breaths. Etiology: neurological disease (meningites, tumors) 3. Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. It is a form of hyperventilation breathing which is increased above the required rate. TYPES OF DYSPNEA Obstructive dyspnea - in obstruction of the respiratory tract, loss of pulmonary elasticity (emphysema) Restrictive dyspnea - in interstitial disease (fibrosis), chest deformities Mixed dispnea  TYPES OF DYSPNEA - CLINICAL 1. On effort 2. Paroxysmal nocturnal dyspnea - dyspnea waking the patient from sleep; includes cardiac asthma and acute pulmonary edema 3. Orthopnea - dyspnea worse on lying flat; in cardiac failure 4. Sudden episodes of breathlessness and wheezing triggered by a variety of factors – suggests asthma 5. Exertion breathlessness progressing rapidly - suggests heart failure 6. Exertion breathlessness progressing over years - suggests diffuse pulmonary disease like fibrosing alveolitis or emphysema  CHEST PAIN CAUSES intrathoracic: - respiratory: pneumonia, pulmonary infarction, pleuritis - cardiovascular: angina pectoris, myocardial infarction, pericarditis - digestive: esophagitis, esophageal carcinoma thoracic wall: osteoarthritis, trauma, intercostal neuralgia, herpes-zoster, ankylosing spondilitis extrathoracic: cervical spondylosis, gallstones, subfrenic abscess  CHEST PAIN ONSET - acute (pneumonia, pneumothorax, pulmonary infarction, pleuritis) - insidious (bronchial carcinoma ) LOCATION/RADIATION - retrosternal, not radiating - tracheitis, laryngitis - retrosternal with radiations - cardiac disorders - anterior - anterior mediastinal disease - apexian - TB or neoplasm - interscapulovertebral pain - aortic aneurysm, mediastinal tumor  CHEST PAIN Aggravating/releaving factors : - pleuritic pain is aggravated by cough and respiration - spinal cord pain is aggravated by mouvement - cardiac pain is aggravated by effort. - aggravating at palpation suggest cellulites, mialgias, neuralgias. - aggravating in alimentary ingestion suggest esophageal disease.  CHEST PAIN Associated simptoms: - Fever, productive cough – pulmonary inflammatory process - Dry cough - pleural process - Haemoptysis – tuberculosis, tumors - Shock - myocardic infarction, pulmonary infarction, pneumothorax  WHEEZE is a musical sound produced by the passage of air through narrowed small airways (bronchial asthma, COPD). It is louder during expiration STRIDOR is an inspiratory sound due to partial obstruction of the upper respiratory tract That obstruction may be due to something within the lumen (foreign body, tumour), within the wall (oedema, laryngospasm, tumour, croup) or extrinsic (goitre, lymphadenopathy). It is a medical (or surgical) emergency if the airway is compromised. THE PHYSICAL EXAMINATION The patient is undressed and in sitting position. The basic steps of the examination are: - Inspection - Palpation - Percussion - Auscultation  INSPECTION 1. Assess the general health of the patient; 2. Respiratory rate: 16-18 f/min Tachypnea: >20 f/min Bradypnea: