Symptoms and signs in Respiratory Medicine PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Symptoms and Signs in Respiratory Medicine Department of Medicine LEARNING OUTCOMES 1. List common respiratory symptoms. 2. List common respiratory signs. 3. Recognise the cardinal signs and symptoms of different types...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Symptoms and Signs in Respiratory Medicine Department of Medicine LEARNING OUTCOMES 1. List common respiratory symptoms. 2. List common respiratory signs. 3. Recognise the cardinal signs and symptoms of different types of common respiratory disease. LEARNING OUTCOME 1 • List common respiratory symptoms. COMMON RESPIRATORY SYMPTOMS • • • • • • • Cough Dysphonia (Hoarseness) Wheeze Stridor Stertor Sputum Haemoptysis(coughing up blood) • • • • • • Dyspnoea (breathlessness) Chest Pain Respiratory Pattern Weight Loss Rigor/Chills Night Sweats COUGH • Coughing is a characteristic sound due to forced expulsion against a closed glottis. • Relatively non-specific, indicates irritation anywhere from the pharynx to the lungs. • Acute cough: < 3 weeks • Subacute: 3-8 weeks • Chronic cough: > 8 weeks • Character of the cough may give clues to underlying cause 1. 2. 3. 4. Chronic dry cough – interstitial lung disease A moist cough – Suggests secretions – Bronchiectasis and lower respiratory tract infections Feeble non-explosive 'bovine' cough with hoarseness – Lung Cancer "Barking" Cough – Croup (Laryngotracheobronchitis) RED FLAG SYMPTOMS ASSOCIATED WITH COUGH • • • • • Haemoptysis (Coughing blood) Breathlessness Fever Chest Pain Weight Loss See lecture "Med - Lung cancer – RESP49" for further reading DYSPHONIA (HOARSENESS) • Most commonly caused by laryngitis. • Damage to the left recurrent laryngeal nerve - impairs the ability of vocal cord to adduct to the midline. • N.B Lung cancer at the left hilum compresses the left recurrent laryngeal nerve causing hoarseness and low pitched "bovine" cough. WHEEZE • High-pitched whistling sound produced by air passing (expired) through narrowed small airways. • Wheeze can be monophonic – single note – signifying partial obstruction e.g., lung mass Polyphonic – multiple notes – signifying widespread narrowing of airways of different calibre (COPD/Asthma) • • • • Can be brought on by exercise – COPD/Asthma Waking at night with wheeze suggest asthma or "cardiac wheeze" in heart failure Wheeze after wakening in the morning suggests asthma See lecture "Med - Asthma – RESP10" for further reading STRIDOR VS STERTOR • Stridor: High pitched harsh inspiratory sound due to partial obstruction of the upper airways. (vocal cords, trachea, bronchus) • 1. 2. 3. Obstruction may be due to Something within the lumen – Foreign body, tumour. Within the wall – oedema from anaphylaxis, acute epiglottitis Extrinsic – Goitre, Oesophageal lymphadenopathy. • Stertor: Muffled "hot potato" speech due to naso- or oropharyngeal blockage – e.g. tonsil abscess (quinsy) SPUTUM • Sputum is mucus produced from the respiratory tract. • The normal lung produces about 100ml of sputum each day, which is normally brought to oropharynx and swallowed. • Changes in colour, volume, taste, smell and consistency can hint at underlying pathology. • Always inspect sputum! (However unpleasant this may be) SPUTUM Type Appearance Cause Purulent Thick yellow/green Infections – pneumonia, abscess Serous Frothy, clear/watery, can be pink Acute Pulmonary oedema Mucoid Clear, grey/white Chronic Obstructive Pulmonary Disease/Asthma Blood Red/ Rusty Red Lung cancer, rusty red – pneumococcal infection HAEMOPTYSIS • Haemoptysis is coughing up blood from the respiratory tract and nearly always requires investigations! • What to clarify? 1. Amount and appearance i.e., blood streaked or clots? Is it associated with purulent sputum? Is it a large or small volume – try to quantify – using teaspoons. 2. Duration and Frequency – Single episode or multiple episodes? 3. Is it associated with any other symptoms such as weight loss, night sweats in malignancy or breathlessness and pleuritic chest pain in pulmonary thromboembolism. DYSPNOEA (BREATHLESSNESS) • From Latin for "hard breathing" • Commonly referred to as "shortness of breath", "difficulty getting enough air in" or "tired breathing" • Questions 1. Mode of onset – lying flat (orthopnoea), sitting up (platypnoea). Waking at night? On exertion? Triggers? 2. Severity of breathlessness – what level of exertion brings on shortness of breath? 3. Associated with pain? Is it Pleuritic (worse on deep breath or cough) MODIFIED MEDICAL RESEARCH COUNCIL (MMRC) DYSPNOEA SCALE Grade Degree of breathlessness related to activities 0 Not troubled by breathlessness except on strenuous exercise 1 Short of breath when hurrying on the level or walking up a slight hill 2 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace 3 Stops for breath after walking about 100 yds or after a few minutes on level ground 4 Too breathless to leave the house, or breathless when undressing CHEST PAIN • Chest pain can be respiratory or cardiac. • The lungs do not cause pain (exclusively autonomic innervation) • • • Pleural pain - Sharp, stabbing pain – worse on inspiration and coughing. eg – Pulmonary embolism Chest wall pain - Sudden and localised after vigorous coughing or trauma. Painful on palpation (does not rule out other causes) eg MSK injury Mediastinal Pain – central, retrosternal and unrelated to inspiration or cough eg irritant dusts. Dull aching that disrupts sleep suggests cancer invading mediastinal lymph nodes RESPIRATORY PATTERN • Ask about changes in the rate or pattern of breathing • Is there respiratory rate increasing or decreasing. • Is there a trigger? Eg: Dust, Dander, Inspiration • Does the patient have daytime sleepiness? If yes, ask the patients partner about apnoea, loud snoring, nocturnal restlessness. NIGHT SWEATS • Drenching sweats unrelated to room temperature, where the patient has to change clothes and bed clothes. Not just sweating at night! • Prolonged symptoms – weeks to months RIGORS (CHILLS) • Bouts of uncontrollable muscular shaking, often with chattering teeth, lasting for minutes • They are associated with rapid temperature rises and may be caused by cytokines and acute-phase proteins resetting hypothalamic temperature set point. • B Symptoms/Constitutional symptoms – Unintentional weight loss, night sweats and fever. - ?Underlying malignancy or systemic involvement in infection for example. WEIGHT LOSS • Weight loss on its own is a very non-specific symptom • May present in non-pulmonary conditions • Questions: 1. Was the weight loss intentional or unintentional? 2. How much weight have they lost and in what period? If unable to quantify – changes in clothing sizes 3. Is the weight loss associated with any other symptoms example B symptoms (night sweats, fever) LEARNING OUTCOME 2 • List common respiratory signs RESPIRATORY SIGNS • General Inspection q q q q q Accessory muscle use Cachexia Cyanosis Altered Mental Status Thoracotomy Scar • Hands q Clubbing q Discolouration of nails and fingers q Signs of CO2 retention RESPIRATORY SIGNS • Closer inspection and palpation q Trachea – central or displaced q Chest Shape • Hyperinflated chest (Barrell chest), pectus excavatum, pectus carinatum. q Chest Expansion – Reduced/normal q Tactile Fremitus – Increased, Decreased, Normal • Percussion q q q q Resonant Hyper resonant Dull Stony dull RESPIRATORY SIGNS • Auscultation q Vesicular vs Bronchial Breathing • Added sounds q Crackles q Wheeze q Pleural Rub GENERAL INSPECTION • Respiratory Rate & Accessory Muscle Use Ø Increase rate - tachypnoea Ø The use of muscles other than those typically used in breathing = accessory muscle use. Eg – SCM, Scalene Ø Indicates increased work of breathing (resp distress) • Cachexia Ø Extreme weight loss and muscle wasting • Cyanosis Ø Peripheral cyanosis – occurs in hypoxaemia and venous stasis. Ø Central cyanosis – occurs when deoxygenated haemoglobin rises above >5 g/dL (more worrying clinical sign than peripheral cyanosis). • Mental Status Ø Agitation or drowsiness may be associated with CO2 retention Ø Confusion also seen in infection GENERAL INSPECTION Cachexia Cyanosis THORACOTOMY SCARS Can be a sign of both pneumonectomy and lobectomy HANDS • Signs of CO2 retention – Bounding pulse – Warm dilated veins in hands – Asterixis – describes the inability to maintain sustained posture with subsequent brief, shock-like, involuntary movements. • Clubbing – Bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and nail bed. • Tar Staining and Nail Discoloration HANDS Asterixis Clubbing Tar Staining TRACHEA • Description: Central or displaced • If pulled towards the abnormal side – Atelectasis, pneumothorax, unilateral fibrosis, pneumonectomy • If pushed away from the abnormal side – Large Pleural Effusion, Tension pneumothorax TRACHEA CHEST SHAPE Barrel Chest Pectus Carinatum and Excavatum CHEST EXPANSION • Description: Normal or reduced • If reduced, state whether symmetrical or unilateral • Symmetrically reduced – Obstructive lung disease – Restrictive lung disease • Unilaterally reduced – Pneumothorax – Pleural effusion TACTILE FREMITUS • Feels the transmission of sound waves (vibrations) from the trachea to the chest wall. • Patient is asked to repeat a certain phrase while the examiner palpates the chest wall. • Increased/ normal/ decreased/ absent • Increased – Only one condition – Consolidation • Decreased or absent – Pleural effusion, pneumothorax, atelectasis TACTILE VOCAL FREMITUS PERCUSSION • Assesses the density of whatever is under the chest wall (doesn't have to be the lung) • Resonant / Hyper–resonant / Dull / Stony Dull • Air > lung > consolidation > fluid PERCUSSION • Resonant – Normal • Hyper Resonant – Pneumothorax, COPD (emphysema) • Dull – Pneumonia, atelectasis, tumour • Stony Dull – Pleural effusion (includes haemothorax, chylothorax, empyema) AUSCULTATION Intensity of breath sounds: • Normal or decreased (decreased in any lung pathology) Nature of Breath Sounds • Vesicular or bronchial Added sounds • • • Wheeze Creps Rub NATURE OF BREATH SOUNDS Vesicular Breath Sounds • • • • Soft, low-pitched sounds. Heard throughout the lungs. These are normal breath sounds. Inspiratory time is 2x longer than expiratory time. Bronchial Breath Sounds • • • Direct transmission of tracheal sounds to the chest wall. i.e. very loud, harsh and clear. Due to consolidation. Inspiratory time is equal to expiratory time. ADDED SOUNDS Wheeze • • • Always an expiratory sound Almost always bilateral Example – COPD, Asthma, Type 1 allergic reaction Creps (Crackles / Rales) • • • Always an inspiratory sound Indicative of fluid in the alveoli Pneumonia, fibrosis, bronchiectasis, pulmonary oedema ADDED SOUNDS Rub • • • • Rare Is heard throughout inspiration and expiration Indicates pleural inflammation Pulmonary infarct, pneumonia, chest drain LEARNING OUTCOME 3 • Recognise the cardinal signs and symptoms of different types of common respiratory disease. PNEUMONIA Symptoms • • • • • • Productive cough, purulent sputum, ± haemoptysis Respiratory rate increased Confusion Fevers (Rigors) Central Cyanosis Pleuritic Chest Pain Signs • • • • Reduced chest expansion Tactile vocal fremitus increased over affected areas Dull percussion Auscultation: decreased intensity vesicular breath sounds or bronchial breathing, coarse creps See lecture on Pneumonia LUNG CANCER Symptoms • • • • • • • Haemoptysis SOB Weight Loss Prolonged dry cough Persistent Hoarseness Night sweats, weight loss, lack of appetite Bone pain, headaches, jaundice (metastases to liver) See lecture on Lung Cancer LUNG CANCER • Findings are variable and often non-specific • Often there are no positive findings on exam General Inspection: • Clubbing • Cachexia • Horner's Syndrome – Ptosis (drooping of the upper eyelid), miosis (constricted pupil), ipsilateral anhidrosis (absence of facial sweating on one side) - Pancoast tumour • Cervical Lymphadenopathy LUNG CANCER Signs of effusion • • • Reduced expansion Stony Dull percussion (suggests pleural effusion or atelectasis) Reduced absent breath sounds SVC Obstruction (Mediastinal Involvement) • • • • Dilated anterior chest veins Distended, non-pulsatile jugular veins +/- Hoarseness Positive Pemberton's sign PEMBERTON'S SIGN ASTHMA Symptoms • • • Intermittent Shortness of breath, Cough, wheeze, chest tightness Nocturnal, occupational, exercise induced symptoms Signs • • • • • Wheeze Difficulty completing full sentences Silent chest in life threatening disease Central Cyanosis Agitation or Drowsiness in severe asthma See lecture on Asthma IDIOPATHIC PULMONARY FIBROSIS Symptoms • • Progressive shortness of breath on exertion initially but eventually at rest also. ± Dry cough Signs • • • • Tachypnoea Finger Clubbing Decreased Chest Expansion Fine inspiratory creps bilaterally See lecture on Pulmonary Fibrosis PULMONARY THROMBOEMBOLISM (PE) Symptoms • • • • • Pleuritic chest pain Shortness of breath Haemoptysis/ Cough ±Symptoms of underlying malignancy ±Unilateral calf swelling and tenderness Common findings • Tachypnoea, tachycardia • Normal chest findings Rare findings • Pleural rub • Signs of right heart failure BRONCHIECTASIS Symptoms • • • • • Productive cough, Copious amounts of purulent sputum Recurrent LRTIs Haemoptysis Chronic/Long history (Years) Signs • • • Clubbing (especially in cystic fibrosis bronchiectasis), Expansion, fremitus, percussion : Non-specific Auscultation: decreased intensity, vesicular BS over affected areas, coarse crepitations over affected areas See Path lecture – Bronchiectasis, Asthma and vasculitis PLEURAL EFFUSION Symptoms • Shortness of breath • Cough Signs • Trachea: Pushed to the opposite side (in larger Pl Eff) • Expansion: decreased on the side of effusion • Tactile Fremitus: decreased over effusion • Percussion: stony dull over the effusion • Auscultation: Decreased or absent breath sounds +/bronchial breathing above a large effusion See Lecture on Pleural Effusion/Pot sessions PNEUMOTHORAX Symptoms • Acute unilateral pleuritic pain • Acute SOB • Any age group • Definite clinical signs (+/- CXR) - confirm diagnosis Signs • Trachea undisplaced or pulled towards – exception: Tension Pneumothorax – trachea pushed to the opposite side • Expansion decreased on the side of pneumothorax • Tactile Fremitus – decreased over the pneumothorax • Percussion – Hyper-resonant • Auscultation: Decreased or absent breath sounds KEY POINTS • • • • • Respiratory symptoms are varied but are common in patients seeking medical attention. Watch out for red flags associated with cough. Approach signs (objective findings) in systematic approach. Start with general inspection, observe hands, neck, face, examine trachea and then anterior to posterior chest. Symptoms and signs together correlate with common medical presentations/diseases. RESOURCES • • Macleod's Clinical Examination, The Respiratory System Oxford Handbook of Clinical Medicine, Chest Medicine