Cough Case Study PDF

A 18-year-old boy with coughing spells Late spring…. MEDICINE OUTPATIENT CLINIC  COUGH Cough is one of the most common symptoms for which patients seek medical attention from primary care physicians  COUGH DEFINITION A cough is a sudden, usual...

A 18-year-old boy with coughing spells Late spring…. MEDICINE OUTPATIENT CLINIC  COUGH Cough is one of the most common symptoms for which patients seek medical attention from primary care physicians  COUGH DEFINITION A cough is a sudden, usually involuntary, expulsion of air from the lungs with a characteristic and easily recognizable sound. Although it is known as the most common symptom of respiratory disorders, it serves the functions of defending the respiratory tract against noxious substances and maintaining airway patency by removing excessive secretions from the air passages.  COUGH CATEGORIES ACUTE: lasting less than three weeks SUBACUTE: lasting three to eight weeks CHRONIC: lasting more than eight weeks  PAST MEDICAL HISTORY Well until approximately 3 weeks before the current presentation when cough and nasal congestion developed and persisted without fever and chills. He took fexofenadine hydrochloride without improvement Fexofenadine hydrochloride, the active ingredient of ALLEGRA, is a histamine H1- receptor antagonist with the chemical name (±)-4-[1 hydroxy-4-[4- (hydroxydiphenylmet hyl)-1- piperidinyl]- butyl]-α, α-dimethyl benzeneacetic acid hydrochloride.  Three days before the current presentation he awoke at night with severe coughing spell, post-tussive emesis and trouble breathing…  Yes, we are at the ER. He awoke coughing like crazy and then vomited.. Now they are examining him…  PHYSICAL EXAMINATION No distress; Temperature 37°C, Blood pressure 152/87 mmHg; Pulse rate 107 bpm; Respiratory rate 18 bpm; Oxygen saturation 100% while he was breathing ambient air Mucosa of the posterior oropharinx: cobblestone appearance, uvula was midline No tonsillar edema or exudate Nasal congestion, boggy nasal mucosa and serous effusion behind both tympanic membranes were evident  PHYSICAL EXAMINATION The lungs were clear on auscultation and the remainder of the examination was normal  A diagnosis of allergic rhinitis with the upper- airway cough syndrome (post nasal drip) was made and fluticasone proprionate nasal spray was prescribed… The patient continued to cough but was able to attend school…That night he awoke from sleep with an episode of severe coughing lasting 10 min associated with two episodes of vomiting… Yes, we are again at the ER. He coughed like crazy for 10 min and then vomited twice.. He feels better now and they are examining him…  PHYSICAL EXAMINATION No chest pain, fever night sweats or weight loss Temperature 36.8°C, Blood pressure 151/87 mmHg; Pulse rate 93 bpm; Respiratory rate 18 bpm; Oxygen saturation 97% while he was breathing ambient air Mild nasal congestion and erythema of the posterior pharinx The remainder examination was normal A diagnosis of broncospasm was made  TREATMENT Dexamethasone + Albuterol inhaler Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs  During the next 2 days the cough persisted without paroxysms. The patient reported epistaxis during the coughing episodes and the parents reported that they thought he was chocking during the episodes….. EPISTAXIS ETIOLOGY OF EPISTAXIS The patient did not have: headaches, hearing problems, chest pain, shortness of breath other than with coughing, abdominal pain, diarrhea, constipation. He had a history of elevated systolic blood pressure. He took no medication. He was fully immunized with childhood vaccines (difhteria, tetanus, acellular pertussis, haemophilus influenzae, hepatitis B, measles, mumps and rubella in infancy and early childhood, and meningococcus at 11 and 16 years of age). He had no known allergies to medications, occasionally drank alcohol and smoked cigarettes. His father had hypertension and his mother who was receiving chemotherapy for cancer had a dry non productive cough of 4 weeks duration  Physical examination The patient appeared well; Blood pressure 140/79 mmHg right arm and 119/72 left arm; Pulse 83 bpm; Temperature 36.5°C Oxygen saturation 99% Examination of the chest: decreased breath sound on the right side The remainder examination was normal  Chemistries WBC 8200/mcl with Neutrophil 46% (40-62%) Lymphocytes 42.6% (27-40%) Monocytes 8.9% (4-11%) Eosinophils 1.6% (0-8%) Basophils 0.6% (0-3%) Hematocrit, hemoglobin level, platelet count were normal and a Chest radiograph was again normal  provide clues for focusing the physical examination and the development of an appropriat TE C O diagnostic evaluation. Questions regarding medication use (prescription and over-the counter preparations) as well as complementary and alternative therapies are relevant fo each. E Y N T O HISTORY OF PRESENT ILLNESS PL R Coughing E Onset: sudden, gradual; duration Nature of cough: dry, moist, wet, hacking, hoarse, barking, whooping, bubbling, pro ductive, nonproductive Sputum production: duration, frequency, with activity, at certain times of day Sputum characteristics: amount, color (clear, mucoid, purulent, blood-tinged, mostl M blood), foul odor Pattern: occasional, regular, paroxysmal; related to time of day, weather, activities (e.g exercise), talking, deep breaths; change over time Severity: tires patient, disrupts sleep or conversation, causes chest pain Associated symptoms: shortness of breath, chest pain or tightness with breathing, fever coryza, stuffy nose, noisy respirations, hoarseness, gagging, choking, stress Efforts to treat: prescription or nonprescription drugs, vaporizers; effectiveness Shortness of breath (Box 13-2) Onset: sudden or gradual; duration; gagging or choking event before onset Pattern  COUGH Cough, with or without obvious wheezing, can be a symptom of asthma or the upper-airway cough syndrome, either of which might be triggered by an upper respiratory tract infection. The paroxysms of cough in this case were more severe than would be expected in a patient with one of these conditions. This patient was overweight, which may increase the likelihood of gastroesophageal reflux disease, and he smoked occasionally. However, the acute onset of his symptoms and the severity of the coughing episodes make smoking and gastroesophageal reflux disease unlikely explanations. There is no history of foreign-body aspiration or loss of consciousness. The chest radiograph does not show evidence of underlying lung disease, which would be expected in a patient with cystic fibrosis, chronic cardiopulmonary disease, or interstitial lung disease. INFECTION  COUGH CHARACTERISTICS Describe a cough according to its moisture, frequency, regularity, pitch and loudness, quality and circumstances. The type of cough may offer some clue to the cause. Although a cough may not have a serious cause, do not ignore it. Dry or Moist. A moist or productive cough may be caused by infection and can be accompanied by sputum production. A dry or non-productive cough can have a variety of causes (e.g., cardiac problems, allergies), which may be indicated by the quality of its sound. Onset. An acute onset, particularly with fever, suggests infection; in the absence of fever, a foreign body or inhaled irritants are additional possible causes. Frequency of Occurrence. Note whether the cough is seldom or often present. An infrequent cough may result from allergens or environmental insults. Regularity. A regular, paroxysmal cough is heard in pertussis. An irregularly occurring cough may have a variety of causes (e.g., smoking, early congestive heart failure, an inspired foreign body or irritant, or a tumor within or compressing the bronchial tree). Pitch and Loudness. A cough may be loud and high-pitched or quiet and relatively low- pitched. Postural Influences. A cough may occur soon after a person has reclined or assumed an erect position (e.g., with a nasal drip or pooling of secretions in the upper airway). Quality. A dry cough may sound brassy if it is caused by compression of the respiratory tree (as by a tumor) or hoarse if it is caused by croup. Pertussis produces an inspiratory whoop at the end of a paroxysm of coughing in older children and adults.  TREATMENT Azithromycin. (suspension, tablets, and capsules). It is administered as a single daily dose. Recommended regimen: Infants aged 6 months: 10 mg/kg (maximum: 500 mg) on day 1, followed by 5 mg/kg per day (maximum: 250 mg) on days 2- -5. Adults: 500 mg on day 1, followed by 250 mg per day on days 2--5. Side effects include abdominal discomfort or pain, diarrhea, nausea, vomiting, headache, and dizziness. Azithromycin should be prescribed with caution to patients with impaired hepatic function.  A 67-year-old male with a 2-year history of cough….. It is worse at night and it is not productive…. The cough had begun after an upper respiratory tract infection and a trip to South America…  Yes, you take the antibiotics for a week and then you call me again  A couple of weeks later…. Doc, I have still an annoying cough.. You’d better use a combination inhaler (salmeterol and fluticasone)….. This patient has chronic cough, which is defined as a cough lasting more than 8 weeks.  Although the long duration of cough may suggest mild asthma, this condition should have improved substantially with the correct use of a  PAST MEDICAL HISTORY He smoked 10 cigarettes a day He experienced every year a couple of episodes of cough and difficult breathing especially during fall and winter  Your ANA test, (rheumatoid factor, extractable nuclear antigens, and anti– cyclic citrullinated peptide antibodies) and HLA-B27 are negative… A tuberculin skin test and ultrasonography of the abdomen were also negative. Additional medical history included pitting edema in the lower limbs bilaterally for the past 2 years (attributed to venous stasis), for which the patient used compression stockings. There was no other clinically significant medical history. He had no pets. His only medications was the inhaler tuberculin skin test  Other signs… Additional medical history included pitting edema in the lower limbs bilaterally for the past 2 years (attributed to venous stasis), for which the patient used compression stockings. There was no other clinically significant medi-cal history. He had no pets. His only medications was the inhaler. Pitting edema  However…. Chest x-ray showed…  Physical examination INSPECTION Note the shape and symmetry of the chest from both the back and the front, the costal angle, the angle of the ribs, and the intercostal spaces. The AP diameter of the chest is ordinarily less than the lateral diameter, at times by as much as half.  Right Right Posterior anterior midclavicular Thyroid cartilage axillary axillary line line line Trachea First rib Right upper lobe Suprasternal Midaxillary notch line Angle of Right Louis middle lobe Left upper AL lobe Right lower Left lobe lower N lobe R FI Midsternal Anterior axillary A B - N IE line line T Vertebral T V line Spinal O Right processes N E upper lobe S Left TE L upper Scapula lobe N E Right middle FIGURE 13-9 lobe F Barrel chest. Note increase in O the anteroposterior diameter. Left Right lower lower lobe lobe Y  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 CHAPTER 13 Chest and Lungs 13 Cross section Cross section of thorax of thorax Posterior Posterior FIGURE 13-12 AL A, Anterior Anterior B, Pectus excavatum (funnel N the child’s poor posture, A B potbelly, and sunken chest. R FI IE T EV O east somewhat kyphotic, and the sternal angle is more prominent. The trachea may  Normal Air trapping Regular and comfortable at a Increasing difficulty in rate of 12-20 per minute getting breath out Bradypnea Cheyne-Stokes Slower than 12 breaths Varying periods of increasing per minute depth interspersed with apnea Tachypnea Kussmaul AL Faster than 20 breaths per minute Rapid, deep, labored N Hyperventilation (hyperpnea) Biot N R FI Faster than 20 breaths Irregularly interspersed periods E per minute, deep breathing of apnea in a disorganized sequence of breaths T VI Sighing Ataxic ns. es O Frequently interspersed Significant disorganization with SE deeper breath irregular and varying depths of respiration  http://www.us.elsevierhealth.com/product.jsp?isbn=9 CHAPT BOX 13-4 I N FLUEN CES ON T H E RAT E AN D D EPT H OF BREAT H IN G The rate and depth of breathing will: Increase With Decrease With Anxiety Myasthenia gravis Aspirin poisoning Narcotic overdoses Pain BOX 13-5 BOX 13-5 - N IE A PN EA T Apnea, the absence of spontaneous respiration, may have its origin in the respiratory T V system and, as well, in a variety of central nervous system and cardiac abnormalities. O N E a variety of infections of the respiratory passageway, drug ingestions, and obstructive sleep disorders. S Primary apnea A self-limited condition, and not uncommon after a blow to the TE L head. It is especially noted immediately after the birth of a N E carbon dioxide accumulates in the circulation. Secondary apnea Breathing stops and it will not begin spontaneously unless O F resuscitative measures are immediately instituted. Any event that severely limits the absorption of oxygen into the C O bloodstream will lead to secondary apnea. When irritating and nausea-provoking vapors or gases are inhaled, there can be an involuntary, temporary halt to respiration. Sleep apnea Y LE T maintained through the nose and mouth. R Apneustic breathing expiration apnea. The neural center for control is in the pons. PE When it is affected, breathing can become gasping because inspirations are prolonged and expiration constrained. Periodic apnea of the newborn breathing interspersed with brief periods of apnea that one O usually associates with rapid eye movement sleep.  PALPATION Palpate Palpate the thoracic the thoracic muscles muscles and skeleton, and skeleton, feelingfeeling for pulsation for pulsations, areasdepressions, masses, of tenderness, bulges,and unusual movement. depressions, masses, and Expect unusualbilateral movement Crepitus, a crackly or crinkly sensation, can be both palpated and heard—a gentle, bubbly feeling. It indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism. It may be localized (e.g., over the suprasternal notch and base of the neck) or cover a wider area potentially involving the arms and face with the associated swelling mimicking an allergic reaction. Crepitus always requires attention. Pleural friction rub : A palpable, coarse, grating vibration, usually on inspiration, suggests a caused by inflammation of the pleural surfaces. Think of it as the feel of leather rubbing on leather. To evaluate thoracic expansion during respiration, stand behind the patient and place your thumbs along the spinal processes at the level of the tenth rib, with your palms lightly in contact with the posterolateral surfaces. Watch your thumbs diverge during quiet and deep breathing. A loss of symmetry in the movement of the thumbs suggests a problem on one or both sides. A barrel-chested patient with chronic obstructive pulmonary disease may not demonstrate this. The chest is so inflated that it cannot expand further and your hands may even come together a bit. Tactile fremitus. the palpable vibration of the chest wall that results from speech or other verbalizations. Fremitus is best felt parasternally at the second inter- costal space at the level of the bifurcation of the bronchi. There is great variability depending on the intensity and pitch of the voice and the structure and thickness of the chest wall. In addition, the scapulae obscure fremitus.  TACTILE FREMITUS http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 18 CHAPTER 13 Chest and Lungs AL A B FIGURE 13-14 FIGURE 13-15 N Palpating thoracic expansion. The thumbs Two methods for evaluating tactile fremitus. A, With palmar surface of both hands. N ER FI are at the level of the tenth rib. B, With ulnar aspect. T VI O EVIDENCE-BASED PRACTICE IN PHYSICAL EXAMINATION SE I S T H ERE A PLEURAL EFFUSION ?  C E PERCUSSION E PL M A B A, Direct percussion using B, Indirect percussion.  PERCUSSION Compare all areas bilaterally, using one side as a control for the other. The following sequence serves as one model. First, examine the back with the patient sitting with head bent forward and arms folded in front. This moves the scapulae laterally, exposing more of the lung. Then ask the patient to raise the arms overhead while you percuss the lateral and ante- rior chest. For all positions, percuss at 4- to 5-cm intervals over the intercostal spaces, moving systematically from superior to inferior and medial to lateral. This sequence is one of many that you may follow. Adopt the one most comfortable for you and use it consistently. Resonance, the expected sound, can usually be heard over all areas of the lungs. Hyperresonance associated with hyperinflation may indicate emphysema, pneumo- thorax, or asthma. Dullness or flatness suggests pneumonia, atelectasis, pleural effusion, pneumothorax, or asthma. Tympany is the sound usually associated with percussion over the abdomen.  AUSCULTATION Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura. All sounds can be characterized in the same manner as the percussion notes: intensity, pitch, quality, and duration. The diaphragm of the stethoscope is usually preferable to the bell for listening to the lungs because it transmits the ordinarily high-pitched sounds better and because it provides a broader area of sound  Breath Sounds Breath sounds are made by the flow of air through the respiratory tree. They are characterized by pitch, intensity, quality, and relative duration of their inspiratory and expiratory phases, and are classified as: vesicular, bronchovesicular, bronchial (tubular) Vesicular breath sounds are low-pitched, low-intensity sounds heard over healthy lung tissue. Bronchovesicular sounds are heard over the major bronchi and are typically moderate  E P PL SA O TABLE 13-2 Characteristics of Normal Breath Sounds PR Sound Characteristics Findings M soft and short expirations (see Figs. 13-22 person or a child, diminished in the overweight or very muscular patient Bronchovesicular Heard over main bronchus area and over Bronchial/tracheal Heard only over trachea; high pitch; loud and long expirations, sometimes a bit longer than inspiration  S TE L - N E T N O F C OY LE T R FIGURE 13-2 Auscultation w stethoscope. Auscultation with a stethoscope.  CHAPTER 13 Ch ILL WELL Rhonchi: coarse low-pitched; Bronchial: coarse, loud may clear with cough Bronchovesicular: Wheeze: whistling, combination bronchial high-pitched bronchus and vesicular, normal in some areas Bronchial: coarse, loud; heard with consolidation Vesicular: low-pitched, Rub: scratchy, high-pitched breezy Crackles: fine crackling, high-pitched R IE FIGURE 13-23 T Schema of breath sounds in the ill and well patient. EV O  TE L A DVEN T IT IOUS BREAT H SOUN DS - N E T Fine crackles: high-pitched, discrete, discontinuous crackling sounds heard N O F during the end of inspiration; not cleared by a cough C O Medium crackles: lower, more moist sound heard during the midstage of inspiration; not cleared by a cough E Y Coarse crackles: loud, bubbly noise heard during inspiration; not cleared by a cough T PL R sounds like a snore most often heard continuously during inspiration or M E expiration; coughing may clear sound (usually means mucus accumulation in P SA O continuously during inspiration or PR expiration; usually louder during expiration Pleural friction rub: dry, rubbing, or grating pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface  Crackle A crackle is an abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds, each lasting just a few milliseconds. The individual noise tends to be brief and the interval to the next one similarly brief. Crackles may be fine, high pitched, and relatively short in duration; or coarse, low pitched, and relatively longer in duration. They are caused by the disruptive passage of air through the small airways in the respiratory tree. High-pitched crackles are described as sibilant; the more low-pitched crackles are termed sonorous. Crackles with a dry quality, more crisp than gurgling, are apt to occur higher in the respiratory tree. You might listen for crackles at the open mouth. If their origin is in the upper airways, they will be easily heard; if in the lower, not so easily.  RHONCHI Rhonchi (sonorous wheezes) are deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles. They are caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth or external pressure. The more sibilant, higher- pitched rhonchi arise from the smaller bronchi, as in asthma; the more sonorous, lower-pitched rhonchi arise from larger bronchi, as in tracheobronchitis. All rhonchi may at times be palpable. It may be difficult to distinguish between crackles and rhonchi. In general, rhonchi tend to disappear after coughing, whereas crackles do not. If such sounds are present, listen to several respiratory excursions: a few with the patient’s accustomed effort, a few with deeper breathing, a few before coughing and a few after.  WHEEZES A wheeze (sibilant wheeze) is sometimes thought of as a form of rhonchus. It is a continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration. It is caused by a relatively high-velocity air flow through a narrowed or obstructed airway. The longer the wheeze and the higher the pitch, the worse the obstruction. Wheezes may be composed of complex combinations of a variety of pitches or of a single pitch, and they may vary from area to area and minute to minute. If a wheeze is heard bilaterally, it may be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis. Unilateral or more sharply localized wheezing or stridor may occur with a foreign body. A tumor compressing a part of the bronchial tree can create a consistent wheeze or whistle of single pitch at the site of compression.  FRICTION RUB It occurrs outside the respiratory tree. It has a dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration. It may have a machine-like quality. It may have no significance if heard over the liver or spleen; however, a friction rub heard over the heart or lungs is caused by inflamed, roughened surfaces rubbing together. Over the pericardium, this sound suggests pericarditis; over the lungs, pleurisy. The respiratory rub disappears when the breath is held; the cardiac rub does not.  C BOX 13-9 E SUMMARY OF EX PECT ED FIN DIN GS OF THE C H EST AN D LUN GS PL When the lungs are healthy, the respiratory tree clear, the pleurae unaffected by disease, and the chest wall symmetrically and appropriately structured and mobile, the following characteristics will be found: and the more prominent bronchial components in the area of the larger bronchi 34 CHAPTER 13 Chest and Lungs TABLE 13-4 Physical Findings Associated With Common Respiratory Conditions* Condition Inspection Palpation Percussion Auscultation Asthma Tachypnea Tachycardia Prolonged expiration Diminished fremitus hyperresonance Intercostal retractions Diminished lung sounds diaphragmatic descent; diaphragmatic level lower Atelectasis Delayed and/or diminished Diminished fremitus Dullness over affected In upper lobe, bronchial chest wall movement Apical cardiac impulse deviated lung breathing, egophony, ipsilaterally intercostals spaces on Trachea deviated ipsilaterally In lower lobe, diminished or AL affected side absent breath sounds Tachypnea crackles in varying amounts N depending on extent of collapse R FI Bronchiectasis Tachypnea A variety of crackles, usually Respiratory distress there are no coarse; and rhonchi, - N IE accompanying sometimes disappearing after pulmonary disorders cough T Bronchitis Tactile fremitus undiminished Resonance Breath sounds may be T V prolonged O Chronic Respiratory distress E Somewhat limited mobility of Postpertussive rhonchi EN S obstructive diaphragm hyperresonance EL pulmonary Cyanosis Somewhat diminished vocal disease Distention of neck veins, fremitus Inspirational crackles (best peripheral edema (in heard with stethoscope held presence of right-sided Breath sounds somewhat F Clubbing, rarely diminished Emphysema Tachypnea Apical impulse may not be felt Hyperresonance Diminished breath and voice Deep breathing Liver edge displaced downward Limited descent of sounds with occasional  peripheral edema (in heard with stethoscope held presence of right-sided N Breath sounds somewhat O F Clubbing, rarely diminished TE Emphysema Tachypnea Apical impulse may not be felt Hyperresonance Diminished breath and voice C O Deep breathing Liver edge displaced downward Limited descent of sounds with occasional Pursed lips Diminished fremitus diaphragm on prolonged expiration Barrel chest inspiration Diminished audibility of heart E Y N Thin, underweight sounds dullness pushed T downward sounds Pleural effusion Diminished and delayed Diminished and delayed Diminished to absent breath PL R and/ or thickening on affected side respiratory movement on affected side Hyperresonant note in area superior to sounds Bronchophony, whispered M E Cardiac apical impulse shifted effusion contralaterally Egophony and/or crackles in P Trachea shifted contralaterally area superior to effusion Diminished fremitus SA O Tachycardia Pneumonia Tachypnea Increased fremitus in presence Dullness if A variety of crackles with PR consolidation Shallow breathing of consolidation consolidation is great lobar and occasional rhonchi Flaring of alae nasi Decreased fremitus in presence Bronchial breath sounds of a concomitant empyema or Egophony, bronchophony, Limited movement at times pleural effusion on involved side; splinting Tachypnea Pneumothorax Tachycardia Diminished to absent fremitus Hyperresonance Diminished to absent breath Cyanosis Cardiac apical impulse, trachea, sounds Respiratory distress and mediastinum shifted Succussion splash audible if air Bulging intercostal spaces contralaterally Respiratory lag on affected Diminished to absent tactile Sternal and precordial clicks side fremitus Tracheal deviation with Tachycardia if air underlies that area tension pneumothorax Subcutaneous crepitance from Diminished to absent air leaking whispered voice sounds *Physical findings will vary in intensity depending on the severity of the underlying problem and on occasion may not be present in the early stages.  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 CHAPTER 13 Chest and Lungs 35 ASTHMA (REACTIVE AIRWAY DISEASE) Small airway obstruction due to inflammation and hyperreactive airways. Pathophysiology History Objective Data Acute episodes triggered by allergens, anxiety, Episodes of paroxysmal dyspnea and Tachypnea with wheezing on cold air, exercise, upper respiratory cough expiration and inspiration infections, cigarette smoke, or other Chest pain is common and, with it, a Expiration becomes more environmental agents feeling of tightness. prolonged with labored Result in mucosal edema, increased Episodes may last for minutes, hours, or breathing, fatigue, and anxious secretions, and bronchoconstriction with days. expression as airway resistance increased airway resistance and impeded May be asymptomatic between episodes increases. respiratory flow Hypoxemia by pulse oximetry Decreased peak expiratory flow AL rate Foreign Body Think about the possibility N of a foreign body when a ER patient, particularly a FI youngster, presents with Video/Animation The history may not at T VI O  Video/Animation The history may not at T NV N NE S O N S-E ATELECTASIS O FE L N The incomplete expansion of the lung at birth or the collapse of the lung at any age (Fig. 13-26). C NOT E ATELECTASIS TE L T - Pathophysiology Subjective Data Objective Data Collapse causedThe incomplete expansion by compression from of the lung at birth Frequently seen or in the thecollapse of the lung at any postoperative age (Fig. 13-26). Auscultation dampened or muted in the TY F Pathophysiology outside (e.g., exudates, tumors) or setting Subjective Data Objective involved Data the affected area of area because Collapse resorption of gas from the caused alveoliby incompressionSymptoms from ofFrequently seen in the postoperative the lungAuscultation postobstructive is airless dampened or muted in the PL CR O outside (e.g., exudates, tumors) or setting involved area because the affected area o the presence of complete internal pneumonia may develop in the setting Radiograph may show consolidation resorption of gas from the alveoli in Symptoms of postobstructive the lung is airless obstruction the presence of complete internal of airway obstruction from foreign pneumonia may develop in the setting associated with a postobstructive Radiograph may show consolidation M PEE TY Loss of elastic recoilobstruction of the lung may body or tumor. of airway obstruction from foreign pneumonia. associated with a postobstructive be due to thoracic Loss or abdominal of elastic recoil of the lung may body or tumor. pneumonia. surgery, plugging, exudates, or foreign be due to thoracic or abdominal E O body. surgery, plugging, exudates, or foreign SA PO R body. MR EP L SA O PR P FIGURE 13-26 A B Atelectasis. (Modified from Wilson FIGURE and Thompson, 1990.) 13-26  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 36 CHAPTER 13 Chest and Lungs BRONCHITIS Inflammation of the large airways. Pathophysiology Subjective Data Objective Data Inflammation of the bronchial tubes Acute bronchitis may be accompanied Minimal auscultation findings with no leads to increased mucous secretions by fever, hacking nonproductive respiratory distress (Fig. 13-27). cough, and chest pain. Greater involvement may lead to Acute bronchitis is usually due to an In chronic bronchitis, the cough may wheezing or dampened auscultation in infection, while chronic bronchitis is be productive. the involved areas. usually due to irritant exposure. AL Mucus secretions in bronchial tree N R FI - N IE T EV O LS FIGURE 13-27 Acute bronchitis. (From Wilson and Thompson, 1990.)  FIGURE 13-27 Acute bronchitis. (From Wilson and TE L - Thompson, 1990.) N E T PLEURISY N O F An inflammatory process involving the visceral and parietal pleura that becomes edematous and fibrinous (Fig. 13-28). C O Pathophysiology Subjective Data Objective Data Often the result of pulmonary Usually sudden onset with chest pain Respirations are rapid and shallow with E Y infections (bacterial or viral) or when taking a breath (pleuritic) diminished breath sounds. connective tissue diseases (e.g., lupus). Rubbing of the pleural surfaces can be A pleural friction rub can be auscultated. T Sometimes associated with neoplasm or asbestosis. felt by the patient. Pain can be referred to the ipsilateral Fever may be present. PL R shoulder if the pleural inflammation is close to the diaphragm. M EP SA O Parietal pleura Visceral pleura PR Fluid Fluid Fluid Fluid FIGURE 13-28 Pleurisy. (Modified from Wilson and Thompson, 1990.)  CHAPTER 13 Chest and Lungs 37 PLEURAL EFFUSION Excessive non-purulent fluid in the pleural space (Fig. 13-29). Pathophysiology Subjective Data Objective Data Sources of fluid vary and include Cough with progressive dyspnea is the The findings on auscultation and infection, heart failure, renal typical presenting concern. percussion vary with the amount of fluid insufficiency, connective tissue disease, Pleuritic chest pain will occur with an present and also with the position of the neoplasm, and trauma. inflammatory effusion. patient. Dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. When the fluid is mobile; it will gravitate AL to the most dependent position. In the affected areas, the breath sounds are muted and the percussion note is often hyperresonant in the area above the N perfusion. R FI - N IE T T V O SE Effusion EL FIGURE 13-29  N FIGURE 13-29 O F Pleural effusion. (Modified from Wilson and Thompson, 1990.) TE C O EMPYEMA E Y N Purulent exudative fluid collected in the pleural space (Fig. 13-30). T Pathophysiology Subjective Data Objective Data PL R Non–free-flowing purulent fluid collection develops most commonly The patient is often febrile and tachypneic, with cough and chest pain, Breath sounds are distant or absent in the affected area. M E from adjacent infected or sometimes and appears ill. Percussion note is dull and vocal fremitus traumatized tissues. Progressive dyspnea develops. is absent. P May be complicated by pneumonia, Cough may produce blood or sputum. SA O simultaneous pneumothorax, or a bronchopleural fistula PR Pus Pus FIGURE 13-30 Empyema. (Modified from Wilson and Thompson, 1990.)  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 38 CHAPTER 13 Chest and Lungs LUNG ABSCESS A well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis (Fig. 13-31). Pathophysiology Subjective Data Objective Data Aspiration of food or infected material Patient is usually obviously ill with Percussion note is dull and the breath from upper respiratory or dental malaise, fever, and shortness of breath. sounds distant or absent over the affected sources of infection are most common area. causes. Pleural friction rub may be auscultated. It may elude diagnosis for a some Cough may produce purulent, foul- time. smelling sputum. AL N Abscess R FI - N IE T EV O FIGURE 13-31 LS Lung abscess. (Modified from Wilson and Thompson, 1990.)  N E T PNEUMONIA N An inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral) (Fig. 13-32). O F Pathophysiology Subjective Data Objective Data TE C O Acute infection of the pulmonary Rapid onset (hours to days) of cough, Febrile, tachypneic, and tachycardic parenchyma may be due to a variety of pleuritic chest pain, and dyspnea Crackles and rhonchi are common with organisms, which depend in part on Sputum production is common with diminished breath sounds. E Y the setting in which the pneumonia bacterial infection. Egophony, bronchophony, and whisper T was acquired (community vs. Chills, fever, rigors, and nonspecific pectoriloquy hospital). abdominal symptoms of nausea and Dullness to percussion occurs over the PL R The infection and concomitant inflammatory exudates lead to lung vomiting may be present. Involvement of the right lower lobe area of consolidation. M E consolidation. can stimulate the tenth and eleventh thoracic nerves to cause right lower P quadrant pain and simulate an SA O abdominal process. Pneumonia In children particularly, but PR also in adults, audible crackles are not necessary to give evidence of pneumonia. Flaring of the alae nasi, tachypnea, and a possibly productive cough in the absence of crackles and out of proportion to should alert you to the possibility of acute bacterial pneumonia. FIGURE 13-32 (Modified from Wilson and Thompson, 1990.)  CHAPTER 13 Chest and Lungs 39 INFLUENZA A viral infection of the lung. While this is normally an upper respiratory infection, due to alterations in the epithelial barrier, the infected host is more susceptible to secondary bacterial infections (Fig. 13-33). Pathophysiology Subjective Data Objective Data When mild, it may seem to be just a Characterized by cough, fever, malaise, Crackles, rhonchi, and tachypnea are cold; however, the aged, the very headache, coryza, and mild sore common. young, and the chronically ill are throat, typical of the common cold. particularly susceptible. Significant respiratory distress can Entire respiratory tract may be develop, leading to high morbidity. overwhelmed by interstitial inflammation and necrosis extending Enlarged area AL throughout the bronchiolar and alveolar tissue. Edema Bronchioles Blood N R FI - N IE T T V O Mucus N ES EL Smooth muscle contraction of bronchioles F FIGURE 13-33  (Modified from Wilson and Thompson, 1990.) TE C O TUBERCULOSIS E Y N A chronic infectious disease that most often begins in the lung but may then have widespread manifestations (Fig. 13-34). T O Pathophysiology Subjective Data Objective Data PL R The tubercle bacillus is inhaled from Latent period: asymptomatic, some Latent disease: no pulmonary findings the airborne moisture of the coughs regional lymph nodes may be involved Active disease: consolidation and/or M E and sneezes of infected persons, P Active infection: fever, cough, weight pleural effusion may develop with infecting the recipient’s lung. loss, night sweats corresponding findings and cough with Latent period is when the organism History of travel to region with blood-streaked sputum SA O entrenches itself. endemic tuberculosis or close contact Positive tuberculin skin test There is always the potential for a with infected person PR post-primary spread locally or throughout the body. FIGURE 13-34 Tuberculosis. (Modified from Wilson and Thompson, 1990.) PNEUMOTHORAX The presence of air or gas in the pleural cavity (Fig. 13-35). Pathophysiology Subjective Data Objective Data May result from trauma or may occur Minimal collections of air may easily The breath sounds over the spontaneously, perhaps because of be without symptoms at first, pneumothorax are distant. rupture of a congenital or acquired particularly because spontaneous A mediastinal shift with tracheal deviation bleb pneumothorax paradoxically has its can be seen with a tension pneumothorax. In tension pneumothorax, air leaks onset most often when the patient is at continually into the pleural space, rest. resulting in a potentially life- Larger collections provoke dyspnea threatening emergency from increasing and chest pain. pressure in the pleural space. AL N Minimal Pneumothorax Collapsed lung O R FI An unexplained but persistent tachycardia may - N IE be a clue to a minimal T pneumothorax that will T V Air accumulation not otherwise be detected on physical examination. E Depressed EN S diaphragm EL FIGURE 13-35 F Pneumothorax.  N FIGURE 13-35 O F Pneumothorax. TE C O HEMOTHORAX E TY N The presence of blood in the pleural cavity (Fig. 13-36). Pathophysiology Subjective Data Objective Data PL R May be the result of trauma or Dyspnea and symptoms of Breath sounds will be distant or absent if invasive medical procedures (e.g., M PE hypovolemia may develop depending blood predominates. thoracentesis, central line placement or on the degree and acuity of blood loss Percussion note will be dull. attempt, pleural biopsy) and decreased pulmonary function. When air is present with the blood; SA O this is called a hemopneumothorax. PR Injury to chest wall Hemorrhage FIGURE 13-36 Hemothorax. (Modified from Wilson and Thompson, 1990.) LUNG CANCER Generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures (Fig. 13-37). Pathophysiology Subjective Data Objective Data Etiologic agents include tobacco smoke, May cause cough, wheezing, a variety of Findings are based on the extent of the asbestos, ionizing radiation, and other patterns of emphysema and atelectasis, tumor and the patterns of its invasion and inhaled carcinogenic agents. pneumonitis, and hemoptysis metastasis. Peripheral tumors without airway With airway obstruction, a obstruction may be asymptomatic. postobstructive pneumonia can develop with consolidation. A malignant pleural effusion may develop with corresponding findings. AL N O R FI A B - N IE T T V E EN S EL FIGURE 13-37 F Cancer of the lung. A, cell carcinoma. B, O C D C, Adenocarcinoma. D, Large cell carcinoma.  FIGURE 13-37 O F Cancer of the lung. A, cell carcinoma. B, TE C O C D C, Adenocarcinoma. D, Large cell carcinoma. E Y N COR PULMONALE T An acute or chronic condition involving right-sided heart failure (Fig. 13-38). PL R Pathophysiology Subjective Data Objective Data M PE In acute phase, the right side of the heart is dilated and fails, most often as a direct result of pulmonary embolism. Dyspnea, fatigue, lightheadedness and potentially syncope, are related to the developing pulmonary hypertension. Right-sided heart failure with a right ventricular heave Elevated jugular venous pulsation and SA O In chronic cor pulmonale, gradual lower extremity edema hypertrophy of the right ventricle PR progresses until ultimate heart failure. Pulmonary emphysema Pulmonary emphysema Right ventricular hypertrophy FIGURE 13-38 Cor pulmonale. Notice extensive pulmonary emphysema and right ventricular hypertrophy. (Modified from Wilson and Thompson, 1990.)  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 42 CHAPTER 13 Chest and Lungs PULMONARY EMBOLISM The embolic occlusion of pulmonary arteries is a relatively common condition that is very difficult to diagnose. Pathophysiology Subjective Data Objective Data Risk factors include, among others, age Pleuritic chest pain with or without There may be a low-grade fever or an older than 40 years, a history of dyspnea is a major clue to embolism. isolated tachycardia. venous thromboembolism, surgery Hypoxia by pulse oximetry may be with anesthesia longer than 30 evident. minutes, heart disease, cancer, fracture of the pelvis and leg bones, obesity, and acquired or genetic thrombophilia. Video/Animation AL N R FI IE INFANTS, CHILDREN, AND ADOLESCENTS T CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD is a nonspecific designation that includes a group of respiratory problems in which coughs, chronic and often excessive sputum production, and dyspnea are prominent features. Ultimately, an irreversible expiratory airflow obstruction occurs. Chronic bronchitis, bronchiectasis, and emphysema are the main conditions that are included in this group. One need not be an older adult to have one of these problems. Most patients, however are certainly not young and most patients have been smokers. A careful history will reveal a legacy of episodes of coughs and sputum and limited tolerance for exercise be an older adult, of course, to have one of these problems. Most patients, however, are certainly not young, and most patients have been smokers. A careful history will reveal a legacy of episodes of coughs and sputum and limited tolerance for exercise. EMPHYSEMA A condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function (Fig. 13-41). Pathophysiology Subjective Data Objective Data Most patients have an extensive Dyspnea is common even at rest, Chest may be barrel shaped, and scattered smoking history. requiring supplemental oxygen when crackles or wheezes may be heard. Chronic bronchitis is a common severe. Overinflated lungs are hyperresonant on precursor leading to dilation of the air Cough is infrequent without much percussion. spaces beyond the terminal production of sputum. Inspiration is limited with a prolonged bronchioles and rupture of alveolar expiratory effort (i.e., longer than 4 or 5 walls, permanently hyperinflating the onds) to expel air. lung. AL Alveolar gas is trapped, essentially in expiration, and gas exchange is seriously compromised. N R FI - N IE T T V O E EN S EL FIGURE 13-41 Chronic obstructive pulmonary disease with lobar emphysema. (Modified from Wilson and Thompson, 1990.) F O BRONCHIECTASIS  FIGURE 13-41 N E Chronic obstructive pulmonary disease with lobar T emphysema. (Modified from Wilson and Thompson, N 1990.) O F TE C O BRONCHIECTASIS Chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction E Y (Fig. 13-42). T Pathophysiology Subjective Data Objective Data PL R Frequently seen in cystic fibrosis Malfunction of bronchial muscle tone The cough and expectoration are most often the major clues. Tachypnea and clubbing Crackles and rhonchi, sometimes M PE and loss of elasticity Severe hemoptysis may occur. disappearing after cough SA O PR FIGURE 13-42 Bronchiectasis. (Modified from Wilson and Thompson, 1990.)  http://www.us.elsevierhealth.com/product.jsp?isbn=9780323055703 46 CHAPTER 13 Chest and Lungs CHRONIC BRONCHITIS Large airway inflammation, usually a result of chronic irritant exposure, is more commonly a problem for patients older than 40. Pathophysiology Subjective Data Objective Data Large airways are chronically inflamed, Dyspnea may be present although not Wheezing and crackles leading to mucus production. severe. Hyperinflation with decreased breath Smoking is prominent in the history Cough and sputum production are sounds and a flattened diaphragm with many of these patients being impressive. Severe chronic bronchitis may result in emphysematous. right ventricular failure with dependent Recurrent bacterial infections are edema. common. AL N N ER FI T I EV O The Differential Diagnosis box below delineates possible pathologic conditions and their accompanying sputum findings. DIFFERENTIAL DIAGNOSIS SOME C AUSES OF SPUT UM Cause Possible Sputum Characteristics Bacterial infection or transparent; purulent; blood streaked; mucoid, viscid R Chronic infectious disease All of the above; particularly abundant in the early morning; - N IE slight, intermittent blood streaking; occasionally, large amounts of blood* Carcinoma Slight, persistent, intermittent blood streaking T V O Infarction Blood clotted; large amounts of blood SE Tuberculous cavity *Remember to ascertain that the blood is not swallowed from a nosebleed. EL COUGH SYRUP A 59-year-old man presented to the hospital with crampy abdominal pain on the left side, irritability, and confusion…. A 59-year-old man presented to the hospital with crampy abdominal pain on the left side, irritability, and confusion that began 2 days before presentation. He reported no nausea, vomiting, diarrhea, or constipation.