Chapter 3. Cardiopulmonary Symptoms.pdf

Copyright © 2018, Elsevier Inc. All Rights Reserved. CARDIOPULMONARY SYMPTOMS Chapter 3  Lecture Outline  Cough  Swelling of the ankle...

Copyright © 2018, Elsevier Inc. All Rights Reserved. CARDIOPULMONARY SYMPTOMS Chapter 3  Lecture Outline  Cough  Swelling of the ankle (dependent edema)  Sputum production  Fever, chills, and night  Hemoptysis sweats  Shortness of breath  Headache, altered mental (dyspnea) status, and personality  Cheat pain changes  Dizziness and fainting  Snoring and daytime (syncope) somnolence (sleepiness) gastroesophageal reflux Copyright © 2018, Elsevier Inc. All Rights Reserved.  Learning Objectives  Cough  Fever, chills, and night sweats  Sputum production  Headache, altered  Hemoptysis mental status, and  Dyspnea personality changes  Chest pain  Snoring  Dizziness and fainting  Gastroesophageal reflux  Swelling of the ankles Copyright © 2018, Elsevier Inc. All Rights Reserved.  Signs and Symptoms  Symptoms  Signs  Subjective  Objective  Patient description  Measureable  Measured by patient  Assessed values perception  Ex: Heart rate, blood  Ex: Pain, shortness of pressure, respiratory rate breath, cough Copyright © 2018, Elsevier Inc. All Rights Reserved.  Overview  Assess symptoms to  Primary symptoms of determine: cardiopulmonary disorders  Seriousness of problem  Cough  Potential underlying  Sputum production cause of problem  Hemoptysis  Effectiveness of  Shortness of breath treatment (dyspnea)  Chest pain Copyright © 2018, Elsevier Inc. All Rights Reserved.  Cough  One of the most common symptoms seen in patients with pulmonary disease  Protective reflex  Stimulation of receptors  Pharynx, larynx, trachea, large bronchi, lung, and visceral pleura  Caused by:  Inflammatory, mechanical, chemical, or thermal stimulation of cough receptors  Key to determine etiology is careful history, physical examination, and CXR Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Cough  Afferent pathway  Vagus, phrenic, glossopharyngeal, and trigeminal nerves  Efferent pathway  Smooth muscles of larynx and tracheobronchial tree via phrenic, spinal nerves  Phases  Inspiratory  Compression  Expiratory Copyright © 2018, Elsevier Inc. All Rights Reserved.  Cough (Cont.)  Reduced effectiveness of cough  Weakness of inspiratory or expiratory muscles  Inability of the glottis to open or close correctly  Obstruction, collapsibility, or alteration in shape or contours of the airways  Decrease in lung recoil (e.g., emphysema)  Abnormal quantity or quality of mucus production (e.g., thick sputum) Copyright © 2018, Elsevier Inc. All Rights Reserved.  Causes and Clinical Presentation  Acute  Chronic  Sudden onset  Persistent  Severe, short course  Last >3 weeks  Self-limiting  Causes:  Viral infection  Postnasal drip (most common), asthma, COPD exacerbation, allergic rhinitis, GERD, chronic bronchitis, bronchiectasis, and left heart failure Copyright © 2018, Elsevier Inc. All Rights Reserved.  Causes and Clinical Presentation (Cont.)  Paroxysmal  Periodic  Prolonged, forceful episodes  Associated symptoms of a cough  Wheezing  Stridor  Chest pain  Dyspnea Copyright © 2018, Elsevier Inc. All Rights Reserved. Description of Cough  Recurrent: allergies, asthma  Dry: Viral infection, inhalation of irritant  Inadequate, weak: debility, weakness, over sedation, pain  Inspiratory Stridor: croup, epiglottitis, obstruction  Wheezy: bronchospasm, asthma  Paroxysmal (often at night) asthma, left heart failure  Barking: croup, laryngotracheal bronchitis  Complications of Cough  Torn chest muscle  Rib fractures  Disruption of surgical wounds  Pneumothorax or pneumomediastinum  Syncope  Arrhythmia  Esophageal rupture  Urinary incontinence Copyright © 2018, Elsevier Inc. All Rights Reserved.  Sputum Production  Sputum  Secretions from tracheobronchial tree, pharynx, mouth, sinuses, nose  Phlegm  Secretions from lungs and tracheobronchial tree  Components  Mucus, cellular debris, microorganisms, blood, pus, foreign particles  Normal sputum 100 mL/day  Upward displacement via wavelike motion of cilia until swallowed Copyright © 2018, Elsevier Inc. All Rights Reserved. 14  Abnormal Sputum Production  Bronchorrhea  More that 100 mL per day  Excessive production by inflamed glands  Caused by: Infection, cigarette smoking, allergies  Describe:  Color  Quantity  Consistency  Odor  Time of day  Presence of blood Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Hemoptysis  Expectoration of sputum containing blood  From streaking to frank bleeding  Causes  Bronchopulmonary  Cardiovascular  Hematologic  Systemic disorders  Tuberculosis or fungal infections Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Description of Hemoptysis  Amount  Massive hemoptysis: 400 mL/3 h or 600 mL/24 h  Emergency condition  Cancer, tuberculosis, bronchiectasis, trauma  Streaky: pulmonary infection, lung cancer, and thromboemboli  Odor  Color  Acuteness Copyright © 2018, Elsevier Inc. All Rights Reserved.  Hemoptysis vs. Hematemesis  Hematemesis: vomited blood  Determine source  Oropharynx  Swallowed from respiratory tract  Esophagus or stomach  Alcoholism or cirrhosis of liver Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Shortness of Breath (SOB)  Most distressing symptom of respiratory disease  Single most important factor limiting ability to function  Cardinal symptom of cardiac disease Copyright © 2018, Elsevier Inc. All Rights Reserved.  Dyspnea  Subjective experience of breathing discomfort  Components  Sensory input to cerebral cortex  Perception of the sensation  “Breathless,” “short-winded,” and “feeling of suffocation” Copyright © 2018, Elsevier Inc. All Rights Reserved.  Dyspnea Scoring Systems  Scale of 0 (no SOB) to 10 (max SOB)  Visual analog scales  Modified Borg scale  ATS SOB Scale  UCSD SOB Questionnaire Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  27 Copyright © 2018, Elsevier Inc. All Rights Reserved.  Causes, Types, and Clinical Presentation of Dyspnea  WOB abnormally high for the given level of exertion  Asthma and pneumonia  Ventilatory capacity is reduced  Neuromuscular disease  Drive to breathe is elevated  Hypoxemia, acidosis, exercise Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  30 Copyright © 2018, Elsevier Inc. All Rights Reserved.  Clinical Types of Dyspnea  Cardiac and circulatory  Inadequate supply of oxygen to tissues  Primarily during exercise  Psychogenic  Panic disorder  Not related to exertion  Hyperventilation  Rate, depth exceeds body’s metabolic need  Results in hypocapnia and decreased cerebral blood flow Copyright © 2018, Elsevier Inc. All Rights Reserved.  Acute and Chronic Dyspnea  Acute or recurrent  Chronic  Children:  Most common causes:  Asthma, bronchiolitis, croup,  COPD epiglottitis  Adults:  CHF  Pulmonary embolism  Asthma  Pneumonia  Pneumothorax  Pulmonary edema  Hyperventilation  Panic disorder Copyright © 2018, Elsevier Inc. All Rights Reserved.  Description of Dyspnea  Paroxysmal Nocturnal Dyspnea (PND)  Sudden dyspnea when sleeping in recumbent position  Associated with coughing  Sign of left heart failure  Orthopnea  Dyspnea when lying down  Associated with left heart failure Copyright © 2018, Elsevier Inc. All Rights Reserved.  Description of Dyspnea (Cont.)  Trepopnea  Dyspnea when lying on one side  Unilateral lung disease, pleural effusion  Platypnea  Dyspnea in upright position Copyright © 2018, Elsevier Inc. All Rights Reserved.  Description of Dyspnea (Cont.)  Orthodeoxia  Hypoxemia in upright position, relieved by returning to a recumbent position  Platypnea and orthodeoxia seen in patients with right-to-left intracardiac shunts or venoarterial shunts Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Chest Pain  Causes  Cardiac ischemia  Inflammatory disorders of thorax, abdomen  Musculoskeletal disorders, trauma, anxiety  Referred pain from indigestion, dissecting aortic aneurysm  Cardinal symptom of heart disease  Angina  Quickly assess if pain is an emergent condition Copyright © 2018, Elsevier Inc. All Rights Reserved.  Pulmonary Causes of Chest Pain  Involvement of chest wall or parietal pleura  Pleuritic pain  Inspiratory, sharp, and abrupt in onset  Worsens with inspiration, cough, sneeze, hiccup, or laughter  Increases with pressure and movement  Chest wall pain  Intercostal and pectoral muscles  Well localized Copyright © 2018, Elsevier Inc. All Rights Reserved.  Dizziness and Fainting (Syncope)  Temporary loss of consciousness  Resulting from reduced cerebral blood flow and oxygen  Causes  Thrombosis, embolism, atherosclerotic obstruction  Pulmonary: embolism, bouts of coughing, hypoxia, hypocapnia  Vasovagal: most common type of syncope  Loss of peripheral venous tone Copyright © 2018, Elsevier Inc. All Rights Reserved.  Dizziness and Fainting (Syncope) (Cont.)  Orthostatic hypotension  Sudden drop in blood pressure when a person stands up  Dizziness, blurred vision, weakness, syncope  Elderly, vasodilator use, dehydration  Tussive syncope  Syncope caused by strong coughing  Seen most often in men with COPD, obesity, a positive smoking history, and frequent use of alcohol Copyright © 2018, Elsevier Inc. All Rights Reserved.  Dependent Edema  Edema is soft tissue swelling from abnormal accumulation of fluid  Anasarca  Generalized edema  Bilateral peripheral edema  Most often occurs in ankles and lower legs  Most often caused by right or left heart failure  Right heart failure often caused by cor pulmonale Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Fever, Chills, and Night Sweats  Euthermia  97°F to 99.5°F  36°C to 37.5°C  Fever (hyperthermia, pyrexia)  Sustained  Remittent  Intermittent  Relapsing Copyright © 2018, Elsevier Inc. All Rights Reserved.  Causes for Fever  Hot environment  Dehydration  Reaction to chemicals  Drugs  Hypothalamic damage  Infection  Malignancy Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved. Copyright © 2018, Elsevier Inc. All Rights Reserved.  Fever With Pulmonary Disorders  Pulmonary infections  Lung abscess, empyema, tuberculosis, pneumonia  Remittent fever in mycoplasma pneumonia, Legionnaire’s disease, acute viral infections  Infections with no fever  High-dose corticosteroids  Immunosuppressants  Immunocompromised (leukemia, AIDS) Copyright © 2018, Elsevier Inc. All Rights Reserved.  Headache, Altered Mental Status, and Personality Changes  Headache as a manifestation of cerebral hypoxia and hypercapnia  Lung disease, high altitude  Altered mental status in hypercapnia  From affected alertness to coma  Personality changes in advanced pulmonary disorders  Forgetfulness, inability to concentrate, anxiety, and irritability Copyright © 2018, Elsevier Inc. All Rights Reserved.  Snoring  Serious concern when associated with apnea  Evaluation for OSA  Incidence and causes  10% to 12% of children  10% to 30% of adults  Peak at age 50 to 59 (male), 60 to 64 (female)  Obesity is one of the most common causes Copyright © 2018, Elsevier Inc. All Rights Reserved.  Snoring Clinical Presentation  Fatigue  Excessive daytime sleepiness (daytime somnolence)  Occupational accidents  Motor vehicle accidents  Loss of employment  Social dysfunction Copyright © 2018, Elsevier Inc. All Rights Reserved.  Gastroesophageal Reflux (GERD)  Heartburn and regurgitation  Extraesophageal manifestations  Laryngitis, asthma, chronic and nocturnal dry cough, chest pain, and dental erosion  GER more than twice a week = GERD  Risk factors  Obesity, cigarette smoking, pregnancy Copyright © 2018, Elsevier Inc. All Rights Reserved.