CLIND 1552 Week 8 Cough PDF

CLIND 1552 – Week #8 – Cough Cough #1 SOS A 23-year-old male patient presents to his primary care physician with a two-week history of fever and cough. He complains of nightly chills and a cough that has become productive in the last several days. He also admits to posttussive emesis (cough-induced...

CLIND 1552 – Week #8 – Cough Cough #1 SOS A 23-year-old male patient presents to his primary care physician with a two-week history of fever and cough. He complains of nightly chills and a cough that has become productive in the last several days. He also admits to posttussive emesis (cough-induced vomiting) and a five-pound weight loss. He states that he gets a headache after coughing and has chest pain with deep breathing. He denies rhinorrhea, nasal congestion, and ear pain. During the history, he states, “I had this last year at the same time of year and the doctor said it was an asthma flare-up, secondary to viral bronchitis.” He is concerned because of the duration and worsening of symptoms. Symptom – Organ System – Science – 1. 2. 3. 4. 5. Objectives Define cough and conduct a history related to cough Describe the anatomy and physiology of the chest and thorax Describe the related organ system approach to this complex symptom Identify common or concerning symptoms related to cough Recognize the characteristics of normal and adventitious breath sounds Objective #1: Define cough and conduct a history related to cough What is a cough? • A cough is the body's way of responding when something irritates the throat or airways - An irritant stimulates nerves that send a message to the brain, and the brain then signals to the muscles in the chest and abdomen to push air out of the lungs in an effort to force out the irritant NOTE: Prolonged, vigorous coughing can cause headaches, urinary incontinence and even broken ribs. • Duration of a Cough Acute: < 3 weeks - Viral URI (most common), acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, ACE-inhibitor therapy • Sub-acute: 3 to 8 weeks - Post-infectious cough, pertussis (whooping cough), acid reflux (gastroesophageal reflux (GER), bacterial sinusitis, asthma • Chronic: > 8 weeks • Postnasal drip (PND), asthma, gastroesophageal reflux (GER), chronic bronchitis, bronchiectasis (bronchial wall inflammation causing inability to clear mucous, usually from an infection) A cough is chronic in children if > 4 weeks Differential Diagnoses of Cough GREAT BAD CAT TOM Objective #2: Describe the anatomy and physiology of the chest and thorax Anatomy of the chest and thorax (with landmarks) • Chest wall • Ribs - First 7 ribs – true ribs - Ribs 8, 9, 10 – false ribs - Ribs 11, 12 – floating ribs - Costal angle - Costochondral junctions - Thoracentesis landmark – interspace T7-8 NOTE: The inferior tip of scapula lies at the level of 7th rib NOTE: Neurovascular structures run under ribs, on the inferior border. • • Sternum - Suprasternal notch - Sternal angle – angle of Louis; adjacent to 2nd rib - Body of sternum - Xiphoid process Spine - C 7 / vertebra prominence – protruding spinous process with neck flexion NOTE: Tracheal bifurcation lies at the level of the T4 spinal column • • • • • • • • • • • • Clavicle Muscles/ligaments; primary muscle of respiration and secondary muscles of respiration Lines of the Chest and Thorax Mid-sternal line Mid-clavicular line Axillary lines - Anterior axillary - Midaxillary - Posterior axillary Vertebral line Lobes of the Lungs RIGHT Lung – THREE lobes; separated by the horizontal and right oblique fissures - Right Upper Lobe (RUL) - Right Middle Lobe (RML) - Right Lower Lobe (RLL) LEFT Lung – TWO lobes; separated by the left oblique fissure - Left Upper Lobe (LUL) - Left Lower Lobe (LLL) The Pleura of the Lungs Membranes that cover the lung - Parietal pleura – lines the inner rib cage & upper surface of diaphragm; richly innervated by the intercostal and phrenic nerves - Visceral pleura – covers the outer surface of lung; lacks sensory nerves Pleural space – a space between parietal and visceral pleura, has some fluid to lubricate surfaces (pleural fluid); may increase its size or fill with fluid (pleural effusion) The Trachea Bifurcates at sternal angle anteriorly and the T4 spinous process posteriorly Bifurcates into 2 main bronchi at the carina - Right mainstem bronchus - Left mainstem bronchus Objective #3: Describe the related organ system approach to this complex symptom • • • • • • Differentials for Cough Chronic Obstructive Pulmonary Disease (COPD) Gastroesophageal Reflux Disease (GERD) Bronchitis Pneumonia Asthma Differential #1: Chronic Obstructive Pulmonary Disease (COPD) A chronic disease of the lungs in which the alveoli become damaged, often with increased mucous production and overly distended alveoli/general hyperaeration; limitation of expiratory air flow - Signs and symptoms – progressive dyspnea (difficulty breathing), +/- wheezing, decreased exercise tolerance, productive (cough with sputum production), increased chest A-P diameter, nicotine stained fingers, central cyanosis, nail clubbing and “pursed lip” breathing (which slows the expiratory phase to get the most of their inspired air) - Etiology – usually from smoking, but also secondhand smoke, occupational dust and chemicals, indoor air pollution from stoves NOTE: COPD involves both bronchitis (increased inflammation and mucus buildup in the lungs) and emphysema (destruction and enlargement of the air spaces). • Differential #2: Gastroesophageal Reflux Disease (GERD) A condition in which gastric fluid flows backward into the esophagus - Signs and symptoms – cough, bloating, burping, nausea, weight loss, wheezing, “heart burn”/chest pain, erythematous/edematous vocal cords, hoarseness, dysphagia, melena, or hematochezia. - Etiology – overeating, weak or dysfunctional lower esophageal sphincter, prolonged transit time, increased stomach acidity, foreign body, anatomic abnormality. - Conditions that increase risk of GERD - obesity, smoking, medications, pregnancy, connective tissue disorders (ie..scleroderma), fatty food diet NOTE: Barrett’s esophagus is the result of repeated exposure of the esophagus to stomach acid, and diagnosed in people with long-term GERD • Differential #3: Bronchitis An inflammation of the mucous membrane in the bronchial tubes usually from an infectious etiology; typically causing bronchospasm and coughing. - Signs and symptoms – cough (+/- productive), nausea, fever, weakness, dyspnea, chest pain, nausea, weakness, weight loss, fever, inspiratory stridor, wheezing, decreased breath sounds - Etiology – can be viral, bacterial, fungal, atypical, chemical or mechanical • Differential #4: Pneumonia An inflammation of the lungs caused by any etiology in which the air sacs fill with pus and become solid, the inflammation may affect both lungs (double pneumonia), one lung (single pneumonia), or only certain lobes (lobar pneumonia) - Signs and symptoms – fever, chills, chest pain, wheezing, dyspnea, fatigue, crackles on auscultation, egophony (‘E’ sound versus ‘ah’ sound), whispered pectoriloquy (increased loudness of whispering noted during auscultation with a stethoscope), dullness to percussion - Etiology – bacterial, viral, fungal, atypical NOTE: Do NOT confuse a pneumonia (consolidation of lung tissue) with a pleural effusion (fluid in the pleural space). NOTE: Do NOT confuse a pneumonia (dullness to percussion) with a pneumothorax (hyperresonance, lot of air). • Differential #5: Asthma A reversible respiratory condition marked by bronchial hyperresponsiveness involving release of inflammatory mediators, increased airway secretions, and bronchoconstriction - Signs and symptoms – cough, wheezing, chest tightness, dyspnea, decreased breath sounds - Etiology – exposure to various irritants; substances that trigger allergies (allergens) - Objective #4: Identify common or concerning symptoms related to cough Common or Concerning Symptoms • Chest pain – can be from the heart, from the lungs or other structures • Shortness of breath - can be from the heart, from the lungs or other structures • Cough - can be from the heart, from the lungs or other structures • • • • • • Additional Symptoms to Note Fever Weight loss/gain Type of cough: Dry, purulent (yellow/greenish sputum), blood (hemoptysis), whitish/clear sputum Post nasal drip (PND) Wheeze Orthopnea (short of breath when laying down) Objective #5: Recognize the characteristics of normal and adventitious breath sounds Normal Lung Sounds • Adventitious Lung Sounds Abnormal sounds that are heard when auscultating a patient’s lungs and/or airways. - Wheezes: o Usually occur during expiration o Musical sounds, may be prolonged through narrow airways o Relatively high pitched o Examples: asthma, chronic obstructive pulmonary disease (COPD) - Crackles (rales): o Intermittent, non-musical o Fine crackles – soft, high pitched o Coarse crackles – louder, low pitched o Do NOT clear with coughing, like atelectasis (focal alveolar collapse) o Examples: pneumonia, congestive heart failure - Rhonchi: o Sounds from secretions in large airways, occur in the bronchi o Relatively low pitched o May change or clear with coughing - Pleural friction rub: o Squeaking or grating sounds of the pleural linings rubbing together o Directly associated with inspiration and expiration (cannot be auscultated if the patient is holding their breath) o Usually the result of inflamed pleural layers which are inflamed and have lost their lubrication (ie. pleurisy)