Clinical Presentation of Pul. Diseases-1.pdf

Clinical Presentation of Pulmonary Diseases Dr. Ahmed Alshammari MBBS MPH FRCPC Assistant professor Internal Medicine ❖ Clinical presentation of pulmonary diseases: Objectives 1. Cough. 2. Sputum production. 3. Shortness of breath. 4. Wheezing 5. Chest pain. 6. Hemoptysis. ❖ Respira...

Clinical Presentation of Pulmonary Diseases Dr. Ahmed Alshammari MBBS MPH FRCPC Assistant professor Internal Medicine ❖ Clinical presentation of pulmonary diseases: Objectives 1. Cough. 2. Sputum production. 3. Shortness of breath. 4. Wheezing 5. Chest pain. 6. Hemoptysis. ❖ Respiratory diseases: 1. Obstructive lung diseases (asthma, COPD). 2. Restrictive lung diseases (e.g. idiopathic pulmonary fibrosis). 3. Lung infections (e.g. pneumonia, TB). 4. Pleural effusion. 5. Pneumothorax. 6. Pulmonary embolism. 7. Pulmonary hypertension. Clinical presentation of pulmonary diseases: • Asthma involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness. ❖ Signs and symptoms: Asthma 1. Coughing (dry) 2. Shortness of breath 3. Chest tightness/pain. 4. Audible Wheezing ❖ Physical exam (Acute exacerbations): 1. Tachypnea, Tachycardia, Cyanosis 2. Accessory muscles use, Tripod position 3. Decreased breath sounds or "quiet" chest (severe asthma). 4. pulsus paradoxus (severe asthma). • Spirometry with postbronchodilator response should be obtained as the primary test to establish the asthma diagnosis. • Chest radiography findings are normal or may indicate hyperinflation. • Exercise spirometry is used for assessing patients with exerciseinduced bronchoconstriction. • Management include allergen avoidance and the use of relief and control bronchodilators. Reversible airflow limitation is a key component in the diagnosis of asthma ! Chronic Obstructive Pulmonary Disease (COPD) • COPD is heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airway (chronic bronchitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction. • Chronic bronchitis is defined as the presence of a chronic productive cough for 3 months during each of 2 consecutive years. • Emphysema is defined as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls without apparent fibrosis.. • Diagnosis of COPD is made with spirometry • The ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is less than 70% • CXR reveal flattening of the diaphragm. • Management include Smoking cessation and bronchodilators ❖ Physical examination reveals the following: 1. Respiratory distress 2. Cyanosis 3. Hyperinflation (barrel chest) ❖ Signs and symptoms of COPD: COPD 4. Wheezing – Frequently heard on expiration 1. Dyspnea 2. Wheezing 5. Diffusely decreased breath sounds 3. cough 6. Hyperresonance on percussion 4. Sputum production 7. Prolonged expiration 8. Coarse crackles. Flattening of the diaphragm. • Chronic, progressive pulmonary fibrosis of unknown cause. • Primarily occurring in older adults. Idiopathic Pulmonary Fibrosis (IPF) • It causes lung scarring, which, over time, results in reduced oxygen intake. ❖ Physical examination: 1. Fine bibasilar inspiratory crackles 2. Digital clubbing 3. Signs of pulmonary hypertension: a. Loud P2 component of the S2 ❖ Symptoms: 1. Exertional dyspnea 2. Nonproductive cough. b. Fixed split S2 c. Holosystolic tricuspid regurgitation murmur. d. pedal edema honeycombing Pneumonia (PNA) • Pneumonia (PNA) is a lung infection secondary to bacteria (bacterial PNA), viruses (viral PNA), fungus (fungal PNA). ❖ Typical bacterial pathogens that cause CAP include: ❖ PNA can be classified into: 2. Haemophilus influenzae 1. Community-Acquired PNA (CAP) 2. Hospital-Acquired PNA 3. Ventilator-Associated PNA 1. Streptococcus pneumoniae 3. Moraxella catarrhalis ❖ Workup: CXR and CBC. Other tests depending on severity: 1. Sputum Gram stain/culture 2. Blood cultures ❖ Treatment: antibiotics (PO vs IV) Pneumonia ❖ Signs and symptoms of PNA: ❖ Physical examination: 1. Fever 1. Tachypnea 2. Productive cough with purulent sputum, 2. Rales (crackles) heard over the involved lobe 3. Dyspnea 3. Increased tactile fremitus, 4. Pleuritic chest pain 4. Bronchial breath sounds, 5. Egophony (also known as “E” to “A” change) 6. Dullness on chest percussion. Pneumonia Pleural Effusion • Collection of fluid abnormally present in the pleural space. • Typically, there are no clinical findings for effusions <300 mL. • Usually resulting from excess fluid production and/or decreased lymphatic absorption. ❖ Physical Examination (on the side of the effusion): • Etiologies range from cardiopulmonary disorders and/or systemic inflammatory conditions to malignancy. ❖ Signs and symptoms: 1. Dyspnea. 2. Cough (nonproductive). 3. Chest pain 1. Dullness to percussion. 2. Decreased tactile fremitus. 3. Asymmetrical chest expansion. 4. Diminished breath sounds. 5. Egophony. 6. Pleural friction rub • Work-up: CXR, thoracentesis • Management: treat the underline cause. Pleural Effusion • Infectious disease caused Mycobacterium tuberculosis • Tuberculosis most commonly affects the lungs but can affect other organs. ❖ Physical Examination 1. Dullness. 2. Decreased fremitus Tuberculosis (TB) ❖ Signs and symptoms: 3. Bronchial breath signs. 1. Productive cough 4. Crackles. 2. Weight loss/anorexia 3. Fever 4. Night sweats 5. Hemoptysis 6. Chest pain 7. Fatigue 5. Lymphadenopathy ❖ Diagnosis: Sputum Acid-fast bacilli (AFB) smear and culture, tuberculin skin test (PPD), interferon gamma release assay. ❖ Management: Anti-TB medications (4-drug regimen) Tuberculosis (TB) cavitary lesion on CXR caseating granuloma on biopsy Pneumothorax • Presence of air or gas in the pleural cavity leading to lung collapse. • Can impair oxygenation and/or ventilation. • Air can enter the intrapleural space through a communication from the chest wall (ie, trauma) or through the lung parenchyma across the visceral pleura. ❖ Types of pneumothorax: 1. Spontaneous pneumothorax (primary and secondary) 2. Iatrogenic pneumothorax. ❖ 1° spontaneous risk factors: Smoking, Tall/thin stature and presence of apical subpleural blebs. ❖ 2° spontaneous pneumothorax: affects patients with pre-existing lung disease ❖ Signs and symptoms: emergency): 1. Sudden-onset unilateral pleuritic chest pain 1. Hypotension. 2. Breathlessness. 2. Cyanosis. ❖ Physical exam: 1. Tachycardia Pneumothorax ❖ In tension pneumothorax (medical 2. Respiratory distress. 3. Absent tactile or vocal fremitus 4. Asymmetric lung expansion. 5. Hyperresonance on percussion. 6. Decreased or absent breath sounds. 3. Tracheal displacement away from the side of the silent hemithorax. 4. Jugular venous distention. 5. Cardiac apical displacement ❖ The combination of absent breath sounds and a hyperresonance percussion is diagnostic of pneumothorax (+ history) . ❖ Management: Chest tube +/percutaneous needle aspiration Pulmonary Embolism (PE) • Blood clot (thrombus) becomes lodged in an artery in the lung and blocks blood flow to the lung. ❖ Physical exam: • Usually arises from a thrombus that originates in the deep venous system of the lower extremities. 2. Tachycardia. ❖ Signs and symptoms: 1. Tachypnea. 3. Rales (crackles). 4. Accentuated second heart sound. 5. Lower extremity swelling, pain, tenderness, warmth and erythema. 1. Abrupt onset of pleuritic chest pain 2. Shortness of breath. ❖ Diagnosis: D-dimer, CT angiography. 3. Hypoxia. ❖ Management: anticoagulation (thrombolysis if hemodynamically unstable). • Mean pulmonary arterial pressure greater than 20 mm Hg at rest (by right cardiac catheterization) Pulmonary hypertension • Characterized by a progressive and sustained increase in pulmonary vascular resistance that eventually may lead to right ventricular failure ❖ Signs and symptoms: 1. Dyspnea upon exertion. 2. Fatigue 3. syncope 4. Chest pain (uncommon) 5. Cough (uncommon) ❖ Physical exam: 1. Loud P2 component of the S2 2. Fixed split S2 3. Holosystolic tricuspid regurgitation murmur. 4. pedal edema. ❖ Diagnosis: transthoracic echocardiography (TTE), right-sided cardiac catheterization ❖ Management: treat the underline cause, +/- vasodilatory therapy Thank you Questions