Presenting Symptoms of Respiratory Diseases PDF

PRESENTING SYMTOMS OF RESPIRATORY DISEASES Prof. Dr.Redha 2024  CHEST PAIN Chest pain is a frequent manifestation of both cardiac and respiratory disease. Differential diagnosis of chest pain Central Cardiac Myocardial ischaemia (angina) Myocardial infarction...

PRESENTING SYMTOMS OF RESPIRATORY DISEASES Prof. Dr.Redha 2024  CHEST PAIN Chest pain is a frequent manifestation of both cardiac and respiratory disease. Differential diagnosis of chest pain Central Cardiac Myocardial ischaemia (angina) Myocardial infarction Myocarditis Pericarditis Mitral valve prolapse syndrome Aortic Aortic dissection Aortic aneurysm Differential diagnosis of chest pain Oesophageal Oesophagitis Oesophageal spasm Mallory-Weiss syndrome Massive pulmonary embolus Mediastinal Tracheitis Malignancy Anxiety/emotion Differential diagnosis of chest pain Peripheral Lungs/pleura Pulmonary infarct Pneumonia Pneumothorax Malignancy Tuberculosis Connective tissue disorders Differential diagnosis of chest pain Musculoskeletal Osteoarthritis Rib fracture/injury Costochondritis (Tietze's syndrome) Intercostal muscle injury Epidemic myalgia (Bornholm disease) Neurological Prolapsed intervertebral disc Herpes zoster Thoracic outlet syndrome  HAEMOPTYSIS ▪ Coughing up blood, irrespective of the amount, is an alarming symptom and patients nearly always seek medical advice. A history : ▪ should be taken to establish that it is true haemoptysis and not hematemesis, or gum or nose bleeding. ▪ Haemoptysis must always be assumed to have a serious cause until this is excluded (Box). ▪ Many episodes of haemoptysis remain unexplained even after full investigation, and are likely to be caused by simple bronchial infection. ▪ A history of repeated small haemoptysis, or blood-streaking of sputum, is highly suggestive of bronchial carcinoma. ▪ Fever, night sweats and weight loss suggest tuberculosis. ▪ Pneumococcal pneumonia often causes 'rusty'-coloured sputum but can cause frank haemoptysis, as can all suppurative pneumonic infections including lung abscess. ▪ Bronchiectasis and intracavitary mycetoma can cause catastrophic bronchial haemorrhage, and in these patients there may be a history of previous tuberculosis or pneumonia in early life. ▪ Finally, pulmonary thromboembolism is a common cause of haemoptysis and should always be considered.  Physical examination: May reveal additional clues. ▪ Finger clubbing suggests bronchial carcinoma or bronchiectasis; other signs of malignancy, such as cachexia, hepatomegaly and lymphadenopathy, should also be sought. ▪ Fever, pleural rub or signs of consolidation occur in pneumonia or pulmonary infarction; a minority of patients with pulmonary infarction also have unilateral leg swelling or pain suggestive of deep venous thrombosis. ▪ Rashes, haematuria and digital infarcts suggest an underlying systemic disease such as a vasculitis, which may be associated with haemoptysis. Causes of haemoptysis Bronchial disease Carcinoma* Bronchiectasis* Acute bronchitis* Bronchial adenoma Foreign body Parenchymal disease Tuberculosis* Suppurative pneumonia Lung abscess Parasites (e.g. hydatid disease, flukes) Trauma Actinomycosis Mycetoma Lung vascular disease Pulmonary infarction* Goodpasture's syndrome Polyarteritis nodosa Idiopathic pulmonary haemosiderosis Cardiovascular disease Acute left ventricular failure* Mitral stenosis Aortic aneurysm Blood disorders Leukaemia Haemophilia Anticoagulants  Investigations : In the vast majority of cases, however, the haemoptysis itself is not life- threatening and a logical sequence of investigations should be followed: Chest X-ray, which may give evidence of a localized lesion including pulmonary infarction, tumour (malignant or benign), pneumonia, mycetoma or tuberculosis Full blood count and clotting screen Bronchoscopy after acute bleeding has settled, which may reveal a central bronchial carcinoma (not visible on the chest X-ray) and permit biopsy and tissue diagnosis CTPA, which may reveal underlying pulmonary thromboembolic disease or alternative causes of haemoptysis not seen on the chest X- ray (e.g. pulmonary arteriovenous malformation or small or hidden tumours).  Management In severe acute haemoptysis, the patient should be nursed: ✓ Upright (or on the side of the bleeding if this is known), and ✓ Given high-flow oxygen and ✓ Appropriate haemodynamic resuscitation. ▪ Bronchoscopy in the acute phase is difficult and often merely shows blood throughout the bronchial tree. ▪ If radiology shows an obvious central cause, then rigid bronchoscopy under general anaesthesia may allow intervention to stop bleeding; however, the source often cannot be visualized. ▪ Intubation with a divided endotracheal tube may allow protected ventilation of the unaffected lung to stabilize the patient. ▪ Bronchial arteriography and embolization , or even emergency pulmonary surgery, can be life-saving in the acute situation.  CYANOSIS ❑ Is an abnormal bluish discoloration of the skin resulting from an increase in the level of reduced hemoglobin in the blood. ❑ In general, reflects an arterial oxygen saturation of 85% or less (normal arterial oxygen saturation, ≥ 95%).  Central cyanosis: Exhibits as cyanosis of the lips or trunk and often reflects right- to-left shunting of blood caused by: 1- Structural cardiac abnormalities e.g. Atrial or Ventricular septal defects) 2- pulmonary parenchymal or vascular disease e.g. Chronic obstructive pulmonary disease, Pulmonary embolism, Pulmonary arteriovenous fistula).  Peripheral cyanosis : May occur because of systemic vasoconstriction in the setting of poor cardiac output or may be a localized phenomenon resulting from venous or arterial occlusive or vasospastic disease e.g. Venous or arterial thrombosis. Arterial embolic disease. Raynaud disease. When cyanosis occurs in childhood, it usually reflects congenital heart disease with right-to-left shunting of blood.  INCIDENTAL PULMONARY NODULE ON IMAGING ▪ A pulmonary nodule may be defined as a round opacity which is at least moderately well marginated and no greater than 3 cm in diameter. ▪ The majority are benign; however, the differential diagnosis is extensive (Box) and includes early malignant disease that may be treatable. Causes of pulmonary nodules Common causes Bronchial carcinoma Single metastasis Localized pneumonia Lung abscess Tuberculoma Pulmonary infarct Uncommon causes Benign tumours Lymphoma Arteriovenous malformation Hydatid cyst. Bronchogenic cyst Rheumatoid nodule Pulmonary sequestration Pulmonary haematoma Wegener's granuloma 'Pseudotumour'-fluid collection in a fissure Aspergilloma (usually surrounded by air 'halo') Clinical and radiographic features distinguishing benign from malignant nodules Risk status of patient Age: Increasing age increases likelihood of malignancy. Lung cancer is uncommon under the age of 40 and rare under 35 Smoking history: Risk of malignancy increases in proportion to duration and amount smoked History of malignancy : Risk of malignancy increased by history of lung cancer in a first-degree relative, and by exposure to asbestos, silica, uranium and radon Characteristics of nodule Size :Greater probability of malignancy with increasing size. Nearly all nodules > 3cm are malignant; less than 1% of very small (< 4 mm) nodules are malignant, even in smokers; 10-20% in the 8 mm range will prove cancerous Margin: Usually smooth in benign lesions; malignant lesions have a speculated margin Density: Most cancerous lesions are solid, but most solid lesions are non-cancerous. A partly solid lesion or one with air lucencies is more likely to be malignant than a solid lesion. Ground glass lesions with malignant potential grow very slowly and require longer follow-up Calcification or fat: These favours benign disease, although CT may detect calcification in some malignant lesions. A laminated or central deposition of calcification is typical of a granuloma, while a 'popcorn' pattern is suggestive of a hamartoma. Fat content is consistent with a hamartoma or a lipoid granuloma. Location: 70% of lung cancers occur in the upper lobes and the right lung is more commonly affected than the left lung. Benign lesions are equally distributed throughout upper and lower lobes. Contrast enhancement: Lack of contrast enhancement (< 15 HU) has a high negative predictive value for malignancy, but is non-specific with a poor positive predictive value. Not useful in lesions < 8 mm in diameter. Lymphadenopathy: Hilar or mediastinal adenopathy favours a malignant process and is important for staging Recommendations for follow-up of incidental nodules smaller than 8 mm1 Nodule size (mm) Low-risk patient High-risk patient ≤4 No follow-up needed Follow-up CT at 12 months; if unchanged, no further follow-up 4-6 Follow-up at 12 months; if unchanged, no further follow-up Initial follow-up CT at 6-12 months, then at 18-24 months if no change 6-8 Initial follow-up CT at 6-12 months then at 18-24 months if no change Initial follow-up CT at 3-6 months, then at 9-12 months if no change >8 Follow-up CT at around 3, 9 and 24 months, dynamic contrast-enhanced CT, PET and/or biopsy As for low- risk patient  PLEURAL EFFUSION ❖ Pleural effusion: the accumulation of serous fluid within the pleural space ❖ Empyema:accumulation of frank pus within the pleural space. ❖ Haemothorax: accumulation of blood within the pleural space. ❖ Chylothorax : accumulation of chyle within the pleural space. ❖ Transudative effusion: pleural fluid accumulates as a result of either increased hydrostatic pressure or decreased osmotic pressure (', as seen in cardiac, liver or renal failure), ❖ Exudative effusion: from increased microvascular pressure due to disease of the pleural surface itself or injury in the adjacent lung.