Respiratory Symptoms & Respiratory Symptoms & SignsSigns

Chief complaints （ CC ）： Presenting complaints and duration.

Present Illness （ PI ）：

A ： The immediate history that brought the patient to the hospital

B ： Background history of disease leading to the immediate history

C ： Significant positive and negative data that might give clues useful in differential diagnosis

Habits ： A ： Use alcohol ， tobacco…… B ： Sexual habits

Allergies ： Hay fever ， asthma ， drugs

Common symptomsCommon symptoms

Cough Expectoration Hemoptysis Chest pain Cyanosis Dyspnea

What is cough?

• A complex reflex arc.• A defense mechanism.• A factor in the spread of

infection.• A common symptom.• A means of providing

cardiopulmonary resuscitation.

Cough Cough ((a protective reflexa protective reflex): ): causescauses

Respiratory diseases___ the most common causes Airway agents

Bronchitis, bronchiectasis, asthma, endobronchial tuberculosis, tumor, pharyngitis

Lung agentsInfection, edema, fibrosis, tumor

Cardiovascular diseases pulmonary edema, pulmonary embolism

Cough : Cough : manifestationsmanifestations

Characteristics Dry cough (non-sputum: non-infectious) Productive cough (sputum: infectious, edema)

Attack Time season

Tone Hoarseness Brassy

Cough: Cough: accompany symptomsaccompany symptoms

Fever (infection) Chest pain (infection, tumor, pleurisy,

pneumothorax, pulmo embolism) Dyspnea Hemoptysis (bronchietasis, tuberculosis, tumor) Bulk pus sputum (bronchietasis, lung abscess) Wheezing (asthma, foreign body) Clubbing fingers (bronchietasis, lung cancer,

chronic lung abscess)

The Duration of Cough

• Cough can be divided into 3 categories

- Acute (<3 weeks)

- Subacute (3-8 weeks)

- Chronic (>8 weeks)

• Estimating the duration is the 1st step in narrowing the list of potential causes.

Most Common Causes of Acute Cough• URT Infections

- Common Colds• “Acute bronchitis”• Acute Bacterial Sinusitis• Bordetella pertussis Infection in

Selected Communities• Exacerbations of Chronic

Bronchitis• Allergic Rhinitis• Environmental Irritant Rhinitis

Commonest Causes of Subacute Cough After a Respiratory Infection

• Postinfectious Cough- B. pertussis infection

• Bacterial sinusitis• Exacerbation of a pre-existing disease

- Asthma- Chronic Bronchitis

Helpful Hints:

1. Pertussis is likely with cough-vomit syndrome with or without whoop

2. Consider all 3 when cough has a biphasic

course

Summary of Results of the Diagnostic Evaluation of Chronic Cough

• Chronic cough is often simultaneously due to more than 1 condition (18-93% of the time).

- It has been due to 3 diseases up to 42% of the time. - Up to 4% of the time, it can be due to 5 conditions.

Summary of Results of the Diagnostic Evaluation of Chronic Cough

• In prospective studies in adults, chronic cough is most commonly due to 6 disorders: - Upper airway cough syndrome (UACS)

• Previously referred to as postnasal drip syndrome

- Asthma- GERD- Chronic bronchitis- Bronchiectasis- Non-asthmatic esosinophilic bronchitis

Sputum: Sputum: amountamount

Bulk frothy sputum Pulmo edema

Bulk pus sputum Bronchiectasis Lung abscess

Sputum: Sputum: consistencyconsistency

Mucoid sputum Bronchitis (without bacterial infection) Asthma

Pus sputum Any bacterial infection

Bloody sputum

Sputum: Sputum: colorcolor

White mucoid or serofluid sputum

Yellow general bacterial infection

Green aeruginosus Bacillus infection

Pink cardiac edema

Red hemoptysis

Sputum: Sputum: foul odorfoul odor

anaerobic bacterium infection

Hemoptysis Hemoptysis

Bleeding from lower respiratory tract

The amount varies from blood-stained sputum to several

hundreds ml pure blood

Mild: 100ml/d

Moderate: 100-500/d

Severe: >500ml/d, or 100-500/time

Differential diagnosis

Bleeding from upper respiratory tract

Hematemesis

Distinguished hemoptysis from Distinguished hemoptysis from hematemesishematemesis

Hemoptysis Hematemesis

Causes Pulmo or cardiac digestive system

Previous symptoms Cough, chest tightness Nausea, vomiting

Spit up Cough up Vomited

Color Bright red Dark red

Mixture Sputum, frothy Gastric contents

Tarry stools + +

Post-bleeding Sputum with blood No sputum

Hemoptysis: Hemoptysis: causescauses

Bronchial disorders Bronchiectasis Bronchogenic carcinoma Chronic bronchitis

Pulmo Disorders Pulmo TB Pulmo embolism

Cardiovascular disorders Acute left heart failure Mitral stenosis

Others Hematologic disease,

Hemoptysis: Hemoptysis: accompany symptomsaccompany symptoms

Fever Infection or carcinoma

Chest pain Infection ， Pulmo Embolism ， Carcinoma

Pusy sputum Bronchiectasis ， Lung abscess

Clubbing of fingers Bronchiectasis ， Lung abscess ， Carcinoma

Diagnostic Caveats to Consider in Diagnosing

Hemoptysis

• Lack of hemoptysis does not rule out a substantial intrapulmonary bleed.

• It is not uncommon for bronchoscopy to establish sites of bleeding different from those suggested by chest radiograph.

• Although as many as 30% of patients with hemoptysis will have normal chest radiographs, routine films may be diagnostically valuable.

Chest pain: Chest pain: causescauses

Chest wall herpes zoster, rib fracture

Cardiovascular angina pectoris, myocardial infarction, pericarditis, dissecting

aneurysm Respiratory

Pleural disorders, pneumothorax, carcinoma

Chest pain: Chest pain: characteristicscharacteristics

Location Radiation Level or feature

Burning pain, pressing pain, pricking pain Duration Influential factors

Exertional, respiration, food intake, administration

Chest pain: Chest pain: accompany symptomsaccompany symptoms

Cough, sputum and/or fever Respiratory disease

Dyspnea Severe pneumonia, pneumothorax, pleurisy, pulmo embolism

Hemoptysis Carcinoma, pulmo embolism

Shock myocardial infarction, dissecting aneurysm (rupture ),

large area pulmo embolism Dysphagia

Esophageal disease

What Is Dyspnea?

Dyspnea is a distressing sensation of difficult,

labored, or unpleasant breathing.

What Is the Differential Diagnosis of Dyspnea?

• There are a multiplicity of causes located in a variety of anatomic locations.

• While the list of causes is nearly endless, 5 major causes account for ~94% of cases:- Cardiac- Respiratory- Psychogenic/hyperventilation syndrome- Deconditioning- GERD

Class Patient Symptoms

Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue symptoms

Class II (Mild) Slight limitation of physical activity. Comfortable at rest, ordinary physical activity results in symptoms.

Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms.

Class IV (Severe) Symptoms of cardiac insufficiency at rest.

If any physical activity is undertaken, discomfort is increased.

Classification of Dyspnea Classification of Dyspnea

Dyspnea: Dyspnea: causescauses

Respiratory system Obstruction: asthma, COPD, tumor Pulmo Diseases: pneumonia, interstitial lung disease, Pleura: pneumothorax, effusion Diaphragma movement disorder: tense ascites

Cardiovascular system Heart failure Pulmo embolism

Features of left heart failureFeatures of left heart failure

Underlying diseases

Position related dyspnea

Crackles or rhonchi in both lungs

PND

Nocturnal paroxysmal dyspnea Nocturnal paroxysmal dyspnea

Characteristics

Awoken due to chest tightness or dyspnea

Forced sitting position or orthopnea

Tachycardia

crackles or rhonchi in both lungs

Pink frothy sputum

Nocturnal paroxysmal dyspneaNocturnal paroxysmal dyspnea

Mechanism Vital capacity decreased in supine position

Returned blood volume increased pulmo edema

Dyspnea: Dyspnea: accompany signs (1)accompany signs (1)

Rhonchi Asthma Acute left heart failure (cardiac asthma) Acute laryngeal edema

Chest pain Infection Pneumothorax Pulmo embolism Acute myocardial infarct

Dyspnea: Dyspnea: accompany signs (2)accompany signs (2)

Fever Infection

Cough and sputum COPD Infection Left heart failure

Unconsciousness CNS disorder Uremia diabetic ketoacidosis

What is the Value of History for Diagnosing the Etiology of Wheeze?

While wheezing is indicative of obstruction of airways, it is insensitive and nonspecific in diagnosing the specific location and cause of the obstruction.- Expiratory wheezing by history may

be predictive of asthma no more than 35% of the time; past history of asthma, no more than 62%; monophonic expiratory wheezing by physical, no more than 43% of the time.

47%

35%

12%

3% 3%

0

10

20

30

40

50

60

70

80

90

100

Postnasaldrip

syndrome

Asthma Psychogenicillness

Industrialbronchitis

Unknown

%

Spectrum and Frequency of Causes of Wheeze

An Approach to the Diagnosis of Wheeze

Be aware that:“All that wheezes is not asthma;

All that wheezes is obstruction.”

Differential Diagnosis of Wheeze According to Anatomic Area

UPPER AIRWAY OBSTRUCTION

Extrathoracic Causes Intrathoracic Causes

PNDS Tracheal stenosis

Vocal cord dysfunction Goiter

Syndrome

Epiglottitis Malignancies

Laryngeal edema Benign tumors

Postextubation granuloma

Anaphylaxis

Differential Diagnosis of Wheeze According to Anatomic Area

LOWER AIRWAY OBSTRUCTION

Asthma Bronchiolitis

COPDBronchiectasis

Pulmonary edema Carcinoid syndrome

Pulmonary embolism Parasitic infections

Cystic fibrosis Lymphangitic carcinomatosis

Cyanosis Cyanosis

An excess of desaturated hemoglobin causes a

blue coloration of the skin or mucosae.

Cyanosis: Cyanosis: classificationclassification

Central (warm) Deficient oxygenation Right-to-left shunt

Peripheral (cold) Reduced cardiac output Local vasoconstriction

Mixed Heart failure

Cyanosis: Cyanosis: accompany signsaccompany signs

Dyspnea Severe cardiac or respiratory disorder

Clubbing fingers Congenital heart disease Chronic respiratory disease

Physical Examination Physical Examination of Respiratory Systemof Respiratory System

Anterior imaginary lines and Anterior imaginary lines and landmarkslandmarks

epigastric angle

Infraclavicular fossa

Suprasternal fossa Supraclavicular fossa

Midclavicular line

Lateral imaginary lines Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line

Posterior imaginary lines and Posterior imaginary lines and landmarkslandmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region

Left lateral view of lobesLeft lateral view of lobes

Right lateral view of lobesRight lateral view of lobes

Anterior view of lobesAnterior view of lobes

Posterior view of lobesPosterior view of lobes

Thoracic deformity Thoracic deformity

Pectus excavatumBarrel chest

Kyphosis

Inspection Inspection

1. Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult

2. Respiratory rate: 16-18 f/min Tachypnea: >20 f/min Bradypnea: <12 f/min Shallow and fast

respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy

Deep and fast Agitation, intension

Deep and slow Severe metabolic acidosis (Kussmaul’s breathing)

Inspection Inspection

Abnormalities in Rate and Rhythm of Breathing

NormalRapid Shallow Breathing

(Tachypnea)

Rapid Deep Breathing

(Hyperpnea, Hypeventilation) Slow Breathing (Bradypnea)

The respiratory rate is about 14-20 per min in normal

adults and up to 44 per min in infants.

Rapid shallow breathing has a number of causes, including

restrictive lung disease, pleuritic chest pain, and an

elevated diaphragm.

Rapid deep breathing has several causes, including exercise, anxiety,

and metabolic acidoses. In the comatose patient, consider

infarction, hypoxia, or phypoglycemia affecting the midbrain or pons. Kussmaul

breathing is deep breathing due to metabolic acidosis. It may be fast,

normal in rate, or slow.

Slow breathing may be secondary to such causes as diabetic coma, drug induced respiratory depression, and

increased intracranial pressure.

Cheyne-Strokes BreathingAtaxic Breathing

(Biot’s Breathing) Sighing Respiration Obstructive Breathing

Periods of deep breathing alternate with periods of apnea (no breathing). Children and aging people normally

may show this pattern in sleep. Other causes include heart failure, uremia, drug-induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or

diencephalon.

Ataxic breathing is characterized by unpredicted irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include

respiratory depression and brain damage, typically at the

medullary level.

Breathing punctuated by frequent sighs should alert you to the

possibility of hyperventilation syndrome – a common cause of

dyspnea and dizziness. Occasional sighs are normal.

In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to airflow. Causes

include asthma, chronic bronchitis, and COPD.

Palpation Palpation

Thoracic expansion

Massive hydrothorax,

pneumonia, pleural

thickening, atelectasis

Vocal fremitus (tactil fremitus)

PercussionPercussion

ClassificationClassification

Resonance Normal

Hyperresonance Emphysema Cavity or pneumothorax

Dullness Hydrothorax, atelectasis

4. Normal sound4. Normal sound

Shifting range of bottom of lung

6-8 cm

5. Abnormal sound5. Abnormal sound

Dullness, flatness, hyperresonance or tympany appear in the area of supposed resonance.

Unchanged sound (resonance) The depth of the lesion > 5 cm The diameter of the lesion 3 cm Mild hydrothorax

5. Abnormal sound5. Abnormal sound

Dullness or flatness Decreased containing gas in alveoli

Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis

No gas in alveoli Tumor Pulmo. Hydatid Pneumocystis Non-liquefied lung abscess

Others Hydrothorax Pleural thickness

5. Abnormal sound5. Abnormal sound

Hyperresonance Emphysema

Tympany Pneumothorax Large cavity (TB, lung abscess, lung cyst)

AuscultationAuscultation

Order of auscultation Order of auscultation

Sound of auscultationSound of auscultation

1. Normal breath sound

2. Abnormal breath sound

3. Adventitious sound

4. Vocal resonance

1. Normal breath sound1. Normal breath sound

Tracheal breath sound Bronchial breath sound

Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra

Bronchovesicular breath sound 1st, 2nd intercostal space

beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung

Vesicular breath sound Most area of lungs Bronchovesicular

Bronchial

Bronchial

Bronchovesicular

Characteristics of Breath Sounds

Duration of Sounds

Inspiratory sounds last longer than expiratory ones.

Inspiratory and expiratory sounds are about equal.

Expiratory sounds last longer than

inspiratory ones.

Inspiratory and expiratory sounds are about equal.

Intensity of Expiratory Sound

Soft

Intermediate

Loud

Very Loud

Pitch of Expiratory

Sound

Relatively low

Intermediate

Relatively high

Relatively high

Locations Where Heard Normally

Over most of both lungs

Often in the 1st and 2nd interspaces anteriorly

and between the scapulae

Over the manubrium, if heard at all

Over the trachea in the neck

Vesicular*

Broncho-vesicular

Bronchial

Tracheal

2. Abnormal breath sound2. Abnormal breath sound

Abnormal vesicular breath sound

Abnormal bronchial breath sound

Abnormal bronchovesicular breath sound

Abnormal vesicular breath Abnormal vesicular breath soundsound(1)(1)

1) Decreased or disappeared Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor

2) Increased Movement of respiration

Abnormal vesicular breath sound Abnormal vesicular breath sound (2)(2)

3) Prolonged expiration Bronchitis Asthma emphysema

Abnormal bronchial breath soundAbnormal bronchial breath sound

Bronchial breath sound appears in supposed vesicular breath sound area

Consolidation: lobar pneumonia (consolidation stage)

Large cavity: TB, lung abscess

Compressed atelectasis: hydrothorax, pneumothorax

Abnormal bronchovesicular Abnormal bronchovesicular breath soundbreath sound

Bronchovesicular breath sound appears in supposed vesicular breath sound area

The lesion is relatively smaller or mixed with normal lung tissue

3. Adventitious sound3. Adventitious sound

Adventitious Lung Sounds

DISCONTINUOUS SOUNDS (CRACKLES OR RALES) are intermittent, nonmusical, and brief – like dots in time

Fine crackles (. . . . . ) are soft, high pitched, and very brief (5 – 10 msec).

Coarse crackles (• • • • • ) are somewhat louder, lower in pitch, and not quite so brief (20-30 msec).

CONTINUOUS SOUNDS are > 250 msec, notably longer than crackles – like dashes in time – but do not necessarily persist throughout the respiratory cycle. Unlike crackles, they are musical.

Wheezes ( ) are relatively high pitched (around 400 Hz or higher) and have a hissing or shrill quality.

Rhounchi ( ) are relatively low pitched (around 200 Hz or lower and have a snoring quality.

Vocal resonanceVocal resonance

Bronchophony Consolidation

Egophony Upper area of hydrothorax

Whispered Pectoriloqny Consolidation

Main symptoms and signs in Main symptoms and signs in common respiratory diseasescommon respiratory diseases

Labor pneumoniaLabor pneumonia

Symptoms Symptoms

Chill Continued fever: 39-40ºC Chest pain Tachypnea Cough Rusty sputum

Signs (1)Signs (1)

General signs Acute facial features, dyspnea Cyanosis Tachycardia Simple herpes around lips

Signs (2)Signs (2)

Inspection Decreased respiratory movement Palpation Increased vocal r

Chronic bronchitis with Chronic bronchitis with emphysemaemphysema

Symptoms Symptoms

Chronic productive cough White mucous sputum or pus sputum (infection) Exertional dyspnea Breathlessness (dyspnea) Chest depression

Signs Signs

Barrel chest Movement of respiratory Vocal fremitus HyperresonanceCardiac dullness area Decreased vesicular breath sound Prolonged expiration Moist crackles and/or rhonchi (acute episode)

Bronchial asthmaBronchial asthma

Symptom Symptom

Expiratory dyspnea with wheezing

Signs Signs

Expiratory dyspnea with wheezing Orthopnea Cyanosis Decreased movement of respiration Hyperresonance Rhonchi in full fields of lungs

HydrothoraxHydrothorax(pleural effusion)(pleural effusion)

Symptoms Symptoms

Dry cough Chest pain

Disappeared with growing of pleural effusion Reappeared with the fluid decreasing

Affected side lying Dyspnea, orthopnea The symptoms of underlying disease

Signs Signs (Moderate to massive effusion)(Moderate to massive effusion)

Tachypnea Limited movement of affected side Trachea shifts to opposite side Decreased vocal fremitus Dullness or flatness Decreased or disappeared vesicular breath sound Pleural friction rub Abnormal bronchial breath sound in upper area of the

fluid

Pneumothorax Pneumothorax

Symptoms Symptoms

Sudden chest pain Dyspnea Forced sitting position Dry cough

Tension pneumonia Progressive dyspnea Tyckycardia Cyanosis Respiratory failure

Signs Signs

Limited movement of affected side Decreased vocal fremitus Trachea and heart shift to opposite side Tympany Vesicular breath sound decreased or

disappeared