Download 9/17/98 - RollaNet

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9/17/98
Phys Dx 2
One of the most common reasons to see a physician is respiratory related symptoms/conditions
Chiro
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-- can correlate rib/muscle pain w/coughing
coughing can lead to vertebral fractures in elderly people ( especially if osteoporosis )
(can get incremental fractures)
Pt. may see Chiro for leg pain/back pain
May mention shortness of breath ( SOB)
SOB may mean lung cancer
Headache (HA)
if >50 yrs & new HA type
 could be a tumor developing
 could be vasculitis
 could be subluxation
dyspnea at rest – ask about blood in the stool etc …
- could be from a metastasized cancer
Chest Pain
 heart problems/ lung problem
 musculoskeletal
 neurological
note – lungs not usually painful until pleura are involved
other symptoms
 stridor ( noisy breathing)
 voice changed ( esp in smokers)
 swelling of ankles
 dependent edema ( heart failure, renal disease, liver disease, obstruction of venous
flow
anasarca- generalized fluid
other – problems sleeping might mean need to do a respiratory exam
** see risk factors in last lecture
COPD
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smokers – irritation, then prone to infection, then chronic bronchitis ( ex -allergies)
infiltrative respiratory problem
* things inhaled
* small cell carcinoma
* miliary TB
* Cystic Fibrosis ( CF )
smoking
- risk index = pack yrs.
= packs per day X
# of years
- other irritants also play a role
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9/17/98
Phys Dx 2
swallowing
esophageal disorders, etc…
Cough--smoking is most common cause of chronic coughing esp in AM
 Dry hacking cough – viral infection, tumor, allergies, stress
 Chronic Productive
 Asthma
 Bronchitis, TB, abscess, fungal infection, chronic bronchitis
 barking – croup
cough – explosive expiration which is a means of clearing nasal & oral cavities of junk
pleural effusion = fluid in the pleural space ( between lungs & pleural sac )
- fluid here can compress lungs
cough
Cough
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stridor – tracheal obstruction
morning – smoker, post-nasal drip
nocturnal – post nasal drip, CHF ( congestive heart failure )
assoc w/ eating – esophageal NMS ds
Croup—treat by putting kid in steamy bathroom * steam helps relax bronchioles
Bronchiectosis
 chronic dilation of bronchioles due to chronic infection, Cystic Fibrosis,etc.
 chronically stretched bronchioles accumulate pockets of fluid
Asthma--thick sputum produced – hard to cough up
croup – an old MD said that steamy air helps relax muscles, then bundle them up and take
them outside on a cold day so cold can help break up inflammation
NBQ---stridor – assoc w/ a harsh inspiratory sound (usually, but can be expiratory)
Morning cough - if pooling of secretions
- smoking, post-nasal drip
Nocturnal
 may also see w/ asthma
 heart failure – may prop themselves up on more pillows to sleep
– can get fluid build-up in the lungs
Heart failure - L ventricle compensates at 1st, but later fatigues & blood backs up, leading to
pulmonary edema (takes time)
 good diet & exercise helps
 meds (especially cholesterol meds) can harm liver
Sputum
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expelled by coughing
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75-100 ml/day normally
may contain cellular debris, mucus blood, pus, microorganisms
appearance
 mucoid and mucopurulent
– tumor asthma, early TB & chronic bronchitis, emphysema, pneumonia
 mucopurulent—all of above plus bacterial pneumonia
 purulent (rusty)—bacterial
 purulent (green/yellow)—chronic bronchitis, bronchiectasis, TB, pneumonia
 foul odor—abscess, bronchiectasis
 pink, frothy—pulmonary edema
 blood tinged—bacteria pneumonia, CHF, valve disease
 chronic bronchitis
 amount of blood important (# of tissues used)
 profuse, colorless--carcinoma
 bloody
 pulmonary emboli, TB, tumor
 abscesses, bronchiectasis, CA
 coagulation disorders (bleeding disorder)
 esophageal tears
 abdominal aorta rupture
 cardiac problem
Hemoptysis—coughing up blood
 Questions—when started, how much?
 If a lot, call 911
 Question—coughed up blood vs vomited blood (hematemesis)
 Ask about
 Blood thinners
 Oral contraceptives
 Recent surgery
 Associated symptoms—vomiting, coughing, nausea, SOB, hoarseness
Features
Preceded by
Past history
Appearance
Color
Contains
*darker color
*brighter color
Hemoptysis
coughing
Hx/CR ds.
frothy
bright red
nothing/pus
problem is past the duodenum
problem before duodenum
Table 2-5 (text)—cough and hemoptysis
Hematemesis
nausea/vomiting
Hx/GI ds.
airless
bright red or dark
food
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9/17/98
Phys Dx 2
TABLE 2-5 (from text)
Problem
Cough and Sputum
Associated Symptoms and Setting
Acute Inflammations
Laryngitis
Dry cough (without sputum), may become
productive of variable amounts of sputum
An acute, fairly minor illness with hoarseness,
Often associated with viral nasopharyngitis
Tracheobronchitis
Dry cough, may become productive (as above)
An acute, often viral illness, with burning
retrosternal discomfort.
Mycoplasma and Viral
Pneumonias
Dry hacking cough, often becoming
productive of mucoid sputum
An acute febrile illness, often with malaise,
headache, and possibly dyspnea
Bacterial Pneumonias
Pneumococcal: sputum mucoid or purulent;
maybe blood~streaked, diffusely pinkish, or rusty
An acute illness with chills, high fever,
dyspnea, and chest pain. Often is preceded
by acute upper respiratory infection.
Typically occurs in older alcoholic men.
Klebsiella: similar; or sticky, red, and jellylike
Chronic Inflammations
Postnasal Drip
Chronic cough; sputum mucoid or mucopurulent
Repeated attempts to clear the throat. Postnasal
discharge may be sensed by the patient or seen in
the posterior pharynx. Associated with
chronic rhinitis, with or without sinusitis.
Chronic Bronchitis
Chronic cough; sputum mucoid to purulent,
maybe blood-streaked or even bloody
Bronchiectasis
Chronic cough; sputum purulent, often
copious and foul-smelling; may be bloodstreaked or bloody
Often longstanding cigarette smoking. Recurrent
superimposed infections. Wheezing
and dyspnea may develop.
Recurrent bronchopulmonary infections
common; sinusitis may coexist.
Pulmonary Tuberculosis
Cough dry or sputum that is mucoid or
purulent; may be blood-streaked or bloody
Early, no symptoms. Later, anorexia, weight
loss, fatigue, fever, and night sweats
Lung Abscess
Sputum purulent and foul-smelling; may be bloody
A febrile illness. Often poor dental hygiene and a
prior episode of impaired consciousness
Asthma
Cough, with thick mucoid sputum,
especially near the end of an attack
Episodic wheezing and dyspnea, but the cough
may occur alone. Often a history of allergy
Gastroesophageal Reflux
Chronic cough, especially at night or early in
the morning
Wheezing, especially at night (often mistaken
for asthma), early morning hoarseness, and
repeated attempts to clear the throat. Often a
history of heartburn and regurgitation
Cough dry to productive; sputum maybe
blood-streaked or bloody
Usually a long history of cigarette smoking.
Associated manifestations are numerous
Left Ventricular Failure or Mitral
Stenosis
Often dry, especially on exertion or at night;
may progress to the pink frothy sputum of
pulmonary edema or to frank hemoptysis
Dyspnea, orthopnea, paroxysmal nocturnal
dyspnea
Pulmonary Emboli
Dry to productive; may be dark, bright red,
or mixed with blood
Dyspnea, anxiety, chest pain, fever; factors that
predispose to deep venous thrombosis
Irritating Particles,
Chemicals, or Cases
Variable. There may be a latent period
between exposure and symptoms.
Exposure to irritants. Eyes, nose, and throat
may be affected.
Neoplasm
Cancer of the Lung
Cardiovascular Disorders
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9/17/98
Acute
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Chronic
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Phys Dx 2
Laryngitis—dry cough (w/o sputum), may become productive; assoc. w/viral
nasopharyngitis
Tracheobronchitis—dry couch, may become productive; often viral
Viral pneumonia
Bacterial pneumonia—more chance of getting complications
Bronchitis—prone to other infections
Bronchiectasis—prone to other infections
TB—no symptoms early on; later—fatigue
Lung abscess—febrile, often dental related
Asthma—often a Hx of allergy
Cancer of lung—Hx of smoking
Coughing—often protective, but can cause problems
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Venous return to heart
 affects Heart Rate & Blood Pressure
 urinary incontinence
What can chiro do for cough (in office)
 examine further, x-ray, Gram stains, etc.
 x-ray may spot tumor
 note—chiro cannot order a cytology study
Dyspnea (SOB)—subject complaint usually
 Differential Dx—cardiopulmonary, neurologic, metabolic, psychological
 Questions
 Onset
 Pattern (position, exercise, inhale vs exhale)
 Other symptoms
 Palliative, provocative
 DOE = dyspnea on exercise (1-5 scale)
 Grade 1—with excessive activity
 Grade 2—moderate activity
 Grade 3—mild activity
 Grade 4—minimal activity
 Grade 5—at rest
 Need to be able to differentiate dyspnea from tachypnea (rapid breathing)
 Grade level is relative to their usual level of activity (an athlete’s ‘3’ might resemble a couch
potato’s ‘5’)
 Illustration (in library)
 Things that can cause SOB
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Know broad categories only (she says)
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9/17/98
Phys Dx 2
Postural Dyspneas NBQ & CBQ
 Paroxysmal nocturnal dyspnea (PND)
 Sudden onset of SOB occurring at night while pt sleeps. Pt sits up &
improves
 Orthopnea
 SOB while lying flat. Pt requires more pillows. Most commonly associated
with CHF and mitral valve disease
 Trepopnea
 Pt more comfortable breathing lying on side. Associated with CHF
 Platypnea
 Rare symptom where pt breathes easier in a recumbent position. Associated
with brain stem or spinal lesions (neurologic Ds, hypovolemia, etc)
**May see above lumped together
Pickwickian Syndrome—assoc w/severe obesity; when pt sits too long, not enough O2 gets to brain
and pt falls asleep
Dyspnea—emphysema, asthma, bronchitis, etc (see text for definitions—Table 2-4); may or may not
be associated with cyanosis
Cyanosis—location, onset, palliative/provocative; associated symptoms—SOB, cough, bleeding
 Central
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O2 in lungs
 chronic lung disease
 lips, mucous, lung beds (ex.: heart attack
blue lips)
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with warming (due to
metabolism)
 darker skinned people—look at buccal mucosa
 Peripheral
 Increased extraction of O2
 Exposure to cold
 Tips of fingers, toes, nose
 Disappears with warming
O2 intake—foreign body, emphysema
Wheezing  causes bronchiospasm
 May or may not see SOB
 Normal breath sounds—quiet, easy
 Questions
 Onset
 Occurrence
 Smoking Hx
 Palliative/provocative
 Precipitating factors (ex.: allergies)
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Chest Pain
 Cardinal sign of cardiac disease
9/17/98
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Phys Dx 2
Pulmonary disease associated with disease of chest wall or pleura (parietal)
Esophageal problems
Pneumonia
Trauma
Table 2-3—Know systems that can cause chest pain
 Cardiac
 Respiratory
 GI
 Musculoskeletal
 Psychogenic
 Neurodermal (Herpes Zoster)
 Herpes Zoster pts often treated with depression meds such as GABA, St. John’s Wort