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1 9/17/98 Phys Dx 2 One of the most common reasons to see a physician is respiratory related symptoms/conditions Chiro - -- 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 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 2 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 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 expelled by coughing 3 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 4 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 5 9/17/98 Acute Chronic 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 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 Know broad categories only (she says) 6 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 O2 in lungs chronic lung disease lips, mucous, lung beds (ex.: heart attack blue lips) 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) 7 Chest Pain Cardinal sign of cardiac disease 9/17/98 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