الرحمن الله بسمالرحيم

الرحمن الله بسمالرحيم

Symptoms and signsSymptoms and signs of the respiratory of the respiratory systemsystem

M.Abbas M.Abbas

Symptoms of the Symptoms of the respiratory system respiratory system

Symptoms of the respiratory tractSymptoms of the respiratory tract History of previous illness History of previous illness Family and social history Family and social history

The six principal The six principal symptoms of the symptoms of the respiratory tractrespiratory tract CoughCough Sputum Sputum HaemoptysisHaemoptysis DyspneaDyspnea Chest painChest pain WheezeWheeze

CoughCough

Cough is a common presenting respiratory symptom.Cough is a common presenting respiratory symptom. It occurs when deep inspiration is followed by It occurs when deep inspiration is followed by

explosive expiration.explosive expiration. Coughing enables the airways to be cleared of Coughing enables the airways to be cleared of

secretions and foreign bodies. secretions and foreign bodies. The duration of a cough is important. The duration of a cough is important. A cough of recent origin, particularly if associated A cough of recent origin, particularly if associated

with fever and other symptoms of respiratory tract with fever and other symptoms of respiratory tract infection, may be due to acute bronchitis or infection, may be due to acute bronchitis or pneumonia.pneumonia.

A chronic cough associated with wheezing may be A chronic cough associated with wheezing may be due to asthma; sometimes asthma can present with due to asthma; sometimes asthma can present with just cough alone. just cough alone.

An irritating chronic dry cough can result from An irritating chronic dry cough can result from oesophageal reflux and acid irritation of the lungs.oesophageal reflux and acid irritation of the lungs.

It may be a feature of late interstitial pulmonary It may be a feature of late interstitial pulmonary fibrosis.fibrosis.

A similar cough is not uncommonly associated with A similar cough is not uncommonly associated with the use of the angiotensin-converting enzyme (ACE) the use of the angiotensin-converting enzyme (ACE) inhibitors-drugs used in the treatment of hypertension inhibitors-drugs used in the treatment of hypertension and cardiac failure.and cardiac failure.

Cough that wakes a patient from sleep may be a Cough that wakes a patient from sleep may be a symptom of cardiac failure or of the reflux of acid from symptom of cardiac failure or of the reflux of acid from the oesophagus into the lungs that can occur when a the oesophagus into the lungs that can occur when a person lies down.person lies down.

A chronic cough that is productive of large volumes of A chronic cough that is productive of large volumes of purulent sputum may be due to bronchiectasis. purulent sputum may be due to bronchiectasis.

A change in the character of a chronic cough may A change in the character of a chronic cough may indicate the development of a new and serious indicate the development of a new and serious underlying problem (e.g. infection or lung cancer). underlying problem (e.g. infection or lung cancer).

Patients' descriptions of their cough may be helpful. A Patients' descriptions of their cough may be helpful. A cough associated with inflammation of the epiglottis cough associated with inflammation of the epiglottis may have a barking quality. Cough caused by tracheal may have a barking quality. Cough caused by tracheal compression by a tumour may be loud and brassy. compression by a tumour may be loud and brassy. Cough associated with recurrent laryngeal nerve palsy Cough associated with recurrent laryngeal nerve palsy has a hollow sound because the vocal cords are has a hollow sound because the vocal cords are unable to close completely; this has been described as unable to close completely; this has been described as a bovine cough. A cough that is worse at night is a bovine cough. A cough that is worse at night is suggestive of asthma or heart failure, while coughing suggestive of asthma or heart failure, while coughing that comes on immediately after eating or drinking that comes on immediately after eating or drinking may be due to a tracheo-oesophageal fistula or may be due to a tracheo-oesophageal fistula or oesophageal reflux.oesophageal reflux.

It is an important (though perhaps a somewhat unpleasant task) It is an important (though perhaps a somewhat unpleasant task) to inquire about the type of sputum produced and then to look to inquire about the type of sputum produced and then to look at it, if it is available. Be warned that some patients have more at it, if it is available. Be warned that some patients have more interest in their sputum than others and may go into more detail interest in their sputum than others and may go into more detail than you really want. A large volume of purulent (yellow or than you really want. A large volume of purulent (yellow or green) sputum suggests the diagnosis of bronchiectasis or lobar green) sputum suggests the diagnosis of bronchiectasis or lobar pneumonia. Foul-smelling dark-coloured sputum may indicate pneumonia. Foul-smelling dark-coloured sputum may indicate the presence of a lung abscess with anaerobic organisms. Pink the presence of a lung abscess with anaerobic organisms. Pink frothy secretions from the trachea, which occur in pulmonary frothy secretions from the trachea, which occur in pulmonary oedema, should not be confused with sputum. oedema, should not be confused with sputum.

Haemoptysis (coughing up of blood) can be a sinister sign of Haemoptysis (coughing up of blood) can be a sinister sign of lung disease (Table 4.2) and must always be investigated. It is lung disease (Table 4.2) and must always be investigated. It is best to rely on the patient's assessment of the taste of the best to rely on the patient's assessment of the taste of the sputum, which, not unexpectedly, is foul in conditions like sputum, which, not unexpectedly, is foul in conditions like bronchiectasis or lung abscess. bronchiectasis or lung abscess.

Causes of haemoptysisCauses of haemoptysis

RespiratoryRespiratory Bronchitis Bronchial carcinoma Bronchitis Bronchial carcinoma Bronchiectasis Pneumonia (The above four Bronchiectasis Pneumonia (The above four account for about 80% of cases) Pulmonary account for about 80% of cases) Pulmonary infarction Cystic fibrosis Lung abscess infarction Cystic fibrosis Lung abscess Tuberculosis Foreign body Goodpasture's* Tuberculosis Foreign body Goodpasture's* syndrome: pulmonary haemorrhage, syndrome: pulmonary haemorrhage, glomerulonephritis, antibody to basement glomerulonephritis, antibody to basement membrane antigens Rupture of a mucosal membrane antigens Rupture of a mucosal blood vessel after vigorous coughing blood vessel after vigorous coughing CardiovascularCardiovascular Mitral stenosis (severe) Acute Mitral stenosis (severe) Acute left ventricular failure left ventricular failure Bleeding diathesesBleeding diatheses

Breathlessness Breathlessness (dyspnoea)(dyspnoea) The awareness that an abnormal amount of work is The awareness that an abnormal amount of work is

required for breathing is called dyspnoea. It can be due required for breathing is called dyspnoea. It can be due to respiratory or cardiac disease (page 29). Careful to respiratory or cardiac disease (page 29). Careful questioning about the timing of onset, severity and questioning about the timing of onset, severity and pattern of dyspnoea is helpful in making the diagnosis.pattern of dyspnoea is helpful in making the diagnosis.11 The patient may be aware of this only on heavy exertion The patient may be aware of this only on heavy exertion or have much more limited exercise tolerance. Dyspnoea or have much more limited exercise tolerance. Dyspnoea can be graded from I to IV based on the New York Heart can be graded from I to IV based on the New York Heart Association classification: Class I-disease present but no Association classification: Class I-disease present but no dyspnoea or dyspnoea only on heavy exertion dyspnoea or dyspnoea only on heavy exertion

Class II-dyspnoea on moderate exertion Class II-dyspnoea on moderate exertion Class III-dyspnoea on minimal exertion Class III-dyspnoea on minimal exertion Class IV-dyspnoea at rest Class IV-dyspnoea at rest

It is more useful, however, to determine the amount of exertion that It is more useful, however, to determine the amount of exertion that actually causes dyspnoea-that is, the distance walked or the number of actually causes dyspnoea-that is, the distance walked or the number of steps climbed. The association of dyspnoea with wheeze suggests steps climbed. The association of dyspnoea with wheeze suggests airways disease, which may be due to asthma or chronic obstructive airways disease, which may be due to asthma or chronic obstructive pulmonary disease (chronic airflow limitation). The duration and pulmonary disease (chronic airflow limitation). The duration and variability of the dyspnoea are important. Dyspnoea that worsens variability of the dyspnoea are important. Dyspnoea that worsens progressively over a period of weeks, months or years may be due to progressively over a period of weeks, months or years may be due to pulmonary fibrosis.pulmonary fibrosis. Dyspnoea of more rapid onset may be due to an Dyspnoea of more rapid onset may be due to an acute respiratory infection (including bronchopneumonia or lobar acute respiratory infection (including bronchopneumonia or lobar pneumonia) or to pneumonitis (which may be infective or secondary to a pneumonia) or to pneumonitis (which may be infective or secondary to a hypersensitivity reaction). Dyspnoea that varies from day to day or even hypersensitivity reaction). Dyspnoea that varies from day to day or even from hour to hour suggests a diagnosis of asthma. Dyspnoea of very from hour to hour suggests a diagnosis of asthma. Dyspnoea of very rapid onset associated with sharp chest pain suggests a pneumothorax. rapid onset associated with sharp chest pain suggests a pneumothorax. Dyspnoea that is described by the patient as inability to take a breath Dyspnoea that is described by the patient as inability to take a breath big enough to fill the lungs and associated with sighing suggests big enough to fill the lungs and associated with sighing suggests anxiety. Dyspnoea that occurs on moderate exertion may be due to the anxiety. Dyspnoea that occurs on moderate exertion may be due to the combination of obesity and a lack of physical fitness (a not uncommon combination of obesity and a lack of physical fitness (a not uncommon occurrence). occurrence).