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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 8 Respiratory symptoms
182
Cough with sputum
The majority of patients presenting with a productive cough will have a
short history of days or weeks, but many will have a background of a
chronic cough.
Some differential diagnoses and typical outline evidence
Chronic
bronchitis (with
emphysema,
part of the
entity COPD)
Suggested by: gray sputum, slow progression over
years, and a smoker (nearly always)
Confirmed by: gray sputum >3 months over 2
consecutive years
Acute viral
bronchitis
Suggested by: onset over hours or days. Fever, white
or yellow sputum
Confirmed by: no consolidation on CXR, quick
spontaneous resolution
Acute bacterial
bronchitis
Suggested by: onset over hours or days. Fever,
mucopurulent sputum, dyspnea
Confirmed by: sputum culture and sensitivities,
response to appropriate antibiotics
Pneumonia Suggested by: onset over hours or days. Rusty brown
sputum (i.e., purulent sputum tinged with blood).
Sharp chest pain worse on inspiration, pleural rub,
fever, cough, consolidation, etc.
Confirmed by: patchy shadowing on CXR (see
Figs. 19.1a, 19.1b, 19.15), sputum and blood cultures
Bronchiectasis Suggested by: progression over months or years. Finger
clubbing, copious (often cupfuls of) purulent sputum
daily. Coarse, late inspiratory crackles
Confirmed by: CXR: cystic shadowing; high-resolution
CT chest: honeycombing and thickened, dilated
bronchi (see Fig. 19.18)
Lung abscess Suggested by: copious, foul-smelling purulent or brown
sputum, hemoptysis, high fever, chest pain over weeks.
Usually preceded by a prior significant respiratory
infection (e.g., pneumonia)
Confirmed by: fluid level in cavity on CXR, CT chest,
response to physiotherapy, antibiotics, and aspiration
PERSISTENT DRY COUGH (NO SPUTUM)1
183
Persistent dry cough (no sputum)
The duration of symptoms, severity, and progression will affect the
causes of a dry cough.
Some differential diagnoses and typical outline evidence
Viral infection
with slow
recovery
Suggested by: original onset over days, fever, sore
throat, generalized aches
Confirmed by: natural history of spontaneous
improvement
Chronic asthma Suggested by: progression or static over months or
years. Worse at night and early morning. Associated
wheeze, exacerbations with exercise or atopic
exposure
Confirmed by: spirometry (reduced FEV
1
), peak expira-
tory flow rate (PEFR) chart—classical diurnal dipping
and variability, >12% improvement in spirometry with
treatment
COPD Suggested by: chronic breathlessness, little variation,
a history of smoking. Signs of hyperinflation, reduced
breath sounds, hyperresonant percussion, wheezing
Confirmed by: CXR showing generalized loss of lung
markings and flat diaphragms. Spirometry: reduced
FEV
1
/FVC, FEV
1
or FVC <12% improvement with
B-agonists. Decreased A
1
-antitrypsin levels in young
patents with genetic component
Bronchogenic
carcinoma
Suggested by: weight loss, chest pain, hemoptysis.
Smoker. Opacity with irregular outline on CXR or
CT chest (see Fig. 19.6)
Confirmed by: tumor cells in sputum or bronchoscopic
biopsy
Tuberculosis Suggested by: fever, malaise, weight loss, contact
history, characteristic CXR (see Figs. 19.7, 19.10)
Confirmed by: AFB on smear, culture of sputum or
biopsy, or response to trial of therapy
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CHAPTER 8 Respiratory symptoms
184
Hoarseness
Hoarseness of some weeks’ or months’ duration may have some sinister
causes that need urgent attention.
Some differential diagnoses and typical outline evidence
Laryngeal
carcinoma
Suggested by: progressive hoarseness over weeks to
months. Smoker, including cannabis. Dysphagia,
hemoptysis, ear pain
Confirmed by: laryngoscopy and biopsy of glottic,
supraglottic or subglottic tumor and staging
Chronic
laryngitis
Suggested by: onset over months or years. History of
recurrent acute laryngitis
Confirmed by: inflamed cords at laryngoscopy and no
other pathology
Singer’s nodes Suggested by: onset over months. Long history, often
occupational in teachers or singers from voice strain,
singing, alcohol, fumes, etc.
Confirmed by: nodules on cord at laryngoscopy.
Resolution with speech therapy or after surgical
removal
Functional
hoarseness
Suggested by: recurrence at times of stress. Able to
cough normally
Confirmed by: no other pathology at laryngoscopy
Vocal cord
paresis
due to vagal
nerve trauma,
cancer (thyroid,
esophagus,
pharynx, bron-
chus) or TB, MS,
polio, syringo-
myelia, (idiopathic
in 15%)
Suggested by: onset after surgery or otherwise over
weeks and months. Bovine cough. Symptoms of cause
Confirmed by: paresis or abnormal movement of cords
on laryngoscopy and CXR, barium swallow, MRI
HOARSENESS1
185
Myxedema Suggested by: onset over months or years. Fatigue,
puffy face, obesity, cold intolerance, bradycardia,
slowly relaxing reflexes
Confirmed by: swollen vocal cords at laryngoscopy.
iTSH, dFT4
Acromegaly Suggested by: swollen vocal cords at laryngoscopy.
Large, wide face, embossed forehead, jutting jaw
(prognathism), widely spaced teeth and large tongue
Confirmed by: IGFi, failure to suppress GH to
<2 mU/L with oral GTT. Skull X-ray confirms bony
abnormalities. Hand X-ray showing typical tufts on
terminal phalanges. MRI
or CT scan showing enlarged
pituitary fossa
Sicca syndrome Suggested by: onset over months to years. Dry mouth
and eyes
Confirmed by: clinical presentation and inflamed cords
at laryngoscopy and no other pathology
Granulomas
due to syphilis,
TB, sarcoidosis,
Wegener’s
Suggested by: onset over months with symptoms and
signs in other systems
Confirmed by: granulomata on cords at laryngoscopy.
Biopsy of cord or other affected tissues
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CHAPTER 8 Respiratory symptoms
186
Unilateral calf or leg swelling
This symptom is included here because of its frequent association with
deep venous thrombosis (DVT) and pulmonary embolus (PE). Swelling is
usually due to accumulation of extravascular fluid, possibly from
increased pressure within the veins or lymphatic vessels.
It can also be due to unilateral damage to the local small veins and
capillaries from local inflammation. Unilateral swelling thus implies local
inflammation, damage, or obstruction to a vein or lymphatic vessel. The
speed of onset allows one to imagine what process might be taking
place—traumatic, thrombotic, or infectious.
Some differential diagnoses and typical outline evidence
Deep venous
thrombosis
Suggested by: onset over hours, presence of risk factors,
e.g., obesity, immobility, carcinoma, contraceptive.
Associated pulmonary embolus.
Confirmed by: poor flow on Doppler ultrasound scan,
filling defect on venogram (now rarely done)
Ruptured
Baker’s cyst
(leaking synovial
fluid, sometimes
no cyst)
Suggested by: onset sudden over seconds, e.g., when
walking up a step. Usually known to have an arthritic knee
Confirmed by: normal flow on Doppler ultrasound scan,
no filling defect on venogram. Leakage of contrast from
joint capsule if arthrogram done soon after the event
Cellulitis Suggested by: firm, warm, tender erythema, tracking
(red lines), fever, very tender over vein, iWBC, with
onset over days
Confirmed by: skin swabs if discharge from skin, blood
cultures, response to antibiotics
Abnormal
lymphatic
drainage
caused by
lymphoma or
malignant
infiltration.
Rarely, a heredi-
tary condition
affecting young
women
Suggested by: onset over years, firm, non-tender,
non-pitting edema of gradual onset over years
Confirmed by: CT
scan or lymphoscintigraphy
(radionuclide imaging) or (rarely) lymphangiogram
Congenital
edema
(Milroy’s
syndrome)
Suggested by: presence since childhood
Confirmed by: history and CT
scan or lymphoscintigraphy
(radionuclide imaging) or (rarely) lymphangiogram
Chapter 9
187
Respiratory signs
Examination of the respiratory system 188
Appearance suggestive of blood gas disturbance 189
Respiratory rate low (<10/minute) 190
Chest wall abnormalities 191
Bilateral poor chest expansion 192
Unilateral poor chest expansion 193
Trachea displaced 194
Reduced vocal fremitus 195
Stony dull percussion 196
Dull to percussion but not stony dull 198
Hyperresonant percussion 199
Diminished breath sounds 200
Bronchial breathing 202
Fine inspiratory crackles 203
Coarse crackles 204
Pleural rub 204
Stridor ± inspiratory wheeze 205
Inspiratory rhonchus or wheeze 206
Expiratory rhonchus 207
Expiratory polyphonic, high-pitched wheeze 208
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CHAPTER 9 Respiratory signs
188
Examination of the respiratory system
The findings discussed here are presented in a sequence of those found
on inspection, palpation, percussion, and then auscultation. While inspect-
ing the patient, think of the arterial blood gas, and when palpating, think of
the mechanisms of ventilation. When percussing, think of the pleural
surfaces, contents of the pleural cavity, and lung tissue. When auscultating,
think of the state of the lung tissue and the airways.
APPEARANCE SUGGESTIVE OF BLOOD GAS DISTURBANCE1
189
Appearance suggestive of blood
gas disturbance
Look for dyspnea, tachypnea, and slow respiratory rate. Examine the
patient’s fingers for peripheral cyanosis and the skin for warmth. Look at
the tongue and lips for central cyanosis.
Some differential diagnoses and typical outline evidence
Hypoxia Suggested by: cyanosis of fingers and/or lips, restlessness,
confusion, drowsiness
Confirmed by: dPaO
2
on blood gas analysis (or pulse
oximetry of <90% (mild) or <80% (severe)
Carbon dioxide
retention
Suggested by: slow respiratory rate, warm hands,
bounding pulse, dilated veins on hands and face,
twitching of facial muscles, changed mental status
Confirmed by: iPaCO
2
on blood gas analysis
Hypocapnia Suggested by: tachypnea, hyperventilation, dizziness,
paresthesias of lips
Confirmed by: dPaCO
2
on blood gas analysis
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CHAPTER 9 Respiratory signs
190
Respiratory rate low (<10/minute)
Count the number of respirations in a minute.
Some differential diagnoses and typical outline evidence
Carbon dioxide
narcosis (very
high blood
carbon dioxide)
Suggested by: warm hands, bounding pulse, dilated
veins on hands and face, twitching of facial muscles,
drowsy
Confirmed by: iPaCO
2
on blood gas analysis
Drugs, e.g.,
opiates, alcohol,
benzodiazepines
Suggested by: Pin-point pupils (in opiates—track
marks). History of ingestion, empty medication bottle
Confirmed by: response to drug withdrawal or
antidotes, e.g., naloxone, flumazenil. Drug levels on
toxicology screen
Raised
intracranial
pressure
Suggested by: papilledema, focal neurology, severe
headaches, and vomiting
Confirmed by: CT brain (loss of normal sulci, edema)
CHEST WALL ABNORMALITIES1
191
Chest wall abnormalities
Inspect the chest shape and then its change on movement for asymmetry,
looking up over the abdomen.
Some differential diagnoses and typical outline evidence
Pectus
carinatum
developmental
or associated
with emphysema
Suggested by: prominent sternum, often associated
with in-drawing of the ribs, causing Harrison’s sulci
above the costal margins
Confirmed by: CXR
Pectus
excavatum
developmental
defect
Suggested by: depression of the lower end or whole
sternum
Confirmed by: CXR
Kyphosis
congenital or
due to anterior
collapse of spinal
vertebrae, e.g.,
spinal TB
Suggested by: spine curved forward and laterally
Confirmed by: CXR, spinal X-ray
Scoliosis
congenital,
neuromuscular
disease, previous
surgery, TB
Suggested by: spine curved laterally
Confirmed by: CXR, spinal X-ray
Absence of part
of chest wall
bone structure
congenital
(Poland’s
syndrome) or
post-surgery
Suggested by: absence of ribs, pectoralis muscle,
clavicle, etc.
Confirmed by: CXR
, spinal X-ray
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