Diseases » Chronic Sinusitis » Diagnosis

Diagnosis of Chronic Sinusitis

Chronic Sinusitis Diagnosis: Book Excerpts

• Ask the following questions - COUGH
• Differential Diagnosis - Cough - Nonproductive
• Differential Diagnosis - Cough - Productive
• Differential Diagnosis - Cough – Acute
• Differential Diagnosis - Cough – Chronic
• Approach to the Diagnosis - COUGH
• History and physical examination - Cough, barking
• History and physical examination - Cough, nonproductive
• History and physical examination - Cough, productive
• Diagnosis - Sinusitis
• Diagnosis - Whooping cough
• History and physical examination - Cough, barking
• History and physical examination - Cough, nonproductive
• History and physical examination - Cough, productive
• History - Cough
• Differential Overview - Acute Cough
• Differential Overview - Chronic Cough
• Diagnosis - Sinusitis
• History - Cough, barking
• History - Cough, productive
• History - Cough, barking
• History - Cough, nonproductive
• History - Cough, productive
• Clinical Features and Diagnosis - Cough
• History and physical examination - Cough, barking
• History and physical examination - Cough, nonproductive
• History and physical examination - Cough, productive
• Approach to the Diagnosis - COUGH

Diagnosis of Chronic Sinusitis: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Chronic Sinusitis:

• Sinusitis factor in prolonged cough
• More news »

Diagnostic Tests for Chronic Sinusitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Chronic Sinusitis.

COUGH: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it acute or chronic? Acute onset of a cough would suggest an acute URI, viral pneumonia, or bronchopneumonia. A chronic cough is more suggestive of pneumoconiosis, chronic bronchitis, emphysema, bronchiectasis, tuberculosis, carcinoma of the lung, or bronchial asthma.
2. Is there exposure to toxic fumes? The most common toxic fume is cigarette smoke. However, if one asks the patient's occupation one might find that he is a miner and therefore pneumoconiosis comes to mind. One might find that he is an aircraft maker or shipbuilder, in which case berylliosis and asbestosis would come to mind, or that he is a farmer and, therefore, farmer's lung would come to mind.
3. Is there significant sputum production? If so, what is the nature of the sputum? Purulent sputum would suggest a pneumonia, abscess, tuberculosis, or bronchiectasis; bloody sputum would suggest carcinoma of the lung, tuberculosis, and bronchiectasis; mucoid sputum would suggest asthma. If the sputum is foamy, one would consider congestive heart failure, mitral stenosis, and inhalation of poison gas.
4. Is there fever? If there is fever associated with the cough, obviously one would suspect an infectious process to be present. This could be viral or bacterial. Most likely the patient has bronchopneumonia, but the possibility of an abscess or pulmonary infarct would still have to be entertained.
5. What other symptoms and signs are associated with the cough? The first thing to be considered would be dyspnea. In acute cases dyspnea would be a sign of congestive heart failure, pulmonary embolism and, of course, advancing pneumonia. In chronic cases dyspnea would be a sign of emphysema, chronic pulmonary fibrosis, and chronic congestive heart failure. Wheezing would be a sign of asthma or congestive heart failure, but of course it is also found in pulmonary emphysema. Cardiomegaly would suggest congestive heart failure and if there is an associated murmur, that makes congestive heart failure even more likely. If there is hepatosplenomegaly, one would suspect a systemic disease involving the lungs such as periarteritis nodosa or other collagen diseases.
6. Is the patient taking drugs? Angiotensin-converting enzyme (ACE) inhibitors such as captopril are well known to cause cough.

DIAGNOSTIC WORKUP

If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.

Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H ₂ antagonist may also be diagnostic.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Cough - Nonproductive: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Smoker's cough
• Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
  –Most common cause of chronic cough in nonsmokers

• GERD
  –Second most common cause of chronic cough in nonsmokers

• Asthma/reactive airway disease
  –Classic triad of chronic cough, dyspnea, and wheezing

ACE inhibitor use

Acute bronchitis
–Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
–Postviral bronchitis may last beyond 6 weeks

Pneumonia
–“Typical” pneumonia (e.g., Streptococcus pneumoniae, Haemophilus influenzae, or influenza/parainfluenza viruses) is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
–“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia) is characterized by more gradual onset, dry cough, headache, fatigue, and minimal lung signs

Aspirated foreign body
–Abrupt onset of unilateral wheezing or stridor, cough, decreased breath sounds
–Leading cause of home accidental death in children younger than 6 (boys >girls)

• Lung cancer
  –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)

COPD (emphysematous variant)

Sarcoidosis

• Cryptogenic organizing pneumonia
  –Most commonly occurs following viral infection or exposure

Congestive heart failure

Filarial disease

Aspiration

Workup and Diagnosis

• Complete history and physical examination
  –Note acute (<3 weeks) versus chronic or recurrent
• Initial tests may include CBC, pulse oximetery, ESR, peak flow measurements, PPD, and eosinophil count
• Chest X-ray and/or CT if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
• Consider blood and sputum cultures
• Initial empiric treatment of postnasal drip (antihistamine, decongestant, nasal steroids), asthma (trial of bronchodilators or a methacholine challenge test), and/or GERD (proton pump inhibitor) may be advisable
• If imaging is normal and empiric treatment for GERD does not resolve symptoms, proceed with upper GI endoscopy or esophageal pH monitoring
• Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
• Consider bronchoscopy to identify subtle pulmonary causes
• Consider cardiac workup if pulmonary and GI evaluations are negative

>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough - Productive: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
  –Most common cause of chronic cough in nonsmokers
• Acute bronchitis
  –Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
  –Bacteria are much less common (e.g., Streptococcus pneumoniae, Mycoplasma, Haemophilus influenzae)
• Pneumonia
  –May be community-acquired, hospital-acquired, or due to aspiration
  –“Typical” pneumonia (e.g., S. pneumoniae, H. influenzae, influenza virus) has acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and productive cough
  –“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia, Pneumocystis carinii) has more gradual onset, dry cough, headache, fatigue
• Smoker's cough
• Lung cancer
  –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)
• Asthma with secondary infection
• COPD (chronic bronchitis component)
• Congestive heart failure
  –Associated with “frothy” sputum
• Tuberculosis

Workup and Diagnosis

• Complete history and physical examination
  –Note acute (<3 weeks) versus chronic or recurrent
• Initial tests may include CBC, pulse oximetry, ESR, peak flow measurements, PPD, chest X-ray, blood cultures, sputum Gram stain and culture, and acid-fast stain for tuberculosis
• Pulmonary function tests with or without methacholine challenge
• Chest CT and/or sputum cytology if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
• Initial empiric treatment for postnasal drip (antihistamine, decongestant, nasal steroids)
• Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
• Consider bronchoscopy with possible bronchoalveolar lavage and/or biopsy
>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Upper airway disease
  –URI or common cold accounts for much pediatric coughing (influenza, parainfluenza, rhinovirus)
  –Chronic sinusitis, tonsillitis, laryngitis, and croup are other common infections
  –Allergic disease
  –Vocal cord dysfunction (VCD)

• Lower airway disease
  –Asthma is inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs (the most common triggers for asthma are viral disease, irritants such as ETS, allergic disease, and gastroesophageal reflux)
  –Infectious diseases: Bronchiolitis, caused by RSV in babies, causes cough from inflammatory changes and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure; other viral lower airway diseases include adenovirus, influenza, and parainfluenza
  –Foreign body aspiration
  –Chronic diseases (e.g., cystic fibrosis and bronchiectasis) and structural abnormalities (e.g., PCD, TEF, or cleft, rings, and slings) may present with intermittent rather than chronic cough

• Parenchymal and pleural disease
  –Infectious diseases account almost exclusively for all parenchymal and pleural causes of cough (i.e., pneumonia and empyema)
  –Usual infectious agents include bacterial disease (e.g., streptococcal, staphylococcal) and atypical pneumonias (e.g., Mycoplasma pneumoniae), TB
  –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger cough

Workup and Diagnosis

• History
  –What started it? History (e.g., infection or FB aspiration) may suggest a mechanism
  –What makes it worse? Activity leading to cough may suggest asthma or structural disease; seasonal onset suggests allergic disease; night cough suggests GER
  –Is the cough productive? Infection is the primary cause of sputum production; also consider asthma, bronchiectasis, smoking, or CF
• Physical exam
  –Loud, “brassy,” vibrato, honking quality suggests tracheomalacia
  –High-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis)
  –Violent paroxysms with an inspiratory whoop suggests pertussis syndrome
  –A productive, “wet” cough suggests bronchitis or pneumonia
  –A wheezy, “tight” cough suggests asthma
• Studies
  –CXR may demonstrate an atypical pneumonia
  –Pulmonary function tests to diagnose asthma or large airway obstruction
  –Bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
  –V/Q scan may diagnose a pulmonary embolus (rare)
• Exercise testing may provoke symptoms of exercise-induced asthma or VCD

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Cough – Chronic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Lower airway disease
  –Asthma
       –Inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs
  –The most common triggers for asthma are viral disease, irritants (e.g., ETS), allergic disease, and GER
  –Airway infections: Bronchiolitis, caused by RSV in babies, may cause chronic cough from persistent inflammatory change and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure
  –Foreign body: Associated with endobronchial infection and damage
  –Cystic fibrosis: The most common life-threatening inherited illness of whites, is associated with production of chronically infected sputum
  –Bronchiectasis: Chronic infection and damage to the airway; may be secondary to another disease (e.g., TB or CF)
  –Structural abnormalities: PCD, TEF, or cleft, rings, slings

• Upper airway disease
  –Infectious diseases: Chronic sinusitis, tonsillitis, laryngitis, including that secondary to GER (although acute disorders, the inflammation from URI may be associated with a chronic cough if frequent enough)
• Parenchymal and pleural disease
  –Infectious disease accounts almost exclusively for all parenchymal and pleural causes of cough (e.g., pneumonia and empyema)
  • CNS causes
    –CNS causes of cough include “habit cough” (or psychogenic cough), Tourette disease associated “cough tic” or throat clearing, VCD
    –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger chronic cough

  Workup and Diagnosis

  • History
    –Cough lasting longer than 2–6 weeks suggests either a predisposing factor (e.g., bronchomalacia) or an ongoing trigger (e.g., asthma)
    –An acute lung or airway injury (i.e., infection or FB) suggests a mechanism for chronic cough
    –An insidious onset is more consistent with a chronic underlying condition (i.e., CF, TB, GER)
    –Seasonal change suggests allergic disease
    –Night cough suggests GER
    –A positive response to asthma therapy suggests asthma
    –Antibiotic responsiveness suggests chronic infection (i.e., CF, bronchiectasis, sinusitis)
    –Distractability suggests habit cough, as may a lack of coughing while asleep
    –Is the cough productive? Culture sputum and consider asthma, bronchiectasis, smoking, or CF
  • Physical exam: Loud, “brassy,” vibrato, honking quality suggests tracheomalacia; high-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis); violent paroxysms with an inspiratory whoop suggest pertussis syndrome
  • Studies: Chest films often not diagnostic; PFT to diagnose asthma or large airway obstruction; bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
  • Exercise testing may provoke symptoms of EIA or VCD

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

COUGH: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. An allergic history (e.g., hay fever) is important. Careful exclusion of cardiovascular disease should be done, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Cough, barking: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, nonproductive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed;  anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as a cough. Ask the patient at risk for TB — one born in another country, in contact with acute TB, or with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, productive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes. (See Productive cough: Common causes and associated findings, page 168.)

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Sinusitis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

The following measures are useful:

❑ Antral puncture promotes drainage of purulent material. It may also be used to provide a specimen for culture and sensitivity testing of the infecting organism, but it’s seldom performed.

❑ Nasal examination reveals inflammation and pus.

❑ Sinus X-rays reveal cloudiness in the affected sinus, air and fluid, and any thickening of the mucosal lining.

❑ Transillumination is a simple diagnostic tool that involves shining a light into the patient’s mouth with his lips closed around it. Infected sinuses look dark and normal sinuses transilluminate.

❑ Ultrasound, computed tomography scan, magnetic resonance imaging, and X-rays aid in diagnosing suspected complications.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Whooping cough: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Classic clinical findings, especially during the paroxysmal stage, suggest this diagnosis; laboratory studies will confirm it. Nasopharyngeal swabs and sputum cultures show B. pertussis only in the early stages of this disease; fluorescent antibody screening of nasopharyngeal smears provides quicker results than cultures but is less reliable. In addition, the white blood cell (WBC) count is usually increased, especially in children older than age 6 months and early in the paroxysmal stage. Sometimes, the WBC count may reach 175,000 to 200,000/µl, with 60% to 90% lymphocytes.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Cough, barking: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, nonproductive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when his cough began and whether any body position, time of day, or specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has any pain associated with coughing, breathing, or activity, when did it begin and where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also ask about recent changes in his appetite, weight, exercise tolerance, or energy level; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

Cultural Cue: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB—those born in another country, those in contact with acute TB, and those with high-risk behaviors—about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note wheezing or “crowing” noises that occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, productive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of the cough. What is the type of cough (barking, brassy, wheezy, nocturnal, paroxysmal)? What are the duration, timing, and triggers? Are there associated symptoms of fever, sputum production, dypsnea, hemoptysis, and weight loss? Are there clear relieving factors? Ask specifically about postnasal drip as patients often do not volunteer this information. A good history is the key to diagnosis.

1. Upper respiratory causes most commonly relate to postnasal drip. In adults, sinusitis, pharyngitis, and allergic rhinitis should be considered. In children, concomitant otitis media should be excluded.

2. Lower respiratory causes include lung (bronchitis, asthma, pneumonia, bronchiectasis, and in children, foreign body aspiration) and cardiac [congestive heart failure (CHF) and mitral stenosis].

3. Nonrespiratory causes include GERD, drug effects [e.g., angiotensin converting enzyme (ACE)-inhibitors], and psychogenic.

B. Smoking patients should be identified early as bronchitis and lung cancer are possibilities. Passive smoking is also a risk factor, especially in children. Office visits for cough represent teachable moments for smoking cessation education. Smoking cessation has been shown to reduce respiratory symptoms by 50%.

 C. Psychosocial impact of the cough reflects severity and the need for further workup. Has the patient missed school or work? Is the sleeping partner disturbed? Is there avoidance of exercise because it triggers cough? In chronic, episodic cough, a correct diagnosis of asthma can considerably improve quality of life. A psychogenic cause for cough and behavioral problems in children may be unmasked here.

D. Other information. Associated chest pain should direct the history toward pleurisy or rib fracture secondary to chronic cough. Occupational exposures (toxic fumes, chemicals, birds and animals), systemic diseases [rheumatoid arthritis, breast and prostate cancer metastases, human immunodeficiency virus disease (HIV)] and drug exposure (ACE-inhibitors, cyclophosphamide, and methotrexate) are important factors to consider in the cause. Cough with significant weight loss should trigger a workup for TB, HIV, or lung cancer in the smoker.

Physical examination

 A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

 B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Acute Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Viral upper respiratory infection

❑ Asthma

❑ Sinusitis

❑ Mycoplasma bronchitis

❑ Pneumonia

❑ Gastroesophageal reflux

❑ Congestive heart failure

❑ ACE inhibitor

❑ Aspiration

❑ Cough in HIV

❑ Thermal

❑ Fume inhalation

❑ Pertussis

❑ Lung abscess

Diagnostic Approach

The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.

Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.

A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Upper respiratory infection

❑ Allergy

❑ Asthma

❑ Chronic bronchitis

❑ Chronic sinusitis

❑ Gastroesophageal reflux

❑ ACE inhibitor

❑ Pollutants

❑ Psychogenic

❑ Foreign body

❑ Congestive heart failure

❑ Lung cancer

❑ Tuberculosis

❑ Mediastinal mass

❑ Bronchiectasis

❑ Pulmonary fibrosis

❑ Cystic fibrosis

❑ Aspergillosis

Diagnostic Approach

Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Sinusitis: Diagnosis
(Handbook of Diseases)

The following measures are useful:

❑ Nasal examination reveals inflammation and pus.

❑ Sinus X-rays reveal cloudiness in the affected sinus, air and fluid, and any thickening of the mucosal lining.

❑ Antral puncture promotes drainage of purulent material. It may also be used to provide a specimen for culture and sensitivity testing of the infecting organism but is rarely done.

❑ Ultrasonography and computed tomography (CT) scan aid in diagnosing suspected complications. CT scans are more sensitive than routine X-rays in detecting sinusitis.

❑ Magnetic resonance imaging is also helpful.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Cough, barking: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Determine when the barking cough began and other associated signs and symptoms. Determine when the child first appeared to be ill and ask if there have been previous episodes of croup syndrome.

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

Physical examination

Assess the respiratory system, noting rate and pattern of respirations. Assess the patient for signs of hypoxia. Stay alert for signs of airway obstruction (nasal flaring, sternal retraction, stridor).

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, productive: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Determine the onset of the cough and amount of daily sputum production. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) Determine the time of day that the most sputum is produced and relationship of food to sputum production. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

Determine cough characteristics. A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Ask the patient about cigarette, drug, and alcohol use and if there has been weight or appetite changes. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. Determine a medication history, including over-the-counter medications. Ask the patient if his work involves chemicals or respiratory irritants.

Physical examination

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for jugular vein distention, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, barking: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, nonproductive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when his cough began and whether body position, time of day, or specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, productive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When the patient’s condition permits, ask when the cough began, and find out how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [88.7 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats, or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants, such as silicone?

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection/Inflammation

Upper Respiratory Tract Infection

URI (commoncold) is acute viral infection.

Common pathogens include rhinoviruses,parainfluenza viruses, respiratory syncytial virus (RSV), and coronaviruses.Other viruses that occasionally cause common cold are adenoviruses,enteroviruses, influenza viruses, and reoviruses.

Usual clinical findings are watery,mucoid, or purulent discharge; dry, hacking cough; and inflamednasal mucosa.

Diagnosis is clinical.

Sinusitis

Usuallypresents with history of purulent nasal discharge and persistentcough of >10 days' duration. Less common presentationis combination of fever, headache, and facial pain or sinus tenderness.

Usually clinical diagnosis.

CT should be performed when orbitalabscess or intracranial complication is suspected.

Laryngitis

Most frequentcause is viral URI.

Hoarseness and dry, hacking cough,which may last up to 1 wk, are usual clinical findings.

Usually clinical diagnosis.

Croup

Characterizedby a barking cough and stridor ± fever.

See Chap.63, Stertor, Stridor, and Airway Obstruction.

Tracheitis

Often crouplikeillness with cough and stridor precedes sudden onset of respiratory distressand high fever.

Clinical picture suggests bacterialtracheitis.

See Chap.63, Stertor, Stridor, and Airway Obstruction.

Bronchitis

Inflammatoryprocess affecting trachea and bronchi. Most episodes are causedby viruses (e.g., RSV, parainfluenza viruses, influenza viruses,rhinoviruses, and adenoviruses).

Hacking cough appears several daysafter onset of typical URI. Rhonchi may be heard, but crackles areinfrequent. Presence of wheezing usually indicates presence of reactiveairways disease.

Usually clinical diagnosis.

Pertussis

B. pertussisinfection begins with nasal discharge, which is followed by paroxysmal coughthat often has staccato quality. Whoop may follow paroxysm.

Fever may or may not occur.

There is usually leukocytosis withpredominance of lymphocytes.

Apnea is serious complication, especiallyin young infants.

Duration of illness may be as longas 6–10 wks.

Chest radiograph may be normal or showperihilar infiltrates.

Positive direct immunofluorescent assayof nasopharyngeal secretions suggests diagnosis, but false-positiveand false-negative results occur.

Positive nasopharyngeal culture confirmsdiagnosis.

Bronchiolitis

Usuallycaused by RSV and occasionally by parainfluenza viruses, influenzaviruses, and adenoviruses.

Occurs during winter months, oftenin epidemics.

Rhinorrhea usually precedes cough,which may be persistent and harsh. Expiratory wheezing is prominentfinding.

See Chap.75, Wheezing.

Pneumonia

Definedas inflammation of lung parenchyma that may be caused by infection.

Frequently presents with fever, cough,and respiratory distress. Crackles and wheezes may be heard on exam.Decreased breath sounds and dullness to percussion indicate areaof lung consolidation.

Presence of pneumonia usually can beconfirmed by chest radiography, although early in illness radiographcan appear normal.

Specific cause requires further investigation.

Viral

Accountsfor most cases of pneumonia in infancy and childhood.

Most common viruses causing pneumoniainclude RSV, parainfluenza viruses, adenoviruses, and influenzaviruses. Less common causes are rhinoviruses and coronaviruses.

Cytomegalovirus and herpes simplexvirus may cause pneumonia in newborn or in immunocompromised individuals.

May also be caused by measles, varicella,and Hantavirus infection.

Chest radiograph frequently shows involvementof both lungs, with peribronchial thickening, perihilar linear densities,and patchy infiltrates. Segmental or lobar consolidation, hilaradenopathy, and pleural effusions are unusual.

Nasal wash cultures or polymerase chainreaction (PCR) of nasal secretions may sometimes diagnose specificviral infection.

RSV antigen may be detected by enzymeimmunoassay or immunofluorescent techniques.

Bacterial

Pathogenscausing bacterial pneumonia vary with age of child.

Most common causes of bacterial pneumoniain neonates are group B Streptococcus and gram-negative entericbacteria (E. coli, K. pneumoniae, P. aeruginosa).

In infancy, childhood, and adolescence,S. pneumoniae is most common, whereas S. aureus and group A Streptococcusare much less common.

H. influenzae type b has become unusualcause of pneumonia, since advent of H. influenzae vaccine.

M. tuberculosis can cause infectionat any age.

Clinical findings with bacterial pneumoniausually include fever, cough that may be productive of sputum inolder child, and some degree of respiratory distress.

Leukocytosis with predominance of polymorphonuclearleukocytes is common finding.

Pleural effusions and pneumatocelesare more frequent with bacterial pneumonia than with viral pneumonia.

Chest radiograph usually shows segmentalor lobar infiltrate.

Diagnosis of bacterial pneumonia canbe confirmed by positive blood, pleural fluid, or lung biopsy cultures.McCarthy et al. (1999) demonstrated that PCR may be used to diagnosepneumonia caused by S. pneumoniae using sample of pleural fluid.

Pharyngeal or sputum culture that haslarge numbers of single organism is suggestive but not diagnostic.

Counterimmune electrophoresis and latexagglutination tests have successfully detected bacterial antigensof S. pneumoniae, group B Streptococcus, and H. influenzae typeb in urine, so these tests may be diagnostic.

Tuberculosis

Usual modeof transmission of M. tuberculosis infection is by inhalation.

Positive skin test with PPD may beobserved 2–12 wks after exposure.

Children with disease usually haveprimary pulmonary TB with cough and fever.

In most cases of TB infection, individualis asymptomatic, primary complex of infection is not seen on chestradiograph, and disease does not progress.

In TB disease, individual has clinicalor radiographic findings and disease may be pulmonary or nonpulmonary.

Chest radiograph shows involvementof segment or lobe, usually with enlarged regional lymph nodes.With progression, cavitary lesions or miliary disease can occur.

Acid-fast bacilli smears and culturesshould be performed in anyone with suspected TB. In young child,especially if cough is nonproductive, best culture material is fromearly morning gastric aspirate. Otherwise, isolation of tuberclebacilli by culture of sputum, urine, pleural fluid, cerebrospinalfluid, other body fluids, or biopsy material confirms diagnosis.

Negative PPD never excludes infectionor disease with TB. Anergy may be due to young age, viral infections,immunosuppression, and severe disseminated TB.

Chlamydia

Pneumoniadue to C. trachomatis usually occurs in infants 1–3 mosof age.

Clinical findings include conjunctivitisor history of conjunctivitis, staccato cough, tachypnea, crackles,and mild peripheral eosinophilia. Fever is variable finding.

Chest radiograph usually shows hyperinflationand bilateral interstitial infiltrates.

Positive nasopharyngeal or eye cultureconfirms diagnosis.

Legionella

Legionnaire'sdisease is transmitted by inhalation of aerosolized water contaminated withLegionella species.

Most common cause of Legionella infectionin U.S. is L. pneumophila serogroup 1.

Frequent findings include fever, nonproductivecough, headache, and myalgia.

Chest radiograph usually shows infiltrate.Pulmonary nodules ± cavitation also may occur.

Diagnosis can be confirmed in a numberof ways:

positiveculture of sputum or lung tissue

detection of organisms on smears ofrespiratory tract secretions by direct immunofluorescent assay usingmonoclonal or polyclonal antibodies

DNA probes

serologic testing using indirect immunofluorescenceantibody assay

Increase in antibody titer to ≥1:128is also considered diagnostic.

Nocardia

Nocardiaspecies are funguslike bacteria that live in soil.

Lung is probable portal of entry aswell as most frequent site of infection.

Most common agent in U.S. is N. asteroides.

Clinical findings include fever, cough,chest pain, night sweats, malaise, and weight loss.

Chest radiography shows scattered infiltrates.

Stained smears of sputum, spinal fluid,or pus may reveal gram-positive rods that are variably acid fast.

Positive culture confirms diagnosis.

Mycoplasma

M. pneumoniaeis common cause of pneumonia in school-aged children and adolescents.

Infection with this organism is uncommonin patients <5 yrs of age.

Persistent nonproductive cough andfever are usual presenting features. Other findings include headache,myalgia, sore throat, and macular or papular rash. Crackles andwheezes may be heard on lung exam.

Typically, chest radiograph shows patchy,unilateral, segmental, or subsegmental consolidation, but diffuse,bilateral, interstitial infiltrates may be seen.

Cold agglutinin titer of ≥1:64 issuggestive of diagnosis, although other viral infections (adenoviruses,Epstein-Barr virus) also can produce elevated titer. Complementfixation test is most widely available serologic test, and titerof ≥1:32 during an acute respiratory illness is suggestive ofinfection.

Fungal

Histoplasmosis

Endemicin eastern and midwestern U.S., especially in Mississippi and OhioRiver valleys.

Infection occurs by inhalation of H.capsulatum spores, which are present in soil or dust in barnyardsor other areas that contain bird and bat droppings.

>95% of infectionsare asymptomatic. Common presentation is acute influenza-like illness withpulmonary infiltrates and hilar adenopathy. Disseminated diseasewith fever, cough, pulmonary infiltrates, hepatosplenomegaly, andpancytopenia occurs most frequently in immunocompromised hosts.

Culture of sputum, blood, or bone marrowconfirms diagnosis, as does demonstration of intracellular yeastsin smears of bone marrow or biopsy material from infected tissues.

Detection of H. capsulatum antigenin urine or serum also can be used to diagnose disseminated disease.Single titer of ≥1:32 or 4-fold increase in yeast phase titersis presumptive evidence of active infection. H bands found in immunodiffusionantibody assay also suggest active infection.

Coccidioidomycosis

Endemicin southwestern U.S. Transmission occurs by inhalation of dust-borne sporesof C. immitis.

Primary infection is often asymptomatic,whereas symptomatic infection usually presents with fever and cough.

Chest radiograph may show hilar adenopathyand calcification of healing primary lesion. Granulomatous lesionscan occur in lungs, lymph nodes, bones, joints, skin, and meninges.

Typical clinical and radiologic findingsand positive skin test or ≥1:32 complement fixation antibodytiter are diagnostic. Spherules seen in tracheal aspirates, sputum,urine, or spinal fluid; biopsies of skin lesions or organs; or positivecultures from any of these sources are also diagnostic.

Aspergillosis

Aspergillusspecies grow in soil and in decaying vegetation. Transmission isby inhalation of airborne spores.

Different clinical presentations mayoccur:

Allergicbronchopulmonary aspergillosis with low-grade fever, productivecough, episodic wheezing, transient pulmonary infiltrates, and eosinophilia

Aspergillomas that do not invade lungtissue

Invasive pulmonary disease with feverand productive cough

Disseminated disease with involvementof skin (cutaneous papules and abscesses), heart (endocarditis),bone (osteomyelitis), sinuses (sinusitis), or brain (abscess).

Chest radiograph may show patchy ornodular infiltrates or consolidation ± cavitation.

Branching and septate hyphae in sputumsuggest diagnosis.

Positive sputum or lung biopsy cultureconfirms diagnosis.

Blastomycosis

Infectionwith B. dermatitidis is endemic in southeastern U.S. and in midwestern statesbordering the Great Lakes.

Pulmonary, cutaneous, and disseminatedforms of disease can occur, but pulmonary disease is most commonin children.

Clinical findings of pulmonary diseaseinclude cough, fever, malaise, chest pain, weight loss, and hemoptysis.

Chest radiograph may show infiltrates,cavities, or nodular densities.

Primary cutaneous blastomycosis maypresent with ≥1 subcutaneous nodules that eventually ulcerate.

Disseminated disease produces granulomatouslesions, which may involve liver, spleen, bone, skin, and brain.

Thick-walled single budding yeast formsmay be seen with 10% KOH preparations from sputum, spinalfluid, urine, or skin lesions.

Positive immunodiffusion test on serathat shows precipitin bands (A and B) is evidence for active infection;however, bronchoalveolar lavage or lung biopsy may be necessaryto establish diagnosis in children with pneumonia.

Serologic assays are not reliable fordiagnosis.

Protozoa

P. cariniiinfection occurs almost exclusively in immunocompromised childrenand is common in those affected with HIV.

Clinical findings include nonproductivecough and fever.

Chest radiograph shows bilateral interstitialor air-space disease.

Diagnosis is confirmed by demonstrationof organism in lower respiratory tract secretions or lung tissue.

Induction of sputum in older childrenand adolescents, bronchoscopy with bronchoalveolar lavage, or lungbiopsy can be performed.

Methenamine silver nitrate and toluidineblue O are most useful stains to identify thick-walled cysts.

Chemical Pneumonia

Gasoline,kerosene, and charcoal lighter fluid are hydrocarbons with low surfacetension and viscosity. Because of these properties, aspiration intotracheobronchial tree can easily occur after ingestion.

Acute onset of cough and respiratorydistress and history of ingestion are diagnostic. Within severalhours of ingestion, chest radiograph may show evidence of pneumonia,with infiltrates commonly in right middle and lower lobes.

Aspiration Pneumonia

Interferencewith normal swallowing predisposes to aspiration of oral and gastricsecretions as well as food. Children with gastroesophageal reflux,tracheoesophageal fistula, or neurologic disorders with swallowingdysfunction are more prone to develop aspiration pneumonia.

Onset of respiratory distress afterchoking, gagging, coughing, or vomiting episodes should lead oneto suspect aspiration pneumonia.

Cystic Fibrosis

Common causeof chronic lung disease in children but also affects other organsystems with epithelial surfaces, especially intestine, pancreas,liver, and sweat glands. Mutations in CFTR gene located on chromosome7 result in abnormal ion transport across epithelial surfaces. Genetictransmission is autosomal recessive.

Age of onset and clinical presentationvary widely. Earliest clinical manifestation is meconium ileus innewborn. Most common manifestation of respiratory disease is coughthat may be dry or productive. Other clinical findings include wheezing;nasal polyps; frequent large, foul-smelling stools; digital clubbing;recurrent rectal prolapse; and poor growth.

Chest radiograph usually shows hyperinflation,irregular aeration with areas of patchy atelectasis, and accentuatedperibronchial markings.

Bacterial organisms that commonly colonizerespiratory tract in this disease are S. aureus, H. influenzae,and gram-negative enteric bacteria, including P. aeruginosa.

Sweat chloride level >60 mEq/Lis diagnostic.

DNA mutation analysis is definitive.

Bronchiectasis

Infectionor chronic inflammation of airways can cause bronchiectasis.

May be focal (foreign body, local infection)or generalized (cystic fibrosis, chronic aspiration).

Chronic productive cough with cracklesand rhonchi on lung exam are usual findings.

Chest radiography may show persistentatelectasis or infiltrates that fail to resolve.

Diagnosis may be confirmed by chestCT, which shows dilated bronchi that do not taper peripherally.

Lung Abscess

May occur ± pneumonia.

Most common organisms found in lungabscesses are Staphylococcus species and group A Streptococcus.Anaerobes also may play role in individuals with aspiration pneumonia.

Persistent fever and cough are usualclinical features.

Abscess (density with air-fluid level)may be seen on chest radiography, with confirmation by chest CT.

Needle aspirate may reveal specificpathogen.

Allergic Disorders

Allergic Rhinitis

Althoughusual clinical findings with allergic rhinitis are persistent orrecurrent rhinorrhea, sneezing, and itchy tearing eyes, nonproductivecough also occurs.

See Chap.41, Nasal Discharge.

Asthma

Definedas inflammatory disorder of smaller airways, which is characterizedby recurrent wheezing that is reversible with bronchodilator therapyor spontaneously. Another common manifestation is recurrent cough, ± wheezing,especially after exercise or at night.

See Chap.75, Wheezing.

Mechanical or Chemical Irritation

Environmental Irritants

Smoke, chemicalfumes, particulate matter from fire, and other environmental pollutantsand toxins may stimulate cough production.

History of exposure is diagnostic.

Foreign Body Aspiration

Aspirationof foreign body into bronchus commonly produces choking or gagging followedby persistent coughing or wheezing.

Some common foreign bodies are food(nuts, seeds, meat), pins, tacks, and plastic tops.

Chest radiography may show segmentalor lobar collapse or unilateral hyperinflation. Chest radiographstaken in inspiration/expiration or in right and left lateraldecubitus positions as well as fluoroscopy may demonstrate unilateralair trapping and movement of mediastinum away from affected side duringexpiration. In some cases, bronchoscopy is necessary to confirmdiagnosis.

Bronchopulmonary Dysplasia

A form ofchronic lung disease that often follows neonatal respiratory distresssyndrome treated with endotracheal intubation, mechanical ventilation,and high concentrations of inspired oxygen.

During course of disease, respiratorydistress waxes and wanes with intermittent cough.

Crackles and rhonchi may be heard onlung exam.

Hypoxemia and hypercapnia occur, andapnea may develop.

Chest radiograph shows combinationof hyperinflation, prominent perihilar markings, and streaky densitiesthat may persist for many months.

Congenital Anomalies

Congenitalanomalies that may produce cough include laryngomalacia, tracheomalacia,tracheoesophageal fistula, pulmonary sequestration, bronchogeniccyst, cystic adenomatoid malformation, and vascular rings and slings.

See Chap.56, Respiratory Distress and Apnea, Chap. 63, Stertor, Stridor, and Airway Obstruction,and Chap. 65, Sucking and SwallowingDifficulty.

Cardiac Failure

Pulmonaryvenous congestion occurring as manifestation of cardiac failuremay cause airway edema leading to cough. Other findings includerespiratory distress, tachycardia, hepatomegaly, and cardiomegaly.

See Chap.7, Cardiac Failure.

Gastroesophageal Reflux

Aspirationof stomach contents into lung may produce airway obstruction andpneumonia with coughing and wheezing. Another proposed mechanismfor cough and respiratory distress is the stimulation of esophagealvagal afferents by gastric contents to produce laryngospasm andbronchospasm.

See Chap.55, Regurgitation and Vomiting.

Swallowing Dysfunction

Disordersthat cause difficulty in swallowing may produce gagging, choking,and recurrent coughing.

See Chap.65, Sucking and Swallowing Difficulty.

Immotile Cilia Syndrome

Autosomal-recessivedisorder characterized by defects in ultrastructure of cilia that impairciliary motion and clearance of mucus from respiratory tract.

1 form of this syndrome has been mappedto chromosome 9p21-p13, whereas another has been mapped to chromosome5p.

Structural defects include absenceof dynein arms and radial spokes.

Onset is in infancy or early childhoodwith chronic cough that is usually productive of sputum. Other manifestationsinclude chronic rhinitis, sinusitis, otitis media, bronchitis, andpneumonia.

Chest radiograph may show hyperinflation,bronchial wall thickening, segmental atelectasis or consolidation,situs inversus, and bronchiectasis.

Electron microscopy of cilia obtainedby nasal or bronchial biopsy brushing techniques demonstrates structuraldefects.

Neoplasm

Chroniccough may occur with airway tumors (hemangioma, papilloma), mediastinal masses,and lung tumors, including metastatic lesions.

See Chap.56, Respiratory Distress and Apnea.

Reflex Cough

In somechildren, foreign body or cerumen in ear canal causes transientreflex cough.

Persistent cough also has been attributedto hair lodged against tympanic membrane.

Otoscopic exam is diagnostic.

Psychogenic/Habitual Cough

Occasionallychild has persistent or recurrent cough with no evidence of underlying respiratorytract disease. Usually occurs in school-aged child after URI, andcough lasts for weeks.

Cough is usually loud, harsh, and foghorn-like,disappearing during sleep and often decreasing when alone or onweekends.

Otherwise, child is well and physicalexam and chest radiograph are normal.

Often secondary gain can be identified.Some of these children may have emotional problems that requirefurther evaluation.

Diagnostic Approach

In manycases history and physical exam are diagnostic.

Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities.

Age of Child and Duration of Cough

In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.

In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).

Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.

Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.

In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.

Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems.

Periodicity and Quality of Cough

Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.

Recurrent viral URIs and asthma causeepisodic coughing.

Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.

Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.

Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.

Neuromuscular disorders produce a weakand feeble cough.

Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease.

Timing of Cough

If coughdisappears while asleep, it usually has psychologic basis.

Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.

Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis.

Nature of Sputum Production

Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.

Associated Findings

Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.

Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.

Cough associated with stridor indicatesairway obstruction.

Evaluation

Etiologyof cough can usually be determined or at least suspected from historyand physical exam.

Chest radiography shows pattern andextent of disease and is confirmatory in many instances.

With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.

If TB is suspected, intermediate-strengthPPD should be placed.

Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.

With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.

Another useful test is sweat test inchildren with recurrent or chronic cough.

With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step.

>

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Cough, barking: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, nonproductive: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, productive: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds—rhonchi, crackles, or wheezes.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

COUGH: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. Postnasal drip from chronic sinusitis should be ruled out. An allergic history (e.g., hay fever) is important. Cardiovascular disease should be carefully excluded, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Chronic Sinusitis

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Signs of Chronic Sinusitis
• Misdiagnosis of Chronic Sinusitis
• Undiagnosed Chronic Sinusitis
• Misdiagnosis of Underlying Causes of Chronic Sinusitis
• Treatments for Chronic Sinusitis

Tools & Services:

• Bookmark this page
• Take a survey relating to Chronic Sinusitis
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

homepage | back to top

Common Health Mistakes

Choose ... Alzheimers & Dementia Asthma Child ADHD ADHD in Adults Allergy Hypertension Bipolar Breast Cancer Celiac Disease Crohns Disease Colon Cancer Contraception Diabetes Cancer Depression Erectile Disorder Cholesterol COPD GERD Heartburn/Reflux Metabolic Syndrome Migraine/Headache Multiple Sclerosis Obesity Osteoporosis Overactive Bladder Psoriasis Sexual Disorder Sleep Disorders Smoking The Pill Ulcerative Colitis All Common Mistakes

Symptom
Checker

Choose... Fever Rash Pain Headache Fatigue Cough Other symptoms

Search Specialists by State and City

Choose... GENERAL PRACTICE CARDIAC HEALTH WOMEN'S HEALTH CANCER CARE RADIOLOGY MENTAL HEALTH PATHOLOGY EAR, NOSE, THROAT MEDICINE GENETICS NEUROLOGY DIALYSIS CARE SURGERY ORTHOPEDICS/SPORTS MEDICINE CHILDREN'S HEALTH OTHER SPECIALTIES