Diagnosis of Cough

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

• Inflammatory
  –Allergy
  –Gastroesophageal reflux disease
  –Sinusitis resulting in postnasal drainage
• Tumors
  –Leukemia
  –Rhabdosarcomas
  –Squamous cell carcinoma secondary to oral ulcerations
• Trauma
  –Foreign body ingestion
  –Caustic ingestion
  –Soft tissue injury from accidental and nonaccidental trauma
• Systemic/rheumatologic disorders
  –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
  –Behçet syndrome
  –Reiter syndrome
  • Others
    –Cigarette smoke
    –Environmental pollutants
    –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

Workup and Diagnosis

• Physical exam
  –Nasal exam: Evidence of rhinosinusitis
  –Mouth: Ulcerations, masses, tonsil size, erythema, exudates
  –Neck: Lymphadenopathy
  –Skin: Rash
  –Chest: Wheezes, asymmetry
• Studies
  –For pharyngitis: A major goal is to differentiate streptococcal pharyngitis from viral etiologies
  –Throat culture: 92% sensitive; 100% specific; requires 24–48 hours
  –Rapid strep test: 72–85% sensitive; 88–100% specific
  –CBC with differential for suspected mononucleosis
  –Chest X-ray (inspiratory and expiratory) for suspected foreign body
  –CT neck: When complication of infection is suspected such as abscess

» READ BOOK EXCERPT ONLINE »

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

Stridor: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Nasal cavity and nasopharynx

• Congenital
  –Piriform aperture stenosis
  –Choanal atresia
  –Lacrimal duct cyst
  –Craniofacial anomaly
  –Nasopharyngeal mass (teratoma)
• Inflammatory/infectious
  –Rhinosinusitis
  –Adenoid hypertrophy

Oral cavity, oropharynx, and hypopharynx
• Congenital
  –Macroglossia
  –Glossoptosis
  –Vallecular cyst
• Inflammatory/infectious
  –Tonsillar hypertrophy
• Tumors
  –Lingual thyroid
  –Dermoid
  –Lymphovascular malformation
• Foreign body

• Congenital
  –Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
  –Saccular cyst
  –Webs
  –Clefts
  –Vocal cord paralysis

• Inflammatory/infectious
  –Epiglottitis
  –Laryngotracheitis (croup)
  –Gastroesophageal reflux
• Tumors
  –Papillomas
  –Hemangiomas
• Trauma
  –Subglottic stenosis
  –Foreign bodies
  –Laryngeal fracture
  –Caustic ingestion
  Tracheobronchial
• Congenital
  –Tracheomalacia
  –Vascular rings
  –Tracheoesophageal fistula
• Inflammatory

Workup and Diagnosis

• History
  –Duration, onset, severity, character, progression
  –Failure to thrive, feeding problems, cyanosis, apnea
  –Reflux history: Frequent spit-ups, vomiting, heartburn, chest pain, hoarseness
  –Birth, neonatal, and past medical history: Complicated labor, respiratory distress at delivery
  –Prior intubations, neurologic problems, prior episodes of croup, prior neck surgery, foreign body ingestion
  –Immunization history
• Physical exam
  –Fever, respiratory rate, heart rate, level of consciousness, cyanosis
  –Auscultation: Chest, nose, mouth, neck (phase of stridor: inspiratory, expiratory, biphasic)
  –Nose: Nasal obstruction
  –Mouth: Tonsillar hypertrophy
  –Neck: Retractions, compressive mass, thyroid
  • Studies
    –Flexible nasolaryngoscopy: Check for choanal patency, adenoid size, laryngomalacia, vocal cord mobility
    –Direct laryngoscopy and bronchoscopy (DLB): Controversial whether all children with stridor need DLB
    –MRI: Vascular compression or external mediastinal mass
    –Modified barium swallow or esophagram in children with history of swallowing difficulties

» READ BOOK EXCERPT ONLINE »

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

Wheezing: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Lower airway (expiratory, polyphonic)

• Extraluminal compression of airways
  –Parenchymal: Pneumonia, pulmonary edema, bronchogenic cyst
  –Vascular: Ring, sling, “cardiac wheeze”
  –Lymphatics: Enlarged lymph nodes (TB, sarcoidosis, malignancy)
  –Structural: CLE, scoliosis, or chest wall deformity with airway “kinking”
• Transluminal change in airway
  –Asthma: Inflammation, edema, hyperemia, mucus gland hypertrophy and proliferation, smooth muscle bronchospasm
  –Bronchiectasis/bronchitis
  –Cystic fibrosis
  –Ciliary disease: Primary ciliary dyskinesia, dysfunction due to ETS or hyperoxia
  –Anatomic: Hemangioma, polyps, TEF, bronchial atresia, BALT, bronchiolitis obliterans, tracheobronchomalacia
  –Immunologic disorders (e.g., IgA deficiency)

• Intraluminal change in airway
  –Mucus (increased production or decreased clearance), pus (infected sputum), blood
  –Foreign body
  –Aspirated food or stomach contents secondary to gastroesophageal reflux
  Upper airway (usually inspiratory and monophonic)

• Nasal (congestion, choanal atresia, FB)
• Oropharyngeal (tonsils, adenoids, macroglossia, foreign body, decreased tone, retropharyngeal abscess)
• Laryngeal (laryngomalacia, vocal cord dysfunction or paralysis, laryngeal web or polyp, subglottic stenosis)

Central nervous system
• Structural disease (e.g., Arnold-Chiari malformation leading to vocal cord paralysis)
• Functional (e.g., vocal cord dysfunction, chronic aspiration)

Workup and Diagnosis

• History
  –Triggers: Viral disease, irritants, and allergic disease
  –Improvement with β -agonists or steroids suggests asthma
  –Worsening with ETS suggests asthma or bronchitis; with exercise, EIA or VCD; with β-agonists, bronchomalacia
  –Delayed onset with exercise suggests EIA; rapid onset with exercise suggests VCD (teens) or bronchomalacia (babies)
  –Age of onset: First month, structural problems (e.g., bronchomalacia); first year, RSV bronchiolitis, GER, or aspiration; early childhood, asthma, possible FB aspiration; adolescence, asthma and VCD
  –Other symptoms: Hemoptysis, chronic cough, weight loss (CF, TB, bronchiectasis, malignancy, recurrent infection, or immunodeficiency); weakness, hypotonia (neuromotor disease, Down syndrome, aspiration); choking on feeds (upper airway disease, TEF, chronic aspiration)

• Exam findings
  –High pitch indicates smaller airways; low pitch, larger airway(s); inspiratory, extrathoracic airway; expiratory, intrathoracic airways; biphasic, fixed obstruction or two sites; expiratory prolongation, small airways or severe larger airways
• Diagnostic tests: CXR may show hyperinflation, peribronchial cuffing, congenital lesions; CT, tissue density abnormalities, airway lesions; MRI, airway, blood vessel interface; MRA defines vascular anatomy; nuclear med, reflux and V/Q studies; PFT, volume and air flow; bronchoscopy, lavage and visualize
• Blood gas; disease-specific studies (e.g., sweat test)

» READ BOOK EXCERPT ONLINE »

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

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

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

The differential diagnosis of hemoptysis can be narrowed considerably by the clinical picture. Acute hemoptysis with chest pain would suggest pulmonary embolism. A chronic cough with occasional hemoptysis suggests neoplasm, tuberculosis, or bronchiectasis. Hemoptysis with chills and fever suggests pneumonia but one should always keep pulmonary embolism in mind. Hemoptysis with dyspnea, edema, or cardiomegaly suggests mitral stenosis or CHF. The sputum is usually foamy in cases of CHF. Hemoptysis with purpura or bleeding from other sites should suggest a systemic disease or coagulation disorder.

The initial workup of hemoptysis includes a CBC, urinalysis, sedimentation rate, chemistry panel, sputum smear and culture, and a chest x-ray. If a pulmonary embolism is suspected, arterial blood gas analysis and a lung scan are ordered. Pulmonary angiography may also be necessary. If routine studies and the clinical picture suggest pneumonia, nothing more may need to be done other than a careful follow up. If CHF is suspected, a circulation time may be done but a cardiology consult and echocardiogram would be more definitive. What would you do if it was your heart?

If a bronchogenic neoplasm or bronchiectasis is suspected, a pulmonary consult and bronchoscopy would be ordered. Bronchiectasis can be identified with a CT scan of the chest also. If tuberculosis is suspected, a tuberculin test is performed, and sputum is cultured for AFB and possibly Guinea pig innoculation performed.

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Source: Differential Diagnosis in Primary Care, 2007

SORE THROAT: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

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Source: Differential Diagnosis in Primary Care, 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.

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Source: Differential Diagnosis in Primary Care, 2007

STRIDOR AND SNORING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis involves a careful examination of the air passage with the laryngoscope and bronchoscope (if necessary, under anesthesia). If these have negative findings, a thorough neurologic examination should be performed and a Tensilon test may be indicated. Laryngismus stridulus in children may be terminated by putting the child in a steam bath; this helps establish that diagnosis. Skin testing for allergies may be necessary. A sleep study is often necessary to rule out neurogenic or obstructive sleep apnea.

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Source: Differential Diagnosis in Primary Care, 2007

Hemoptysis: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?

Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.

Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.

Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.

» READ BOOK EXCERPT ONLINE »

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

Stridor: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.

» 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

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.

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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

Wheezing [Sibilant rhonchi]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 599.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds.)  

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

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.

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

Hemoptysis: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? How much blood is he coughing up now and how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out which drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has recently had any infections or been exposed to tuberculosis. When was his last tine test and what were the results?

Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.

Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.

Obtain a sputum specimen and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.

» READ BOOK EXCERPT ONLINE »

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

Stridor: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.

» 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.)

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

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.

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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.

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

Wheezing [Sibilant rhonchi]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma and recent changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a specimen for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 766.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds. See also Differential diagnosis: Wheezing, pages 826 and 827.)

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

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

 A. Identification of the site of bleeding. What is the source of the bleeding? Is the problem truly hemoptysis or could the bleeding originate in a nonpulmonary location such as the nose and oropharynx or the gastrointestinal tract? Blood that is coughed from the respiratory tract is bright red in color and may be frothy or mixed with sputum. Hemoptysis is more likely with a history of underlying pulmonary disease, smoking, or mitral valve disease. Hematemesis is associated with blood that is dark red, brown, or coffee ground in appearance and that may be mixed with food particles. Hematemesis is favored in the presence of preexisting gastrointestinal condition, especially with a history of liver disease, alcohol use, or peptic ulcer disease. Sputum that is blood-streaked often arises from the nasal mucosa and oropharynx.

 B. Characteristics of the sputum. What are the characteristics of the sputum in terms of color, odor, and consistency? A description of the sputum can assist in defining the disease process causing the hemoptysis: (a) frothy, pink sputum is suggestive of pulmonary edema fluid; (b) putrid or foul-smelling sputum suggests a lung abscess; (c) currant jelly sputum may suggest a necrotizing pneumonia; (d) the sputum of pneumococcal pneumonia is typically rust-colored and can be confused with true hemoptysis; (e) large amounts of blood-streaked sputum often suggest bronchiectasis.

C. Other information. Does the patient have other associated symptoms? Cough, dyspnea, and sputum production over several years may suggest chronic bronchitis or bronchiectasis. Weight loss and fatigue may suggest an underlying malignancy, and fever and night sweats might indicate tuberculosis. Does the patient have a history of known pulmonary, cardiac, or hematologic problems? Does the patient have hematuria, which might suggest a pulmonary-renal syndrome (Chapter 10.2)? Is the patient a smoker or have specific environmental exposures? Is the patient taking medications, especially anticoagulants, that might contribute to the bleeding?

Physical examination

 A focused physical examination should include vital signs and examinations of the nose, sinuses, oropharynx, neck, lungs, and heart. The neck should be palpated for the presence of lymphadenopathy and inspected for jugular venous distension. The lower extremities should be checked for edema. Examination of the skin may reveal lesions associated with systemic lupus erythematosus; Kaposi’s sarcoma; clubbing (consistent with neoplasm, bronchiectasis, or lung abscess); or ecchymosis related to a coagulopathy.

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

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

A. Characteristics of stridor. When confronted with stridor, check the age of the patient and the duration of the symptoms.

1. A child aged less than 6 months with stridor of a few weeks to months has a congenital cause of stridor.

2. Patients aged more than 6 months with stridor lasting hours to days usually have an acquired cause of stridor, most commonly viral croup, epiglottitis, or aspiration of a foreign body.

 3. A typical history is a child aged less than 6 years with a 2- to 3-day history of upper respiratory infection (URI) and gradually worsening cough, especially at night. A barking cough with the inspiratory stridor heralds the diagnosis of croup, which accounts for 90% of all cases of stridor. This condition will classically improve with moist air (1,3).

 4. A history of choking, coughing, or gagging points to aspiration or ingestion of a foreign body.

5. In older children and adults, a concomitant sore throat and fever may indicate acute supraglottitis, which constitutes an emergency.

B. Other information

1. Whether stridor is acute, recurrent, or chronic.

 2. Personal or family history of atopy, would suggest spasmodic croup, which presents with stridor at night, not necessarily associated with a URI.

Physical examination

A. Focused physical examination (PE)

1. The PE should include vital signs, notably temperature and respiratory rate, and pulse, with emphasis on general appearance and examination of the head and neck, including ears, nose, and throat.

2. Signs of respiratory distress may be present, including dyspnea, tachypnea, chest retractions, nasal flaring, and stridor. If cyanosis is present, this is an ominous sign (2,4) (Chapter 8.2).

B. Additional physical examination may reveal:

1. A toxic-appearing child with high fever, drooling, severe respiratory distress, and preference for a sitting and forward-leaning position (1,4)

2. Varying degrees of anxiety, which will increase during examination, cause a worsening of stridor (1,4)

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

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

A. Onset. Is this the first episode? If so, were there problems with wheezing or asthma in childhood?

B. Exposures. Are there any precipitating factors? Have there been any recent exposures? Is there an exposure to cigarette smoke? What is the patient’s occupation?

1. Cigarette smoke is one of the most potent and ubiquitous avoidable allergens.

2. Occupational exposures can frequently be identified, especially among agricultural and industrial workers.

3. Family or household exposure to tuberculosis or pertussis can indicate an infectious cause.

 C. Concurrent illnesses. Has the patient recently suffered an upper respiratory infection or sinusitis? Is there a history of gastroesophageal reflux disease?

 D. Family history. A history of asthma, allergies, or atopic disease in family members can support the diagnosis of asthma.

E. Past history. A childhood history of atopic disease or allergies suggests adult onset asthma. Past history of exercise-induced wheezing also supports this diagnosis.

 F. Psychosocial aspects. Emotional stress can lead to exacerbation of chronic asthma. Psychogenic wheezing is a conversion disorder, which can coexist with other psychopathology.

Physical examination

 A. Vital signs. A full set of vital signs is essential to the assessment of the wheezing patient. The respiratory rate and the pulse are a more objective, and often more accurate, assessment of the severity of wheezing than the auditory volume of the wheezing itself. Fever suggests a concurrent respiratory infection. Hypotension is an ominous sign that points to a decompensating patient.

 B. Lung examination. During auscultation, note the location, intensity, and duration of wheezing. Wheezing caused by asthma, chronic obstructive pulmonary disease (COPD), or interstitial disease should be diffuse and symmetric and present during expiration. The expiratory phase will be prolonged. Focal obstruction (e.g., tumors and foreign bodies) can give asymmetric findings and inspiratory wheezing. Mucus plugging will change with cough. Rhonchi and crackles suggest a concurrent infectious process. Percussion and egophony can be present with consolidation.

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

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).

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

Hemoptysis: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Bronchitis

❑ Pneumonia

❑ Pulmonary edema

❑ Pulmonary infarction

❑ Tuberculosis

❑ Bronchogenic carcinoma

❑ Chest trauma

❑ Bronchiectasis

❑ Bronchial adenoma

❑ A-V malformation

❑ Aspergilloma

❑ Vasculitis

❑ Lung abscess

❑ Mitral stenosis

❑ Hereditary hemorrhagic telangiectasia

❑ Parasitic

Diagnostic Approach

In primary care practice, neoplasm is the cause of less than 2% of cases of hemoptysis. A chest radiograph is nonetheless an essential component of the evaluation of every case of hemoptysis.

Differentiate hemoptysis from hematemesis. Hemoptysis is frothy, blood-tinged sputum that the patient can usually distinguish as coming from the lungs. Hematemesis is associated with nausea and vomiting, and it may be darker. Nasal or pharyngeal bleeding with posterior pharyngeal drainage could also be a source.

Clubbing indicates a chronic disorder and may be found in association with neoplasm, bronchiectasis, and lung abscess. Massive hemoptysis is usually due to lung cancer, tuberculosis, or aortic aneurysm.

Differential Diagnosis

Bronchitis  Hemoptysis occurring in the setting of an acute vigorous productive cough suggests bronchitis, and is associated with typical upper respiratory symptoms.

Pneumonia  Fever, cough tinged with blood, pleuritic chest pain, and focal rales with consolidative findings may occur in any combination. Pneumococcus classically produces rust-colored sputum. Klebsiella may produce a tenacious “currant jelly” sputum.

Pulmonary edema  In acute left heart failure, frothy pink sputum occurs with dependent rales, S₃ gallop, and dyspnea.

Pulmonary infarction  In acute pulmonary embolism, sudden onset of pleuritic chest pain and dyspnea with a pleural rub will occur. A source may be found in a unilateral swollen leg.

Tuberculosis  The classic presentation is blood-tinged sputum. Epidemiologic exposure/risk factors (e.g., being a health care worker, an Asian immigrant, or at risk for HIV) or upper lung field consolidative findings provide additional clues.

Bronchogenic carcinoma  When presenting with hemoptysis, the lung cancer is usually primary because metastatic cancer is rarely endobronchial. Environmental exposure to tobacco or asbestos or a family history of this disease increases the risk. A firm, palpable supraclavicular node is sometimes found.

Chest trauma  Rib fracture may cause a lung laceration. There will be exquisite tenderness over the rib segment, and the fragment will “float.”

Bronchiectasis  It is recognized clinically by recurrent episodes of grossly bloody sputum (due to necrosis of bronchial mucosa) in a patient with chronic copious purulent sputum.

Bronchial adenoma  Being quite vascular, these often present with episodes of self-limited hemoptysis recurrent over years.

A-V malformation  There may be an audible bruit on auscultation of the lung.

Aspergilloma  Suspect in an immunosuppressed host with prior cavitary lung disease or bullous disease with wheezing.

Vasculitis  Goodpasture syndrome and Wegener granulomatosis are characterized by hemoptysis in association with hematuria. Wegener granulomatosis will be associated with a nasal septal ulcer or perforation.

Lung abscess  Unmistakably fetid sputum will be intermittently mixed with blood.

Mitral stenosis  Hemoptysis is a diagnostic pearl in a patient with a soft, low-pitched apical diastolic murmur and an opening snap. This condition is often not considered because of its rarity and the orientation toward considering pulmonary causes of hemoptysis.

Hereditary hemorrhagic telangiectasia  Telangiectasias are evident on the lips and skin, and there is usually a history of bleeding from other sites.

Parasitic  Schistosomiasis, paragonomiasis, or echinococcus should be considered in international travelers or immigrants.

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Source: Field Guide to Bedside Diagnosis, 2007

Sore Throat: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

Diagnostic Approach

The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

 Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

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Source: Field Guide to Bedside Diagnosis, 2007

Wheezing: Differential Overview
(Field Guide to Bedside Diagnosis)

Wheezing

❑ Asthma

❑ Reactive airways disease

❑ Pulmonary edema

❑ Pulmonary embolism

❑ Emphysema

❑ Gastroesophageal reflux

❑ Drug/toxin reaction

❑ Vocal cord dysfunction

❑ Foreign body aspiration

❑ Mediastinal mass

❑ Carcinoid syndrome

Stridor

❑ Mucus plug

❑ Laryngeal trauma

❑ Angioedema

❑ Acute epiglottitis

❑ Retropharyngeal abscess

Diagnostic Approach

A wheeze is a continuous musical sound produced by vibration of airway walls when they are near closure. A wheeze consisting of a single musical note indicates small airways disease, usually asthma. Polyphonic wheezes (multiple musical notes) are produced by dynamic compression of large central airways.

Stridor signifies central airway obstruction, and is an ominous portent of impending complete airway closure. Causes such as an aspirated foreign body or bronchogenic cancer should be suspected when the onset of wheezing is sudden and focal, allergic markers and specific triggers are absent, and response to bronchodilator is poor. A history of aspiration, or smoking and clubbing are also helpful.

Nocturnal wheezing could be the result of congestive heart failure (paroxysmal nocturnal dyspnea) or gastric aspiration with reflux.

Dyspnea on exertion correlates with an FEV1 below 50% predicted, and dyspnea at rest with FEV1 below 25% predicted. Forced expiratory time (FET) is measured by ausculting over the trachea, and timing until airflow is no longer heard. FET of 9 seconds predicts an FEV1/FVC ratio of 70%. Stridor indicates that the airway diameter is less than 5 mm.

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Source: Field Guide to Bedside Diagnosis, 2007

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.

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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.

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Source: Field Guide to Bedside Diagnosis, 2007

Hemoptysis: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had any recent infections. Has he been exposed to tuberculosis? When was his last tine test and what were the results?

Physical examination

Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.

Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.

Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.

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

Stridor: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

When the patient’s condition permits, obtain his medical history. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

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

Wheezing: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in respiratory distress, obtain his medical history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Physical examination

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, jugular vein distention, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 299.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or a pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. (See Evaluating breath sounds.) Also note arrhythmias, bradycardia, or tachycardia. (See Wheezing: Causes and associated findings, pages 318 and 319.)

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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.

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

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).

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

Hemoptysis: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had any recent infections. Has he been exposed to tuberculosis? When was his last tine test and what were the results?

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

Stridor: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

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

Wheezing: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

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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?

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

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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.

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

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

Neonates

Airway Trauma

Pulmonary Hemorrhage