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Diseases » Croup » Tests
 

Diagnostic Tests for Croup

Contents
  1. Croup: Introduction
  2. Symptoms of Croup
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Alternative Diagnoses
  6. Misdiagnosis
  7. Complications

Croup Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Croup:

Croup Diagnosis: Book Excerpts

Diagnostic Tests for Croup: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Croup.

COUGH: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HEMOPTYSIS: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, coagulation profile, sputum smear, culture and sensitivity, a chest x-ray, and an EKG.

If a pulmonary embolism or infarction is suspected, arterial blood gases and a ventilation-perfusion scan should be ordered. In some cases, a pulmonary angiogram may be necessary. Objective testing for deep vein thrombosis with ultrasonography or impedance plethysmography may help confirm suspicion of a pulmonary embolism.

If tuberculosis is suspected, one should order a sputum or gastric washings for AFB smear, culture, and guinea pig inoculation. A tuberculin test should also be done. Apical lordotic views of the lung as well as lateral and oblique views may help identify a tuberculous cavity. There are serologic tests for antibodies against specific mycobacterial antigens.

Sputum cultures for fungi and skin tests for the various fungi may need to be done. If congestive heart failure is suspected, venous pressure and circulation time should be measured, and a pulmonary function test should be done. Echocardiography will help diagnose mitral stenosis.

A consultation with a pulmonologist and bronchoscopy need to be done if bronchogenic carcinoma or bronchiectasis is suspected. Other studies that are helpful in diagnosing bronchogenic carcinoma are sputa for Pap smear, transbronchial needle biopsy, and CT. MRI may confirm vascular etiologies for the bleeding such as pulmonary aneurysm. Serologic studies [ANA, antineutrophil cytoplasmic antibody (C-ANCA), etc.] may be useful in detecting collagen diseases. A bronchogram will be helpful in diagnosing bronchiectasis and foreign bodies.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SORE THROAT: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

In a sore throat with typical exudates very suggestive of streptococcal pharyngitis, a throat culture may be all one needs before starting definitive antibiotic therapy. In the more difficult cases, screening for streptococcal antigens (streptozyme test and ASO titer) might be indicated. An ASO titer is particularly important when one suspects rheumatic fever. If the patient's streptococcal sore throat persists, a Monospot test and a culture for gonorrhea should be done. Although there are hardly any false-negative Monospot tests, there are 10% false positives, and that should be kept in mind. A blood smear for atypical lymphocytes may be helpful, as well as a heterophile antibody titer in those cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

STRIDOR: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests may include a CBC; sedimentation rate; smear and culture of material from the nose, throat, and sputum; x-ray of the chest and sinuses; and, in adults, an EKG. In adults also it might be wise to order a chemistry panel, thyroid profile, and VDRL test, depending on the clinical picture. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. In addition, fiberoptic bronchoscopy may be valuable. A Tensilon test may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. If there are neurologic signs, a neurologist should be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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, 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

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, 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, 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, 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

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, 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: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 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).

Testing

A. Clinical laboratory tests. Most acute presentations of cough do not require blood, urine, or other laboratory tests. White blood count with differential and blood cultures are indicated for pneumonia. Gram’s stain and culture of sputum are rarely practical in the office. A purified protein derivative (PPD) test should be placed early if TB is suspected, unless the patient is known to be anergic or thought to have overwhelming active TB disease. Systemic causes require testing specific to the disease in question.

B. Radiologic tests. A chest x-ray study is not indicated for upper respiratory causes or bronchitis. It is only useful when pneumonia, TB, COPD, CHF, or cancer (primary or metastatic) are being considered. Computed tomography of the sinuses is more sensitive and specific than PE to differentiate sinusitis from other causes of cough.

C. Pulmonary function tests. The simple peak flow meter used with a therapeutic trial of bronchodilators will identify most cases of asthma. This important test should be supervised by the physician or an experienced nurse. Additional testing is suggested for COPD and pulmonary fibrosis.

D. Invasive tests. Bronchoscopy is useful for foreign body aspiration, cancer, or chronic interstitial lung disease. Esophageal pH monitoring will most likely confirm suspected GERD.

Diagnostic assessment

A thorough history is vital to accurate diagnosis. Acute cough is likely to be infectious. A pertinent observation is that physicians overtreat acute bronchitis with antibiotics. The literature suggests that most cases are viral in origin and antibiotics are ineffective. Chronic cough has a longer list of differential diagnoses. Asthma tends to be underdiagnosed in adults and children. Smoking-related causes should prompt educational intervention and workup, especially in older patients. GERD is a diagnosis often missed because it is not considered. Often, more than one office visit is needed to unravel the cause of chronic cough. Up to 80% of cases have multiple causes (5). Making an accurate diagnosis is essential to successful treatment. Of cough presentation, 90% can be adequately managed in the family physician’s office, although it can take 3 to 5 months to arrive at a correct diagnosis in some cases (2). Referral to a pulmonary specialist is needed only in complicated cases (e.g., cancer, occupational and connective tissue diseases, and failed therapy).


References

1. Weiss BD. 20 common problems in primary care. New York: McGraw-Hill, 1999.

2. Lawler WR. An office approach to the diagnosis of chronic cough. Am Fam Physician 1998;58(9):2015–2022.

3. Heath JM. Chronic bronchitis: primary care management. Am Fam Physician 1998;57(10):2365–2372, 2376–2378.

4. Irwin RS. Managing cough as a defense mechanism and as a symptom. A consensus report of the American College of Chest Physicians. Chest 1998;114:133S–181S.

5. Irwin RS. Silencing chronic cough. Hosp Pract 1999;34:53–60.>

» READ BOOK EXCERPT ONLINE »

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

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

 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.

Testing

The evaluation should begin with a chest x-ray study to look for possible clues to the diagnosis: a mass lesion, focal or diffuse parenchymal disease, pneumonitis, abscess, infiltrate, hilar adenopathy, enlarged heart, pulmonary edema, coin lesion of aspergilloma, or the peribronchial cuffing suggestive of bronchiectasis. A computed tomography scan may be necessary to define a lesion seen on chest x-ray film (3). Additional basic testing should include a complete blood count with differential and a coagulation profile. For patients in whom infection is suspected, skin testing, a Gram’s stain, acid fast stain, or sputum cultures may be appropriate. Cytologic examination of the sputum is indicated in cases of suspected malignancy.

A. Other special tests. Fiberoptic bronchoscopy is used to localize the bleeding site of specific lesions noted on x-ray film. It is also used in cases of persistent or recurrent bleeding and for smokers aged more than 40 years with a negative chest x-ray study. Ventilation-perfusion scanning is indicated if pulmonary embolism is suspected.

Diagnostic assessment

Determining the site of bleeding is the first step. If the bleeding is from the nasopharynx or gastrointestinal tract then it is not classified as hemoptysis. The basic approach depends on the severity of the bleeding. Most cases of blood-tinged sputum are upper respiratory in nature and do not require extensive workup. Bronchitis is the most common cause. However, bronchogenic carcinoma and bronchiectasis are also common causes that do require further evaluation (4). Mild hemoptysis can be evaluated with elective bronchoscopy of the respiratory tract. Massive hemoptysis (definitions in the literature range from 100 ml/24 hours to 1,000 ml over several days) requires an emergent diagnostic approach, typically with rigid bronchoscopy (5). If hemoptysis persists despite treatment of a presumed infection, bronchial arteriography with embolization or resection of the involved segment may be necessary.


References

1. Colice GL. Hemoptysis: three questions that can direct management. Postgrad Med 1996;100(1):227–236.

2. DiLeo MD, Amedee RG, Butcher RB. Hemoptysis and Pseudohemoptysis: the patient expectorating blood. Ear Nose Throat J 1995;74(12):822–824, 826, 828.

3. Marshall TJ, Flower CD, Jackson JE. The role of radiology in the investigation and management of patients with hemoptysis. Clin Radiol 1996;51(6):391–400.

4. Marwah OS, Sharma OP. Bronchiectasis: how to identify, treat, and prevent. Postgrad Med 1995;97(2):149–150, 153–156, 159.

5. Cahill BC, Ingbar DH. Massive hemoptysis: assessment and management. Clin Chest Med 1994;15(1):147–167.

» READ BOOK EXCERPT ONLINE »

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

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

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)

Testing

A. The best test is a lateral neck x-ray study to assist with a diagnosis that is mostly made on clinical grounds. Films of the larynx and trachea in anteroposterior and lateral neck views may show narrowing of the trachea or extrinsic pressure on the tracheobronchial airway. Acutely, lateral neck radiographs showing the classic swollen glottis described by some as a thumbprint, assist with the diagnosis of acute supraglottitis and eminent respiratory collapse. Chest x-ray studies are of little value. Films showing hyperinflation or bronchial thickening may help to make a diagnosis of asthma rather than stridor. Additionally, foreign body aspiration or mass will be elucidated in x-ray studies (2).

B. Tomograms or computed tomography (CT) of the neck may provide additional information, especially in chronic stridor (2).

C. Blood tests (e.g., complete blood count) can be useful in the acutely ill patient, especially if viral or bacterial infection is suspected.

D. With suspicion that the stridor is a result of a laryngomalacia or laryngeal lesions such as papilloma, direct laryngoscopy is the test of choice for accurate diagnosis. Direct observation via fiberoptic bronchoscope positioned in the pharynx would provide diagnostic views of the larynx (2,4).

Diagnostic assessment

In making the diagnosis of stridor, two key elements exist: acute onset in a toxic-appearing patient, versus chronic stridor in a relatively stable patient.

A. Acute stridor

 1. The most likely cause of acute stridor in the febrile child with the additional features of barking cough and antecedent coryza is laryngotracheobronchitis or croup. Acute stridor is a non–life-threatening condition accounting for 90% of stridor cases. Classically, it improves with exposure to moist air. It has a viral cause, usually from one of the following: respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza virus, and influenza virus. Generally, this diagnosis is made on clinical grounds (1). The child is less ill and, although often febrile, not toxic appearing. The entire illness usually abates in 5 days. Hospitalization, unlike with epiglottitis, is rarely needed (2).

2. In the toxic patient with fever, respiratory distress, sore throat, or drooling, especially in the younger age group, consider epiglottitis—a medical emergency. As use of the Haemophilus influenzae vaccine has increased in recent years, acute epiglottis is becoming increasingly rare. H. influenzae is the most common bacterial cause of stridor, although streptococcus, staphylococcus and viral agents are also possible causes.

 3. The patient with a history of suspected foreign body aspiration will have similar symptoms without fever. Foreign body aspiration is common in the 1- to 2-year age groups, although it does occur in adults. It can be a cause of chronic stridor (3).

 4. Additionally, an acute allergic reaction can cause stridor. The history should herald a possible offending agent and, although respiratory collapse may be eminent, the patient will not be toxic, as no infectious agent is involved.

 5. Trauma can also cause laryngeal damage; however, the history will assist with this diagnosis.

 B. Chronic stridor. For the most part, these causes of stridor occur in early childhood. With the exception of laryngeal papillomas, tumors, and subglottic stenosis after instrumentation as in intubation (there is a congenital form also), foreign body aspiration with partial obstruction and hysterical stridor can occur at any age. Laryngomalacia and laryngeal lesions are caused by webs, hemangiomas, and cysts; they are usually identified early in life (1–3).


References

1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–112.

2. Behrman RE, Kliegman RM, Arvin AM. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1996:241, 1173, 1198, 1238.

3. Behrman RE, Vaughan VC. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1983:1031–1032, 1076–1077.

4. Tintinalli JE, Ruiz E, Krome RL. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 1996:247–251.

5. Campbell AGM, MacIntosh N. Textbook of pediatrics. London: Pearson Ltd., 1998:
508–513, 563.

» READ BOOK EXCERPT ONLINE »

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

Hemoptysis: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Sore Throat: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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

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

Observe the child for signs of respiratory distress. Note use of sternal or intercostal retractions or nasal flaring. Observe his skin for cyanosis and diaphoresis. Take his vital signs, noting respiratory rate and depth. Although stridor can be heard without a stethoscope, auscultate his lungs. Decreased breath sounds and crackles may be present.

» READ BOOK EXCERPT ONLINE »

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

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

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 pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

» READ BOOK EXCERPT ONLINE »

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

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

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.

» READ BOOK EXCERPT ONLINE »

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

Respirations, stertorous: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When the patient is awake, perform a complete respiratory assessment, followed by an examination of his head, nose, and throat. If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch for periods of apnea and note their length.

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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 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, and 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 rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

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

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

  • 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

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

    Age of Onset

  • In neonates,blood in tracheal aspirate signifies mucosal bleeding from aggressive suctioning,trauma from endotracheal tube, or pulmonary hemorrhage. With thelatter, there is usually a history of perinatal asphyxia, neonatalrespiratory distress syndrome, or septicemia.
  • In infants, children, and adolescents,blood in mouth or upper airway is most commonly due to epistaxis,gingivitis, tonsillitis, nasopharyngeal trauma, retching duringvomiting, or persistent cough. Most common causes of persistentcough and hemoptysis are bronchitis, bacterial pneumonia, and cystic fibrosis.

    • Evaluation

  • CBC, includingplatelet count, and chest radiography should be performed in anyindividual with hemoptysis. Depending on suspected diagnosis, otheruseful tests include tuberculin skin test, prothrombin and activatedpartial thromboplastin times, and sputum culture for bacteria, tuberclebacilli, and fungi.
  • With suspected heart disease, chestradiography, ECG, and 2-D echocardiography are often diagnostic.Sometimes cardiac catheterization and angiography are necessary.
  • Laryngoscopy and bronchoscopy helpdistinguish between upper and lower respiratory tract bleeding.Bronchoscopy may diagnose foreign body or bronchial tumor. Materialfrom this procedure may be collected for culture, acid-fast stain,cytology, and Prussian blue stain. The latter can demonstrate hemosiderin-ladenmacrophages, which are seen in hemosiderosis.
  • Chest CT helps locate and define extentof any respiratory tract or mediastinal mass. It also can diagnoseand define extent of bronchiectasis.
  • Angiography of bronchial and pulmonaryarteries may demonstrate site of focal, unilateral, massive bleeding.
  • Hemoptysis combined with other evidenceof bleeding usually signifies a bleeding disorder. Diagnostic approachto these disorders is discussed in Chap.52, Purpura and Bleeding.

    • » READ BOOK EXCERPT ONLINE »

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

    Sore Throat: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Historyand physical exam provide important clues for proper diagnosis ofsore throat.
  • Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.
  • Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.
  • Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.

    • » READ BOOK EXCERPT ONLINE »

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

    Stertor, Stridor, and Airway Obstruction: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Stertorand stridor are signs of upper airway obstruction. With seriousairway obstruction, establishing control of the airway and maintainingventilation are the most important immediate priorities. In absenceof life-threatening airway obstruction, prompt but thorough investigationis essential.
  • Age of onset is useful in diagnosis.Onset of stridor at birth or during neonatal period suggests laryngomalacia,laryngeal web, vocal cord paralysis, or vascular ring. In infancyand childhood, onset of acute stridor suggests croup, supraglottitis,or foreign body. Most common cause of persistent stertor in children2–8 yrs of age is adenoid or tonsillar hypertrophy.
  • Phase of respiration in which stridoroccurs, pitch of the sound, character of voice or cry, and changein position help in assessing degree of obstruction and its localization.

  • The phaseof respiration associated with different levels of airway obstructionhas already been described.
  • Variation in pitch depends on leveland degree of obstruction. Coarse low-pitched snoring sounds (stertor)localize lesion to nose, nasopharynx, or oropharynx. Harsh inspiratorystridor may occur with supraglottic, glottic, or subglottic lesions.Stridor associated with deep barking cough signifies subglotticor tracheal obstruction, whereas stridor associated with hoarsenessor change in character of voice or cry signifies glottic lesion.
  • When infants with laryngomalacia orinnominate artery compression are placed in prone position withneck extended, stridor decreases.
  • After history and physical exam, othertests may be useful depending on suspected diagnosis. These includeneck and chest radiography and flexible laryngoscopy. If resultsof these tests are normal, upper GI radiographic series with attentionto the pharynx and esophagus should be considered. With suspectedobstruction below glottis, bronchoscopy is necessary. Usefulnessof esophagoscopy, CT, and MRI depends on suspected diagnosis.
  • Histologic diagnosis is necessary forany suspected neoplasm except perhaps hemangioma, which can usuallybe recognized clinically.

    • » 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, 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

    Hemoptysis: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If 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 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: Nursing: Interpreting Signs and Symptoms, 2007

    Respirations, stertorous: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch carefully for periods of apnea and note their length.

    If the patient isn't in severe respiratory distress, begin with the history. Question the patient about his snoring habits. Is his partner frequently awakened by his snoring? Does the snoring improve if the patient sleeps with the window open? Does he talk in his sleep or sleepwalk? Ask about signs of sleep deprivation, such as personality changes, headaches, daytime somnolence, or decreased mental acuity.

    Perform the physical examination by first assessing the patient's level of consciousness and his orientation to time, place, and person. Observe spontaneous movements, and test muscle strength and deep tendon reflexes. Next, inspect the chest for deformities or abnormal movements such as intercostal retractions. Inspect the extremities for cyanosis and digital clubbing.

    Now, palpate for expansion and diaphragmatic tactile fremitus, and percuss for hyperresonance or dullness. Auscultate for diminished, absent, or adventitious breath sounds and for abnormal or distant heart sounds. Do you note peripheral edema? Finally, examine the abdomen for distention, tenderness, or masses.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Stridor: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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 cough?

    Then examine the patient's mouth for excessive secretions, foreign matter, inflammation, andswelling. 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: 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


     » Next page: Diagnosis of Croup

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