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Diseases » Laryngitis » Tests
 

Diagnostic Tests for Laryngitis

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

Laryngitis Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Laryngitis:

Laryngitis Diagnosis: Book Excerpts

Diagnosis of Laryngitis: medical news summaries:

The following medical news items are relevant to diagnosis of Laryngitis:

Diagnostic Tests for Laryngitis: Online Medical Books

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

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

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

Acute hoarseness will require only a CBC, sedimentation rate, nose and throat culture, and sputum culture if sputum is available. A chest x-ray may also be ordered. Laryngoscopic examination is rarely necessary unless the acute hoarseness becomes chronic.

The laryngoscopic examination is the single most important test for chronic hoarseness. It will identify most intrinsic lesions. If vocal cord paralysis is found, a chest x-ray and possibly a CT scan of the mediastinum may be ordered. However, an ear, nose, and throat specialist should be consulted before ordering these expensive tests. If the chords are edematous, hypothyroidism or angioneurotic edema may be the cause. The latter may be excluded by ordering a C1-esterase inhibitor level. If there are other neurologic abnormalities, a referral to a neurologist should be made before ordering a CT scan or MRI of the brain. In cases of intermittent hoarseness, a Tensilon test or acetylcholine receptor antibody titer should be done.

 

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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

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

Obtain a patient history. First, consider his age and sex; laryngeal cancer is most common in men between ages 50 and 70. Be sure to ask about the onset of hoarseness. Has the patient been overusing his voice? Has he experienced shortness of breath, a sore throat, a dry mouth, a cough, or difficulty swallowing dry food? In addition, ask if he has been in or near a fire within the past 48 hours. Be aware that an inhalation injury can cause sudden airway obstruction.

Next, explore associated symptoms. Does the patient have a history of cancer, rheumatoid arthritis, or aortic aneurysm? Does he regularly drink alcohol or smoke?

Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory infection. Palpate the neck for masses and the cervical lymph nodes and thyroid for enlargement. Palpate the trachea — is it midline? Ask the patient to stick out his tongue; if he can’t, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren’s syndrome). Dilated jugular and chest veins may indicate compression by an aortic aneurysm.

Take the patient’s vital signs, noting especially a fever and bradycardia. Inspect for asymmetrical chest expansion or signs of respiratory distress — nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.

» 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, 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

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

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

Obtain a patient history. First, consider the patient’s age and sex; laryngeal cancer is most common in men between ages 50 and 70. Be sure to ask about the onset of hoarseness. Has the patient been overusing his voice? Has he experienced shortness of breath, a sore throat, dry mouth, a cough, or difficulty swallowing dry food? In addition, ask if he has been in or near a fire within the past 48 hours. Be aware that inhalation injury can cause sudden airway obstruction.

Next, explore associated symptoms. Does the patient have a history of cancer, rheumatoid arthritis, or aortic aneurysm? Does he regularly drink alcohol or smoke?

Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory tract infection. Palpate the neck for masses and the cervical lymph nodes and the thyroid gland for enlargement. Palpate the trachea to determine if it’s midline. Ask the patient to stick out his tongue; if he can’t, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren’s syndrome). Dilated neck and chest veins may indicate compression by an aortic aneurysm.

Take the patient’s vital signs, noting especially fever and bradycardia. Examine him for asymmetrical chest expansion or signs of respiratory distress—nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Cough: 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

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

 A. Voice quality. Begin the physical examination by listening to the patient’s voice while obtaining the history. No specific features of hoarseness are definitively diagnostic, but a raspy voice suggests cord thickening caused by edema or inflammation; a breathy voice indicates poor vocal cord position or approximation; and a high, shaky or soft voice is more likely caused by malfunction of the larynx (2).

 B. Focused physical examination (PE). Obtain vital signs with attention to temperature and weight. Completely examine the scalp, neck, thyroid gland, cervical nodes, ears, nose, sinuses, and oral cavity. Tender neck adenopathy suggests infection, whereas painless enlargement may imply malignancy (Chapters 15.1 and 15.2). Unless a diagnosis is obvious from the history and initial PE, visualization of the larynx is required. Using one of the techniques described below (section III.C.), carefully inspect the posterior nasopharynx, tongue, lymphoid tissue, and entire larynx. Perform vocal maneuvers while directly observing vocal cord movement. Assess for mucosal and cartilagineous lesions, edema, erythema, and excess mucus—the latter finding suggesting prominent allergies. Edematous vocal cords and glottis with hyperemia suggests GERD or laryngitis.

 C. Techniques for laryngeal visualization

 1. Indirect laryngoscopy is performed by placing a laryngeal mirror (warmed to prevent fogging) against the soft palate while grasping the tongue with gauze. A bright light source and head mirror, or a headlight, is focused on the laryngeal mirror to reveal an image of the larynx. This technique, although simple, can prove difficult secondary to a strong tongue or gag reflex.

 2. Fiberoptic laryngoscopy provides an excellent view of the larynx and avoids the problems noted above in III.C.1. The scope is placed via one nares after topical anesthesia is applied intranasally (e.g., 2% lidocaine gel). The larynx is visualized while the patient swallows and phonates. The procedure is quick and painless and allows a thorough evaluation of the larynx.

Testing

A. Clinical laboratory tests. Routine blood testing is not helpful, unless dictated by features of the history or PE.

B. Imaging. If indicated by history or PE, magnetic resonance imaging is used to assess the extent of serious laryngeal or neck disease.

Diagnostic assessment

The key to diagnosis is a thorough history combined in most cases with visualization of the larynx. Hoarseness of less than 2 weeks duration is considered acute and is usually self-limited. Chronic hoarseness (>2 weeks duration) suggests a more serious cause and a laryngeal examination is critical (2–4).

Some laryngeal lesions have a pathognomonic appearance (3). Vocal polyps are benign and result from chronic voice abuse or direct trauma. They occur on the anterior portion of one vocal cord. Vocal nodules result from poor voice use (e.g., singers, preachers) and always occur at the junction of the anterior and middle third of the vocal cords bilaterally. Contact ulcers present as bilateral ulcerations at the tips of the laryngeal cartilages and are the only common lesion other than cancer that causes throat pain. Leukoplakia presents as a raised, white plaque at the anterior extremity of one vocal cord. It is usually premalignant, related to alcohol use or smoking, and needs to be biopsied.

Although most causes of hoarseness are benign, laryngeal cancer produces early changes in voice quality and is the most serious cause of hoarseness. This cancer presents as persistent hoarseness with a lesion in the hypophyarnyx, glottis, or supraglottis. Any suspicious lesion seen on laryngoscopy needs to be referred for biopsy.


References

1. Yanagisawa E. The larynx. In: Lee KJ, ed. Essential otolaryngology—head and neck surgery, 5th ed. Norwalk: Appleton & Lange, 1995:757–800.

2. Rosen CA, Anderson D, Murry T. Evaluating hoarseness. Am Fam Physician 1998;57:2775–2782.

3. Garrett CG, Ossoff RH. Hoarseness. Med Clin North Am 1999;83:115–123.

4. Vaughan C. Glottic carcinoma. In: Gates G, ed. Current therapy in otolaryngology—head and neck surgery, 5th ed. St. Louis: Mosby, 1994:288–298.

» 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

Hoarseness: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Persistent or progressive hoarseness is the most suspicious finding.

If the voice is coarse, rough, gravelly, or husky, the medial surface of the cord is irregular, and a polyp or an early malignancy should be suspected. A breathy voice occurs when the vocal cords do not approximate completely, due to unilateral vocal cord paralysis. A wet, gurgling, full voice suggests supraglottic salivary pooling, as with a peritonsillar abscess or supraglottic tumor. Loss of vocal range with weakness and cracking of the voice may occur with excessive vocal strain. An elderly patient may develop a high, shaky voice resulting from decreased respiratory force.

» 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

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

Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory infection. Palpate the neck for masses and the cervical lymph nodes and the thyroid for enlargement. Palpate the trachea — is it midline? Ask the patient to stick out his tongue; if he can’t, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren’s syndrome). Dilated jugular and chest veins may indicate compression by an aortic aneurysm.

Take the patient’s vital signs, noting especially fever and bradycardia. Inspect for asymmetrical chest expansion or signs of respiratory distress — nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.

» 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, 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, 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, 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

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

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

  • In assessmentof children with hoarseness, history and physical exam are diagnostic, especiallywith viral laryngitis, croup, and vocal abuse.
  • If hoarseness is persistent, progressive,or associated with history of trauma or stridor, neck radiographyand laryngoscopy should be performed.
  • Combination of neck radiography, laryngoscopy,bronchoscopy, and CT may be used to locate and define extent ofneoplastic lesions.

    • » 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

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

    Obtain a patient history. First, consider his age and sex; laryngeal cancer is most common in men between ages 50 and 70. Be sure to ask about the onset of hoarseness. Has the patient been overusing his voice? Has he experienced shortness of breath, a sore throat, a dry mouth, a cough, or difficulty swallowing dry food? In addition, ask if he has been in or near a fire within the past 48 hours. Be aware that an inhalation injury can cause sudden airway obstruction.

    Next, explore associated symptoms. Does the patient have a history of cancer, rheumatoid arthritis, or aortic aneurysm? Does he regularly drink alcohol or smoke?

    Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory infection. Palpate the neck for masses and the cervical lymph nodes and thyroid for enlargement. Palpate the trachea—is it midline? Ask the patient to stick out his tongue; if he can't, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren's syndrome). Dilated jugular and chest veins may indicate compression by an aortic aneurysm.

    Take the patient's vital signs, noting especially a fever and bradycardia. Inspect for asymmetrical chest expansion or signs of respiratory distress—nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Laryngitis

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