Causes of Respiratory infections

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

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

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

Fever – Cyclic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• PFAPA, or Marshall syndrome
  –Periodic fever (usually high, 104°F [40°C]), aphthous stomatitis, pharyngitis, and adenitis
  –Most common diagnosis for true cyclic fever, usually in children <5 years
  –Recurs every 3–4 weeks
• Cyclic neutropenia
  –Periodic fever, average cycle of 21 days
  –Pharyngitis, mouth ulcers, and lymphadenopathy are also noted
  –May not be associated with infection
• Infectious diseases
  –Relapsing fever due to Borrelia recurrentis,
  relapses every 10–14 days
  –EBV may occur at 6–8 week intervals
• Familial Mediterranean fever
  –Brief attacks of fever and serositis
  –Autosomal recessive disease
  –Sephardic Jews, Arabs, Turks, and Armenians commonly affected
  –50% have onset before 10 years of age
  –May occur in regular 7–28-day intervals
  –Amyloidosis is a possible complication
• Hyper-IgD and periodic fever syndrome (HIDS)
  –High fevers, abdominal pain, cervical lymphadenopathy, sometimes diarrhea and arthritis, in early infancy
  –Autosomal recessive, most patients from Western Europe (French, Dutch)
  –Cycles may be regular every 14–28 days
  • TNF-receptor-associated periodic syndrome (TRAPS) or Hibernian fever
    –Fever, myalgias with migratory pattern, conjunctivitis and rash
    –Autosomal dominant
    –first described in Irish/Scottish individuals but other ethnic groups involved
    –Amyloidosis is a possible complication (25% of untreated individuals)
  • Familial cold autoinflammatory syndrome or familial cold urticaria
    –Rash, fever, arthralgia, and conjunctivitis
    –Precipitated by exposure to cold
  • Factitious fever
  >

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

Fever – Recurrent: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Repeated viral infections
  –Most common cause of recurrent febrile episodes in childhood
  –Start of day care or change of geographic location may be related
• Urinary tract infection (UTI)
  –May be self-limited but recur especially if underlying anomaly exists
• Epstein-Barr virus (EBV)
  –May present with recurrent febrile episodes due to one initial infection
• Other specific viral syndromes
  –Parvovirus B19
  –CMV
• Immunodeficiency
  –Repeated bacterial infections should lead to investigation of immune status
• Dental abscess (non-dental abscesses typically present with prolonged daily fever)
• Chronic meningococcemia
• Acute rheumatic fever
• Inflammatory bowel disease (IBD)
• Juvenile rheumatoid arthritis (JRA)
• Behçet disease
• Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) or Hibernian Fever
  –Autosomal dominant disease with fever, myalgias with migratory pattern, conjunctivitis and rash
• Familial cold autoinflammatory syndrome or familial cold urticaria
  –Rash, fever, arthralgia, and conjunctivitis
  –Precipitated by exposure to cold
• Muckle-Wells syndrome
  –Similar presentation to familial cold urticaria
  –Symptoms not triggered by cold
• Brucellosis
  –Most prevalent around the Mediterranean and Arabic countries, also present in South America and India
• Yersiniosis
• Typhoid fever
• Rat-bite fever
• Malaria
• Factitious fever

» READ BOOK EXCERPT ONLINE »

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

Fever – Unknown Origin: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infections (40%)
  –Infectious mononucleosis (EBV, CMV)
  –Other systemic viral syndromes (e.g., HIV)
  –UTI (e.g., E. coli)
  –Osteomyelitis (e.g., staphylococcus)
  –Upper and lower respiratory infections (sinusitis, mastoiditis, pneumonia)
  –Cat-scratch disease (Bartonella henselae)
  –Tuberculosis, nontuberculous mycobacterial infections
  –Abscess (abdominal or retroperitoneal)
  –CNS infections
  –Endocarditis (subacute)
  –Salmonellosis
  –Lyme disease (Borrelia burgdorferi)
  –Leptospirosis
  –Congenital syphilis
  –Others: Brucellosis, histoplasmosis, leishmaniasis, yersiniosis, Q fever (Coxiella burnetii), Rocky Mountain spotted fever (Rickettsia rickettsii)

• Autoimmune diseases (15%)
  –Rheumatoid arthritis accounts for 3/4 of FUO due to autoimmune diseases
  –Systemic lupus erythematosus
  –Rheumatic fever
  –Vasculitis (e.g., HSP)
  –Sarcoidosis
• Neoplastic diseases (7%)
  –Leukemia/lymphoma accounts for 80% of
  FUO due to malignancies
  –Neuroblastoma
  –Hepatoma
  –Soft tissue sarcoma
• Inflammatory bowel disease (3%)
• Drugs and nutritional supplements (drug fever)
• Factitious fever
• Munchausen by proxy
• Neurologic disorders
  –Familial dysautonomia
  –Central thermoregulatory disorder
  –Head injury
• Hyperthyroidism
• Anhidrotic ectodermal dysplasia
• Diabetes insipidus
• Kikuchi disease

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

• Viral infections
  –Account for the majority of febrile illnesses (FI) in infancy and childhood
  –Upper respiratory infections (e.g., parainfluenza virus)
  –Lower respiratory infections (e.g., RSV)
  –Non-bacterial gastroenteritis (e.g., rotavirus)
  –Aseptic meningitis (e.g., enterovirus)
• Bacterial infections
  –UTIs account for 1.7% of FI in children 5 years and 7.5% in infants <8 weeks
  –Pneumonia (e.g., group A streptococcus)
  –Bacteremia (2% of FI in all children, highest rates seen in younger infants)
  –Meningitis (0.8% of FI in all children)
  –In febrile neonates, the overall rate of serious bacterial infections (SBI) is ~13%
• Vaccine reaction
  • Collagen vascular diseases
    –Kawasaki disease: 3,000 cases per year in the U.S., rates higher in Asia, 80% of cases occur in children <5 years
    –Henoch-Schönlein purpura: Low-grade fever is present in 50% of cases
    –Juvenile rheumatoid arthritis: Incidence 1/10,000
    –SLE
    –Acute rheumatic fever
  • Malignancy
    –Leukemia: Most common childhood malignancy; early symptoms include fever, fatigue, pallor, anemia, bone pain
    –Lymphoma
    –Solid tumors (neuroblastoma, sarcoma)
  • Inflammatory bowel disease
    –Diarrhea, pain, fever, blood loss
    –Crohn disease, ulcerative colitis
  • Tissue injury (trauma, hematoma, burns)
  • Drug reaction
  • Biologic agents (blood products, gamma-globulin)
  • Endocrinologic disorders
    –Thyrotoxicosis
    –Pheochromocytoma
  • Genetic diseases
    –Familial Mediterranean fever
  • Factitious fever
  >>

» READ BOOK EXCERPT ONLINE »

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

Cough, barking: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Aspiration of foreign body.

Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.

 Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute).

Also known as viral croup, laryngotracheobronchitis is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.

 Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

» READ BOOK EXCERPT ONLINE »

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

Cough, productive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Actinomycosis.

 Actinomycosis begins with a cough that produces purulent sputum. A fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis.

Aspiration pneumonitis causes coughing that produces pink, frothy and, possibly, purulent sputum. The patient also has marked dyspnea, a fever, tachypnea, tachycardia, wheezing, and cyanosis.

Bronchiectasis.

The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, a recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic).

Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis.

Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, a fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.

 When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications include a dry hacking cough, sneezing, a headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, a sore throat, myalgia, and arthralgia.

Lung abscess (ruptured).

The cardinal sign of a ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, and possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, a fever with chills, dyspnea, a headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient's chest is dull on percussion on the affected side.

Lung cancer.

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, a fever, diaphoresis, wheezing, and clubbing.

Nocardiosis.

 Nocardiosis causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient's chest is dull on percussion.

North American blastomycosis.

 North American blastomycosis is a chronic disorder that produces coughing that's dry and hacking or produces bloody or purulent sputum. Other findings include pleuritic chest pain, a fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague

(Yersinia pestis).  Plague is one of the most virulent acute bacterial infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to a human when bitten by an infected flea. Signs and symptoms include a fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia.

 Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, a high fever, myalgia, a headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Typically, however, a nonproductive cough starts 2 to 3 days after the onset of malaise, a headache, a fever, and a sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles, but generally don't appear seriously ill.

Psittacosis.

 As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, a fever, a headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis.

 Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with a fever, occasional chills, pleuritic chest pain, a sore throat, a headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema.

When severe, pulmonary edema, which is a life-threatening disorder, causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include a fever, fatigue, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. As the patient's respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism.

Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis (TB).

 Pulmonary TB causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis.

 A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis.

Inflammation initially causes a nonproductive cough that later — following the onset of chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests.

Bronchoscopy and pulmonary function tests (PFTs) may increase productive coughing.

Drugs.

 Expectorants increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.

Respiratory therapy.

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

» READ BOOK EXCERPT ONLINE »

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

Fever: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anthrax, cutaneous

The patient may experience a fever along with lymphadenopathy, malaise, and a headache. After the bacterium

Anthrax, GI

Following the ingestion of contaminated meat from an animal infected with the bacterium

Anthrax, inhalation

 The initial signs and symptoms of inhalation anthrax are flulike, including a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours

Escherichia coli O157:H7

 A fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

When present, a fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), a fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include a headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome)

Infectious and inflammatory disorders

A fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or

Ebola or

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Listeriosis

Signs and symptoms of listeriosis include a fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include a fever, a headache, nuchal rigidity, and a change in the LOC

Gender cue

Infections during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Neoplasms

In addition to a fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

The bubonic form of plague(transmitted to man when bitten by infected fleas) causes a fever, chills, and swollen, inflamed, and tender lymph nodes near the bite site. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, a fever, a headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency

Q fever

Q fever is a rickettsial disease that’s caused by the infection of

Coxiella burnetii

It causes a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis

 Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms that include a fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream

Rift Valley fever

Typical signs and symptoms of Rift Valley fever include a fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have been documented in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other signs and symptoms include a headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death

Smallpox (variola major)

Initial signs and symptoms of smallpoxinclude a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection

Thermoregulatory dysfunction

Thermoregulatory dysfunction is marked by a sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C). It occurs in such life-threatening disorders as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia and in lesions of the central nervous system (CNS). A low or moderate fever appears in dehydrated patients

A prolonged high fever commonly produces vomiting, anhidrosis, a decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes, such as dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (a decreased LOC with bradycardia, a widened pulse pressure, and an increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Tularemia, also known as rabbit fever, causes an abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema

Typhus

Typhus is a rickettsial disease in which the patient initially experiences a headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of a fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases

West Nile encephalitis

West Nile encephalitis is a brain infection caused by West Nile virus — a mosquito-borne flavivirus that’s commonly found in Africa, West Asia, and the Middle East and rarely in North America. Mild infection is common; signs and symptoms include a fever, a headache, and body aches, usually with skin rash and swollen lymph glands. More severe infection is marked by a high fever, a headache, neck stiffness, stupor, disorientation, coma, tremors, occasional convulsions, paralysis and, rarely, death

Other causes

Diagnostic tests

Immediate or delayed fever infrequently follows radiographic tests that use contrast medium

Drugs

A fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. A fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. A fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments

Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of a fever and chills

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

Cough, nonproductive: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Airway occlusion.

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation).

Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in the cutaneous, inhalation, or GI form.

Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic).

Aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma.

Asthma attacks typically occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis.

As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Bronchitis (chronic).

Bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma.

The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.

Common cold.

 The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and a sore throat.

Esophageal achalasia.

 In esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia.

Esophageal diverticula.

 The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion.

 Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Hantavirus pulmonary syndrome.

A nonproductive cough is common in patients with Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other findings include a headache, myalgia, fever, nausea, and vomiting.

Hypersensitivity pneumonitis.

 With hypersensitivity pneumonitis, an acute nonproductive cough, a fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen.

Interstitial lung disease.

A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor.

 A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and an earache may occur.

Laryngitis.

 In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Lung abscess.

Lung abscess typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling, and possibly bloody sputum.

Pleural effusion.

 A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia.

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 to 3 days after the onset of malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn't appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and a low-grade fever.

Pneumothorax.

 Pneumothorax is a life-threatening disorder that causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema.

Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. If pulmonary edema is severe, the patient's respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism.

A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis.

With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS).

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days; the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Tracheobronchitis (acute).

Initially, tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm, with severe wheezing and increased coughing.

Tularemia.

Also known as rabbit fever, tularemia is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. It's typically a rural disease found in wild animals, water, and moist soil. It's transmitted to humans through the bite of an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It's considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests.

 Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough receptors and trigger coughing.

Treatments.

 Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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

Acute respiratory failure in COPD: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

ARF may develop in patients with COPD as a result of any condition that increases the work of breathing and decreases the respiratory drive. Such conditions include respiratory tract infection (such as bronchitis or pneumonia). The most common precipitating factor is bronchospasm, or accumulating secretions secondary to cough suppression. Other causes of ARF in COPD include:

❑ central nervous system (CNS) depression — head trauma or injudicious use of sedatives, opioids, tranquilizers, or oxygen (O₂)

❑ cardiovascular disorders — myocardial infarction, heart failure, or pulmonary emboli

❑ airway irritants — smoke or fumes

❑ endocrine and metabolic disorders — myxedema or metabolic alkalosis

❑ thoracic abnormalities — chest trauma, pneumothorax, or thoracic or abdominal surgery.

The incidence of ARF increases markedly with age and is especially high among people age 65 and older.

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

Infant respiratory distress syndrome: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Although airways and alveoli of a neonate’s respiratory system are present by 27 weeks’ gestation, the intercostal muscles are weak and the alveolar capillary system is immature. The premature neonate with IRDS develops widespread alveolar collapse due to a lack of surfactant, a lipoprotein pres-ent in alveoli and respiratory bronchioles. Surfactant lowers surface tension and helps prevent alveolar collapse. This surfactant deficiency results in widespread atelectasis, which leads to inadequate alveolar ventilation with shunting of blood through collapsed areas of lung, causing hypoxemia and acidosis.

IRDS occurs almost exclusively in neonates born before 37 weeks’ gestation (in 60% of those born before the 28th week). The incidence is greatest in the 1,000 to 1,500 g birthweight group. Infants of diabetic mothers, those born by cesarean delivery, second-born twins, infants with perinatal asphyxia, and those delivered suddenly after antepartum hemorrhage are more commonly afflicted.

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

Respiratory syncytial virus infection: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The organism that causes RSV is transmitted from person to person by respiratory secretions and has an incubation period of 4 to 5 days. Antibody titers seem to indicate that few children younger than age 4 escape contracting some form of RSV, even if it's mild. In fact, RSV is the only viral disease that has its maximum impact during the first few months of life (incidence of RSV bronchiolitis peaks at age 2 months). School-age children, adolescents, and young adults with mild reinfections are probably the source of infection for infants and young children.

This virus occurs in annual epidemics during the late winter and early spring in temperate climates and during the rainy season in the tropics. It can also be seen in immunocompromised adults, especially patients with bone marrow transplants.

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

Lung cancer: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Most experts agree that lung cancer is attributable to inhalation of carcinogenic pollutants by a susceptible host. Who's most susceptible? Any smoker older than age 40, especially if he began to smoke before age 15, has smoked a whole pack or more per day for 20 years, or works with or near asbestos.

Pollutants in tobacco smoke cause progressive lung cell degeneration. Lung cancer is 10 times more common in smokers than in nonsmokers; 80% of patients with lung cancer are smokers. Cancer risk is determined by the number of cigarettes smoked daily, the depth of inhalation, how early in life smoking began, and the nicotine content of cigarettes. Two other factors also increase susceptibility: exposure to carcinogenic industrial and air pollutants (asbestos, uranium, arsenic, nickel, iron oxides, chromium, radioactive dust, and coal dust) and familial susceptibility.

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

Severe acute respiratory syndrome: Causes
(Professional Guide to Diseases (Eighth Edition))

SARS is caused by the SARS-associated coronavirus (SARS-CoV). Coronaviruses are a common cause of mild respiratory illnesses in humans, but researchers believe that a virus may have mutated, allowing it to cause this potentially life-threatening disease.

Close contact with a person who’s infected with SARS, including contact with infectious aerosolized droplets or body secretions, is the method of transmission. Most people who contracted the disease during the 2003 outbreak contracted it during travel to endemic areas. However, the virus has been found to live on hands, tissues, and other surfaces for up to 6 hours in its droplet form. It has also been found to live in the stool of people with SARS for up to 4 days. The virus may be able to live for months or years in below-freezing temperatures.

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

Colorado tick fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Colorado tick fever is transmitted to humans by a hard-shelled wood tick called Dermacentor andersoni. The adult tick acquires the virus when it bites infected rodents and remains permanently infective.

Incidence is high in Colorado, where up to 15% of people who regularly camp show past exposure. It's much less common in the rest of the United States.

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

Lassa fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

A chronic infection in rodents, Lassa virus is transmitted to humans by contact with infected rodent urine, feces, and saliva. The virus enters the bloodstream, lymph vessels, and respiratory and digestive tracts. It then multiplies in the cells of the reticuloendothelial system. In the early stages of this illness, when the virus is in the throat, human transmission may occur through inhalation of infected droplets.

As many as 100 cases of Lassa fever occur annually in western Africa; the disease is rare in the United States.

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

Relapsing fever: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The body louse (Pediculus humanus corporis) carries louse-borne relapsing fever (B. recurrentis), which typically occurs in epidemics during wars, famines, and mass migrations. Cold weather and crowded living conditions also favor the spread of body lice.

Inoculation takes place when the victim crushes the louse, causing its infected blood or body fluid to soak into the victim's bitten or abraded skin or mucous membranes.

Louse-borne relapsing fever is most common in North and Central Africa, Europe, Asia, and South America. No cases of louse-borne relapsing fever have been reported in the United States since 1900.

Tick-borne relapsing fever, however, is found in the United States and is caused by at least 15 Borrelia species; the three species most commonly identified with tick carriers are B. hermsii (associated with Ornithodoros hermsi), B. turicatae (associated with O. turicata), and B. parkeri (associated with O. parkeri). This form of the disease is most prevalent in Texas and other western states, usually during the summer when ticks and their hosts (chipmunks, goats, squirrels, rabbits, mice, rats, owls, lizards, and prairie dogs) are most active. In the colder weather, outbreaks sometimes afflict people such as campers who sleep in tick-infested cabins.

Because tick bites are virtually painless and most Ornithodoros ticks feed at night but don’t imbed themselves in the victim’s skin, many people are bitten unknowingly.

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

Rheumatic fever and rheumatic heart disease: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Rheumatic fever appears to be a hypersensitivity reaction to a group A beta-hemolytic streptococcal infection, in which antibodies manufactured to combat streptococci react and produce characteristic lesions at specific tissue sites, especially in the heart and joints. Because very few persons (3%) with streptococcal infections ever contract rheumatic fever, altered host resistance must be involved in its development or recurrence. Although rheumatic fever tends to be familial, this may merely reflect contributing environmental factors. For example, in lower socioeconomic groups, incidence is highest in children between ages 5 and 15, probably as a result of malnutrition and crowded living conditions. This disease strikes generally during cool, damp weather in the winter and early spring. In the United States, it’s most common in the northern states.

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

Cough, barking: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aspiration of foreign body

Partial obstruction of the upper airway first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing, and possibly cyanosis.

Epiglottiditis

This life-threatening disorder has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute)

Also known as viral croup, this infection is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup

Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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

Cough, productive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Actinomycosis

This disorder begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis

This disorder causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis.

Asthma (acute)

A severe asthma attack, which can be life-threatening, may produce tenacious mucoid sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expiration, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.

Bronchiectasis

The chronic cough of this disorder produces copious mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic)

The cough associated with chronic bronchitis may be nonproductive initially; eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood tinged and foul smelling. The cough, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expiration, accessory muscle use, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis

This disorder causes a cough with purulent sputum. It may also cause dyspnea, wheezing, orthopnea, fever, malaise, crackles, laryngitis, rhinitis, and mucous membrane irritation of the conjunctivae, throat, and nose. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; in severe pneumonitis, however, they may recur 2 to 5 weeks later.

Common cold

The common cold may cause a productive cough with mucoid or mucopurulent sputum, but it usually starts with a dry, hacking cough, sore throat, sneezing, rhinorrhea, and nasal congestion. Headache, malaise, fatigue, myalgia, and arthralgia may also occur.

Emphysema

This disorder causes a chronic productive cough with scant mucoid, translucent, grayish white sputum that can become mucopurulent. Patients with emphysema are typically thin and have the characteristic pink or red complexion (“pink puffer” appearance). They may also exhibit increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, anorexia, and weight loss. Clubbing is a late sign.

Legionnaires’ disease

This disorder causes a cough that produces scant mucoid, nonpurulent and, possibly, blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia, and possibly diarrhea. Within 12 to 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.

Lung abscess (ruptured)

The cardinal sign of a ruptured lung abscess is a cough that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.

Lung cancer

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms of lung cancer include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.

Nocardiosis

This disorder causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, weight loss, malaise, fatigue, and diminished or absent breath sounds. The patient’s chest is dull on percussion.

North American blastomycosis

This chronic disorder may produce a dry hacking cough or a productive cough with bloody or purulent sputum. Other findings include pleuritic chest pain, fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague

Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia

Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasmal pneumonia may cause a cough that produces scant blood-flecked sputum. In most cases, however, a nonproductive cough starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.

Psittacosis

As this disorder progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly with chills, fever, headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe psittacosis may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis

This disorder causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic chest pain, sore throat, headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema

When severe, this life-threatening disorder causes a cough that produces frothy, blood-tinged sputum. Early signs and symptoms include exertional dyspnea, paroxysmal nocturnal dyspnea followed by orthopnea, and a cough that may be nonproductive initially. Fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop may also occur. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and the productive cough, worsening tachycardia, and possibly arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism

This life-threatening disorder causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, in a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis

This disorder causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may exhibit chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis

A productive cough with mucopurulent sputum is the earliest sign of this disorder. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis

Inflammation initially causes a nonproductive cough followed by chills, sore throat, slight fever, muscle and back pain, and substernal tightness. As secretions increase, the cough produces mucoid, mucopurulent, or purulent sputum. The patient typically has rhonchi and wheezing; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests

Bronchoscopy and pulmonary function tests may increase productive coughing.

Drugs

Expectorants, such as ammonium chloride, guaifenesin, potassium iodide, and terpin hydrate, increase productive coughing.

Respiratory therapy

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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

Cough, nonproductive: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Airway occlusion

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient exhibits gagging, wheezing, hoarseness, stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation)

This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Aortic aneurysm (thoracic)

This disorder causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor, and possibly paresthesia or neuralgia.

Asthma

Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing and progressing to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis

As lung tissue deflates in atelectasis, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, tachycardia, decreased breath sounds, cyanotic skin, and diaphoresis. His chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Avian influenza

These potentially life-threatening viruses are spread to humans through infected poultry and surfaces contaminated with infected bird excretions. Infected individuals may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia. To date this strain of the virus has not surfaced in the United States; however, a recent outbreak in Asian and European countries has caused worldwide concern that the virus may spread through both infected humans and birds. Treatment with two of the four FDA-approved antiviral medications has proven effective with some virus strains, and an experimental vaccine is currently under investigation.

Bronchitis (chronic)

This disorder starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma

The earliest indicators of this disease can be a chronic nonproductive cough, dyspnea, and vague chest pain. The patient may also be wheezing.

Common cold

Most colds start with a nonproductive, hacking cough and progress to some mix of sneezing, rhinorrhea, nasal congestion, sore throat, headache, malaise, fatigue, myalgia, and arthralgia.

Esophageal achalasia

In this disorder, regurgitation and aspiration produce a dry cough and, possibly, recurrent pulmonary infections and dysphagia.

Esophageal diverticula

The patient with this disorder has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion

This disorder is marked by sudden nonproductive coughing and gagging with a sensation of something stuck in the throat. Other findings include neck or chest pain and dysphagia.

Esophagitis with reflux

This disorder commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may also experience chest pain that mimics angina pectoris, heartburn that worsens if he lies down after eating, increased salivation, dysphagia, hematemesis, and melena. Hantavirus Pulmonary Syndrome A nonproductive cough is common in patients with this disorder, which is marked by noncardiogenic pulmonary edema. Other findings include headache, myalgia, fever, nausea, and vomiting.

Hodgkin’s disease

This disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.

Hypersensitivity pneumonitis

In this disorder, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen.

Interstitial lung disease

A patient with this disorder has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor

A mild nonproductive cough, minor throat discomfort, and hoarseness are early signs of this disorder. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.

Laryngitis

Acute laryngitis causes a nonproductive cough with localized pain (especially when the patient swallows or speaks) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Legionnaires’ disease

After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, nonpurulent and, possibly, blood-tinged sputum.

Lung abscess

This disorder typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, blood-tinged sputum.

Mediastinal tumor

A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, jugular vein distention, and facial or neck edema.

Pericardial effusion

The most common signs and symptoms of this disorder are dysphagia, fever, pleuritic chest pain, and pericardial friction rub. A severe nonproductive cough occurs rarely.

Pleural effusion

A nonproductive cough, dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.

In mycoplasmal pneumonia, a nonproductive cough develops 2 to 3 days after the onset of malaise, headache, and sore throat. The cough may be paroxysmal, causing substernal chest pain. The patient commonly has a fever but doesn’t appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.

Pneumothorax

This life-threatening disorder causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Psittacosis

In this disorder, an initially dry, hacking cough later produces small amounts of blood-streaked, mucoid sputum. Psittacosis may begin abruptly with chills, fever, headache, myalgia, and prostration. The patient may also have tachypnea, fine crackles, epistaxis and, rarely, chest pain.

Pulmonary edema

This disorder initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and a cough that produces frothy, blood-streaked sputum.

Pulmonary embolism

A life-threatening pulmonary embolism may suddenly produce a dry cough, dyspnea, and pleuritic or anginal chest pain. In most cases, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis

In this disorder, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Sinusitis (chronic)

This disorder can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.

Tracheobronchitis (acute)

Initially, this disorder produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezing are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm, severe wheezing, and increased coughing.

Tularemia

Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests

Pulmonary function tests and bronchoscopy may stimulate cough receptors and trigger coughing.

Drugs

Certain drugs, such as angiotensin-converting enzyme inhibitors, may also cause a nonproductive cough.

Treatments

Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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

Fever [Pyrexia]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anthrax, cutaneous

In this disorder, the patient may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black necrotic center.

Anthrax, GI

After ingesting contaminated meat from an animal infected with the bacterium Bacillus anthracis, the patient experiences fever, anorexia, nausea, vomiting and, possibly, abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation

This acute infectious disease initially produces flulike signs and symptoms, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours.

Avian influenza

Avian influenza, also known as bird flu, is an infection caused by viruses that originate in the intestines of wild birds but are highly contagious to domesticated birds, such as chickens, turkeys, and geese. Infected poultry and surfaces contaminated with infected bird excretions have recently led to human infections and deaths in several Asian countries. Fever is commonly an initial symptom of these viruses along with other conventional influenza symptoms, such as muscle aches, sore throat, and cough. Individuals infected with the most virulent avian virus, influenza A (H5N1), may develop pneumonia, acute respiratory distress, and other life-threatening complications.

Escherichia Coli O157:H7

Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. Children younger than age 5 and elderly patients may develop hemolytic uremic syndrome, which can ultimately lead to acute renal failure.

Immune complex dysfunction

When present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (in AIDS) or morning stiffness (in rheumatoid arthritis). Other disease-specific findings include headache and vision loss (in temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (in ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (in erythema multiforme); and urethritis with urethral discharge and conjunctivitis (in Reiter’s syndrome).

Infectious and inflammatory disorders

Fever ranges from low (in Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, Ebola virus or Hantavirus pulmonary syndrome). It may be remittent, as in infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in a lung abscess, influenza, or endocarditis; sustained, as in meningitis; or relapsing, as in malaria. Fever may arise abruptly, as in toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Kawasaki syndrome

Fever, typically high and spiking, is the primary characteristic of this acute illness. The diagnosis of Kawasaki syndrome is confirmed when fever persists for 5 or more days (or until administration of I.V. gamma globulin if given before the fifth day) and is accompanied by other clinical signs, including conjunctival injection, erythema, lymphadenopathy, and peripheral extremity swelling. This syndrome occurs worldwide, with the highest incidence in Japan. It primarily affects children under age 5, is more prevalent in boys, and can cause serious heart damage and death without prompt treatment with I.V. gamma globulin.

Listeriosis

Signs and symptoms of this infection include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, it may cause meningitis, whose symptoms include fever, headache, nuchal rigidity, and change in LOC.

Gender Cue: Listeriosis during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Monkeypox

Fever is one of the initial symptoms that occurs in almost all patients infected with this rare viral disease. A papular rash that may be localized or generalized appears within 1 to 3 days after the fever begins. Additional symptoms commonly include sore throat, chills, and lymphadenopathy. There is no treatment for monkeypox, but the disease is rarely fatal in developed countries and usually lasts 2 to 4 weeks.

Neoplasms

Primary neoplasms and metastases can produce prolonged fever of varying elevations. For instance, acute leukemia may manifest insidiously with a low fever, pallor, and bleeding tendencies, or more abruptly with a high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

Besides fever and nocturnal diaphoresis, neoplastic disease commonly causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

Caused by Yersinia pestis, plague is one of the most virulent bacterial infections known. The bubonic form of plague is transmitted to man from the bite of infected fleas and causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. Septicemic plague may deveop as a complication of untreated bubonic or pneumonic plague, and occurs when bacteria enter the bloodstream and multiply. Pneumonic plague manifests as a sudden onset of chills, fever, headache, and myalgia after person-to-person transmission by respiratory droplets. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Q fever

This rickettsial disease caused by Coxiella burnetii causes fever (which may last up to 2 weeks), chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. In severe cases, the patient may develop hepatitis or pneumonia.

Respiratory syncytial virus (RSV)

Fever is one of the initial symptoms of this common illness that affects most children by age 2. Healthy adults and children older than age 3 usually develop a low-grade fever along with other common coldlike symptoms of runny nose, cough, and wheezing. Many children less than age 3 have a high-grade fever that may be accompanied by a severe cough, rapid breathing, and high-pitched expiratory wheezing. Infants with RSV typically exhibit lethargy, poor eating, irritability, and difficulty breathing; severe cases may require hospitalization. To avoid repeated RSV infection, individuals should practice infection-control techniques, such as proper hand-washing and avoiding contact with contaminated surfaces.

Rhabdomyolysis

This disorder results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream. Signs and symptoms include fever, muscle weakness or pain, nausea, vomiting, malaise, and dark urine. Acute renal failure, the most common complication rhabdomyolysis, results from renal structure obstruction and injury during the kidneys’attempt to filter the myoglobin from the bloodstream.

Rift Valley fever

Typical signs and symptoms of this infection include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. SARS may produce only mild symptoms, or it may progress to pneumonia and, in some cases, even respiratory failure and death.

Smallpox (variola major)

i> Initial signs and symptoms of this virus include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 or 9 days, they form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction

Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). A low or moderate fever occurs in dehydrated patients.

Prolonged high fever commonly produces vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes (dry skin and mucous membranes, poor skin turgor) and oliguria in dehydration; mottled cyanosis in malignant hyperthermia; diarrhea in thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) in CNS tumor, trauma, or hemorrhage.

Tularemia

This infectious disease, also known as “rabbit fever,” causes abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus

In this rickettsial disease, the patient initially experiences headache, myalgia, arthralgia, and malaise. These symptoms are followed by an abrupt onset of fever, chills, nausea, vomiting, and—in some cases—a maculopapular rash.

West Nile encephalitis

This brain infection is caused by West Nile virus, a mosquito-borne flavivirus commonly found in Africa, West Asia, and the Middle East and rarely in North America. Most patients have mild signs and symptoms, including fever, headache, body aches, rash, and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors and, occasionally, paralysis or seizures. Death rarely occurs.

Other causes

Diagnostic tests

Immediate or delayed fever infrequently follows radiographic tests that use a contrast medium.

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments

A remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of fever and chills.

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

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

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

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Source: Field Guide to Bedside Diagnosis, 2007

Fever of Unknown Origin: Differential Overview
(Field Guide to Bedside Diagnosis)

Infection

❑ HIV

❑ Tuberculosis

❑ Endocarditis

❑ Osteomyelitis

❑ Malaria

❑ Syphilis

❑ Zoonosis

❑ Typhoid fever

❑ Chronic meningococcemia

Neoplasm

❑ Lymphoma

❑ Liver metastases

❑ Renal cell carcinoma

❑ Atrial myxoma

Collagen-Vascular Disease

❑ Giant cell arteritis

❑ Systemic lupus erythematosus

❑ Vasculitis

❑ Rheumatic fever

❑ Still disease

Other

❑ Drugs

❑ Heat stroke

❑ Factitious

❑ Malignant hyperthermia

❑ Multiple pulmonary emboli

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Viral upper respiratory infection

❑ Asthma

❑ Sinusitis

❑ Mycoplasma bronchitis

❑ Pneumonia

❑ Gastroesophageal reflux

❑ Congestive heart failure

❑ ACE inhibitor

❑ Aspiration

❑ Cough in HIV

❑ Thermal

❑ Fume inhalation

❑ Pertussis

❑ Lung abscess

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Upper respiratory infection

❑ Allergy

❑ Asthma

❑ Chronic bronchitis

❑ Chronic sinusitis

❑ Gastroesophageal reflux

❑ ACE inhibitor

❑ Pollutants

❑ Psychogenic

❑ Foreign body

❑ Congestive heart failure

❑ Lung cancer

❑ Tuberculosis

❑ Mediastinal mass

❑ Bronchiectasis

❑ Pulmonary fibrosis

❑ Cystic fibrosis

❑ Aspergillosis

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Source: Field Guide to Bedside Diagnosis, 2007

Acute respiratory failure in COPD: Causes
(Handbook of Diseases)

ARF may develop in COPD patients from any condition that increases the work of breathing and decreases the respiratory drive. Such conditions include respiratory tract infection (such as bronchitis or pneumonia), which is the most common precipitating factor; bronchospasm; or accumulating secretions secondary to cough suppression. Other causes include:

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Source: Handbook of Diseases, 2003

Respiratory acidosis: Causes
(Handbook of Diseases)

Respiratory acidosis can result from airway obstruction or parenchymal lung disease, which interferes with alveolar ventilation, or from chronic obstructive pulmonary disease (COPD), asthma, severe adult respiratory distress syndrome, chronic bronchitis, large pneumothorax, extensive pneumonia, or pulmonary edema.

Hypoventilation compromises excretion of carbon dioxide produced through metabolism. The retained carbon dioxide then combines with water to form an excess of carbonic acid, decreasing the blood pH. As a result, the concentration of hydrogen ions in body fluids, which directly reflects acidity, increases.

In addition, several factors predispose the patient to respiratory acidosis:

❑ Drugs: Narcotics, anesthetics, hypnotics, and sedatives decrease the sensitivity of the respiratory center.

❑ Central nervous system (CNS) trauma: Medullary injury may impair ventilatory drive.

❑ Chronic metabolic alkalosis: Respiratory compensatory mechanisms attempt to normalize pH by decreasing alveolar ventilation.

❑ Neuromuscular disease (such as myasthenia gravis, Guillain-Barré syndrome, and poliomyelitis): Failure of respiratory muscles to respond properly to respiratory drive reduces alveolar ventilation.

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Source: Handbook of Diseases, 2003

Respiratory alkalosis: Causes
(Handbook of Diseases)

Respiratory alkalosis can result from pulmonary or nonpulmonary causes:

❑ Pulmonary causes include pneumonia, interstitial lung disease, pulmonary vascular disease, and acute asthma.

❑ Nonpulmonary causes include anxiety, fever, aspirin toxicity, metabolic acidosis, CNS disease (inflammation or tumor), sepsis, hepatic failure, and pregnancy.

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Source: Handbook of Diseases, 2003

Respiratory distress syndrome: Causes
(Handbook of Diseases)

Although the airways and alveoli of a neonate’s respiratory system are present by the 27th week of gestation, the intercostal muscles are weak and the alveoli and capillary blood supply are immature. In respiratory distress syndrome, the premature neonate develops widespread alveolar collapse because of lack of surfactant, a lipoprotein present in alveoli and respiratory bronchioles.

Surfactant normally lowers surface tension and aids in maintaining alveolar patency, preventing collapse, particularly at end expiration. But a deficiency results in widespread atelectasis, which leads to inadequate alveolar ventilation with shunting of blood through collapsed areas of lung, causing hypoxia and acidosis.

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Source: Handbook of Diseases, 2003

Respiratory syncytial virus infection: Causes
(Handbook of Diseases)

Antibody titers seem to indicate that few children younger than age 4 escape contracting some form of RSV, even if it’s mild. In fact, RSV is the only viral disease that has its maximum impact during the first few months of life (incidence of RSV bronchiolitis peaks at age 2 months).

This virus creates annual epidemics that occur during late winter and early spring in temperate climates and during the rainy season in the tropics. The organism is transmitted from person to person by respiratory secretions and has an incubation period of 4 to 5 days. Those at higher risk include infants who are exposed to tobacco smoke, attend day-care centers, live in crowded conditions, or have school-age siblings.

Reinfection is common, producing milder symptoms than the primary infection. School-age children, adolescents, and young adults with mild re-infections are probably the source of infection for infants and young children.

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Source: Handbook of Diseases, 2003

Lung abscess: Causes
(Handbook of Diseases)

A lung abscess is a manifestation of necrotizing pneumonia, commonly the result of aspiration of oropharyngeal contents. Poor oral hygiene with dental or gingival (gum) disease is strongly associated with a putrid lung abscess. Septic pulmonary emboli commonly produce cavitary lesions. Infected cystic lung lesions and cavitating bronchial carcinoma must be distinguished from lung abscesses.

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Source: Handbook of Diseases, 2003

Lung cancer: Causes
(Handbook of Diseases)

Most experts agree that lung cancer is attributable to inhalation of carcinogenic pollutants by a susceptible host. Most susceptible are those persons who smoke or who work with or near asbestos.

Pollutants in tobacco smoke cause progressive lung cell degeneration. Lung cancer is 10 times more common in smokers than in nonsmokers; indeed, 80% of lung cancer patients are or were smokers.

Cancer risk is determined by the number of cigarettes smoked daily, the depth of inhalation, how early in life smoking began, and the nicotine content of the cigarettes. Two other factors also increase susceptibility: exposure to carcinogenic industrial and air pollutants (asbestos, uranium, arsenic, nickel, iron oxides, chromium, radioactive dust, and coal dust), and familial susceptibility.

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Source: Handbook of Diseases, 2003

Rheumatic fever and rheumatic heart disease: Causes
(Handbook of Diseases)

Rheumatic fever appears to be a hypersensitivity reaction to a group A beta-hemolytic streptococcal infection, in which antibodies manufactured to combat streptococci react and produce characteristic lesions at specific tissue sites, especially in the heart and joints. About 3% of patients with untreated streptococcal infections develop rheumatic fever.

Although rheumatic fever tends to run in families, this may merely reflect contributing environmental factors. It primarily affects children between ages 6 and 15, usually within 1 to 5 weeks after strep throat or scarlet fever. The disease strikes most often during cool, damp weather in winter and early spring. In the United States, it’s most common in the northern states.

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Source: Handbook of Diseases, 2003

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

Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.

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

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

Actinomycosis begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur. Aspiration pneumonitis causes coughing that produces pink, frothy, and possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis. A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, and then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep. The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing. Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing. Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, and then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.

Nocardiosis.

North American blastomycosis.

Pneumonia.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Most common, however, is a nonproductive cough that starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.

Psittacosis.

Pulmonary coccidioidomycosis.

Pulmonary embolism.

Pulmonary emphysema.

Pulmonary tuberculosis.

Silicosis.

Other causes

Drugs.

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

Fever: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Anthrax, cutaneous

Anthrax, GI

Anthrax, inhalation

The initial signs and symptoms of inhalation anthrax are flulike ones, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Escherichia coli O157:H7. Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with E. coli O157:H7. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

Infectious and inflammatory disorders

Associated signs and symptoms involve every system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Listeriosis

Neoplasms

Primary neoplasms and metastasis can produce prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with low fever, pallor, and bleeding tendencies, or more abruptly with high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

Besides fever and nocturnal diaphoresis, neoplastic disease often causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague (Yersinia pestis)

Q fever

Rhabdomyolysis

Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms including fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most frequently reported complication of the disorder. It results from renal structure obstruction and injury during the kidney’s attempt to filter the myoglobin from the bloodstream.

Rift Valley fever

Typical signs and symptoms of Rift Valley fever include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS)

Smallpox (variola major)

Thermoregulatory dysfunction

Prolonged high fever commonly produces vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes: dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Typhus

West Nile encephalitis

Other causes

Diagnostic tests

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Medical treatments

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

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

Aspiration of foreign body

Partial obstruction of the upper airway caused by aspiration of foreign body first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis

Epiglottiditis, a life-threatening disorder, has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute)

Also known as viral croup, acute laryngotracheobronchitis is most common in children between 9 and 18 months old and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup

Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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

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

Aspiration pneumonitis

Aspiration pneumonitis causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, fatigue, chest pain, halitosis, tachycardia, wheezing, and cyanosis.

Asthma (acute)

A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.

Bronchiectasis

The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic)

Chronic bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis

Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold

When a common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications of the common cold include a dry, hacking cough, sneezing, headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, sore throat, myalgia, and arthralgia.

Legionnaires’ disease

Legionnaires’ disease causes a cough that produces scant mucoid, nonpurulent, possibly blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly, diarrhea. Then, within 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.

Lung abscess (ruptured)

The cardinal sign of ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.

Lung cancer

One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.

Plague

Signs and symptoms of plague, caused by the bacterium Yersinia pestis, include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The onset of the pneumonic form is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia

Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Pulmonary edema

Severe, pulmonary edema is a life-threatening disorder that causes a cough that produces frothy, bloody sputum. Early signs and symptoms of pulmonary edema include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism

Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary emphysema

Pulmonary emphysema causes a chronic productive cough with scant, mucoid, translucent, grayish white sputum that can become mucopurulent. The patient is thin and has the characteristic “pink puffer” appearance with weight loss, increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, and anorexia. Clubbing is a late sign.

Pulmonary tuberculosis

Pulmonary tuberculosis causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis

A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis

With tracheobronchitis, inflammation initially causes a nonproductive cough that later — following the onset of chills, sore throat, slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests

Bronchoscopy and pulmonary function tests may increase productive coughing.

Drugs

Expectorants, of course, increase productive coughing. These include guaifenesin, potassium iodide, and terpin hydrate.

Respiratory therapy

Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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

Fever: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anthrax, cutaneous

The patient with cutaneous anthrax may experience a fever along with lymphadenopathy, malaise, and headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.

Anthrax, GI

Following the ingestion of meat contaminated with the bacterium Bacillus anthracis, the patient experiences fever, loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation

The initial signs and symptoms of inhalation anthrax are flulike, including fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Escherichia coli 0157:H7

Fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating foods contaminated with the bacterial strain Escherichia coli 0157:H7. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction

When immune complex dysfunction is present, fever usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter’s syndrome).

Infectious and inflammatory disorders

Fever ranges from low (in patients with Crohn’s disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola virus or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. Fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every system. General systemic complaints include weakness, anorexia, and malaise.

Neoplasms

Primary neoplasms and metastases can produce prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with low fever, pallor, and bleeding tendencies, or more abruptly with high fever, frank bleeding, and prostration. Occasionally, Hodgkin’s disease produces undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

In addition to fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague

Plague is an infection caused by the bacterium Yersinia pestis. The bubonic form of plague causes fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the bite. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, fever, headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Rhabdomyolysis

Rhabdomyolysis produces fever, muscle weakness or pain, nausea, vomiting, malaise, or dark reddish brown urine. Acute renal failure is the most frequently reported complication of the disorder.

Severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is an acute infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox

Initial signs and symptoms of smallpox (also known as variola major) include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After about 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction

Sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C) occurs in life-threatening disorders, such as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia, and in lesions of the central nervous system (CNS). Low or moderate fever appears in dehydrated patients.

Prolonged high fever commonly produces vomiting, anhidrosis, decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes: dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (decreased LOC with bradycardia, widened pulse pressure, and increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia

Also known as rabbit fever, tularemia is an infectious disease that causes abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

West Nile encephalitis

Mild infection is common from West Nile encephalitis, a mosquito-borne Flavivirus. Signs and symptoms include fever, headache, and body aches, commonly with skin rash and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

CULTURAL CUE:West Nile encephalitis is commonly found in Africa, West Asia, and the Middle East. It rarely occurs in North America.

Other causes

Drugs

Fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. Fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. Fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

» READ BOOK EXCERPT ONLINE »

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

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

Airway occlusion

Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds. If the patient has aspirated a foreign body he may exhibit the universal sign for choking — a hand clutched to the throat, with thumb and fingers extended.

Anthrax (inhalation)

Inhalation anthrax is caused by inhalation of aerosolized spores of the gram-positive bacterium Bacillus anthracis. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic)

A thoracic aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, neck vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma

Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis

As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient with atelectasis may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Bronchitis (chronic)

Chronic bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma

The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough, dyspnea, and vague chest pain. The patient may also have wheezing, hemoptysis, and stridor.

Common cold

The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headache, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and sore throat.

Esophageal achalasia

With esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia. The patient may report weight loss, heartburn, and chest pain that increases after eating.

Esophageal diverticula

The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion

Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Esophagitis with reflux

Esophagitis with reflux commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may experience chest pain that mimics angina pectoris; heartburn that worsens if he lies down after eating; and increased salivation, dysphagia, hematemesis, and melena.

Hodgkin’s disease

Hodgkin’s disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.

Hypersensitivity pneumonitis

With hypersensitivity pneumonitis, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen. The patient may also report chest tightness and extreme fatigue.

Interstitial lung disease

A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss. Other findings include dyspnea on exertion and vague chest pain.

Laryngeal tumor

A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.

Laryngitis

In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Legionnaires’ disease

After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, mucopurulent and, possibly, bloody sputum.

Lung abscess

Lung abscess typically begins with nonproductive coughing, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling, possibly bloody sputum.

Mediastinal tumor

A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, neck vein distention, and facial or neck edema.

Pleural effusion

A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia

Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 to 3 days after the onset of malaise, headache, and sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn’t appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.

Pneumothorax

Pneumothorax, a life-threatening disorder, causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema

Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism

A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. More commonly, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis

With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.

CULTURAL CUE:The risk of sarcoidosis is greatest in young adult Blacks, especially Black women. Others at high risk include those of Scandinavian, German, Irish, or Puerto Rican descent.

Severe acute respiratory syndrome

The incubation period of this acute infectious disease of unknown etiology is 2 to  7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms of severe acute respiratory syndrome (SARS) include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

CULTURAL CUE:Most cases of SARS have been reported in Asia (China, Vietnam, Singapore, Thailand), although some cases have appeared in Europe and North America.

Sinusitis (chronic)

Chronic sinusitis can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.

Tracheobronchitis (acute)

Initially, acute tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° F to 102° F (38.3° to 38.9° C) and possibly bronchospasm, with severe wheezing and increased coughing.

Tularemia

Following inhalation of the gram-negative, non-spore-forming bacterium Francisella tularensis, patients with tularemia show signs and symptoms including the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests

Pulmonary function tests and bronchoscopy may stimulate cough receptors, triggering coughing.

Treatments

Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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

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

1. Infection/inflammation
   1. Upperrespiratory tract infection
   2. Sinusitis
   3. Laryngitis
   4. Croup
   5. Tracheitis
   6. Bronchitis
   7. Pertussis
   8. Bronchiolitis
   9. Pneumonia
      1. Viral
      2. Bacterial
         1. Tuberculosis
         2. Chlamydia
         3. Legionella
         4. Nocardia
      3. Mycoplasma
      4. Fungal
         1. Histoplasmosis
         2. Coccidioidomycosis
         3. Aspergillosis
         4. Blastomycosis
      5. Protozoa
      6. Chemical pneumonia
      7. Aspiration pneumonia
   10. Cystic fibrosis
   11. Bronchiectasis
   12. Lung abscess
2. Allergic disorders
   1. Allergicrhinitis
   2. Asthma
3. Mechanical or chemical irritation
   1. Environmentalirritants
   2. Foreign body aspiration
4. Bronchopulmonary dysplasia
5. Congenital anomalies
6. Cardiac failure
7. Gastroesophageal reflux
8. Swallowing dysfunction
9. Immotile cilia syndrome
10. Neoplasm
11. Reflex cough
12. Psychogenic, including habitual cough

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

Fever: Principal Causes of Acute Fever
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Commoncauses
   1. Infectious
      1. Respiratorytract
         1. Upperrespiratory tract infection (common cold)
         2. Pharyngitis
         3. Tonsillitis
         4. Otitis media
         5. Herpes gingivostomatitis
         6. Herpangina
         7. Sinusitis
         8. Croup
         9. Bronchiolitis
         10. Bronchitis
         11. Pneumonia (viral, bacterial, Mycoplasma)
         12. Pertussis
      2. Gastrointestinal
         1. Gastroenteritis
         2. Appendicitis
         3. Hepatitis
      3. Genitourinary
         1. Urinary tract infection (includingpyelonephritis)
         2. Sexually transmitted diseases
      4. Musculoskeletal
         1. Septicarthritis
         2. Osteomyelitis
         3. Myositis
      5. Central nervous system
         1. Meningitis(viral, bacterial)
         2. Viral encephalitis
      6. Infections associated with prominentrash
         1. Roseola
         2. Hand-foot-mouth syndrome
         3. Varicella
         4. Erythema infectiosum (parvovirus B19)
         5. Measles
         6. Scarlet fever
         7. Meningococcemia
         8. Rocky mountain spotted fever
      7. Other
         1. Viral illnesses
         2. Septicemia/bacteremia
         3. Infectious mononucleosis
         4. Lymphadenitis
         5. Cellulitis/abscess
         6. Cat scratch disease
         7. Dental abscess
         8. Periorbital cellulitis
         9. Parotitis
   2. Noninfectious
      1. Drug reactions
      2. Vaccine reactions
      3. Trauma
      4. Burns
      5. Kawasaki disease
2. Uncommon causes
   1. Infectious
      1. Respiratorytract
         1. Viral
            1. Hantaviruspulmonary syndrome
         2. Bacterial
            1. Supraglottitis
            2. Bacterial tracheitis
            3. Abscess (peritonsillar, retropharyngeal,lateral pharyngeal)
            4. Tuberculosis
            5. Actinomycosis
            6. Nocardiasis
            7. Legionella
         3. Fungal
            1. Aspergillosis
            2. Blastomycosis
            3. Histoplasmosis
            4. Coccidioidomycosis
         4. Parasitic
            1. Pneumocystis carinii
      2. Gastrointestinal
         1. Amebiasis
         2. Pancreatitis
         3. Cholecystitis
         4. Cholangitis
         5. Peritonitis
         6. Intraabdominal abscess
      3. Genitourinary
         1. Epididymitis
         2. Orchitis
         3. Abscesses (perinephric, tuboovarian)
      4. Cardiac
         1. Acute rheumatic fever
         2. Myocarditis
         3. Pericarditis
         4. Endocarditis
      5. Central nervous system
         1. Brainabscess
      6. Other
         1. Viral
            1. Human immunodeficiency virus
            2. Rabies
         2. Bacterial
            1. Staphylococcal scalded skin syndrome
            2. Toxic shock syndrome
            3. Orbital cellulitis/abscess
            4. Borrelia (relapsing fever)
            5. Brucellosis
            6. Leptospirosis
            7. Plague
            8. Psittacosis (ornithosis)
            9. Rat-bite fever
            10. Syphilis
            11. Tularemia
            12. Tetanus
         3. Fungal
            1. Disseminated histoplasmosis
            2. Nonpulmonary blastomycosis
         4. Parasitic
            1. Malaria
            2. Ascariasis
            3. Toxocariasis (visceral larva migrans,ocular larva migrans)
            4. Toxoplasmosis
            5. Trichinosis
         5. Rickettsial
            1. Endemic typhus (murine)
            2. Epidemic typhus (louse-borne typhus)
            3. Q fever
            4. Rickettsial pox
            5. Ehrlichiosis
   2. Noninfectious
      1. Respiratory
         1. Pulmonary infarction
         2. Pulmonary embolism
      2. Gastrointestinal
         1. Pulmonaryinfarction
         2. Pulmonary embolism
      3. Intestinal obstruction
      4. Inflammatory bowel disease
      5. Cardiac
         1. Postpericardiotomy syndrome
      6. Hematologic
         1. Intravascular hemolysis
         2. Bleeding into a closed space
      7. Endocrine
         1. Thyrotoxicosis
         2. Diabetes insipidus
      8. Central nervous system
         1. Intracranialinjury and hemorrhage
         2. Spinal cord injury
         3. Hypothalamic and brain stem lesions
         4. Status epilepticus
      9. Neoplasia
         1. Leukemia
         2. Lymphoma
         3. Neuroblastoma
         4. Pheochromocytoma
      10. Connective tissue disorders
          1. Juvenilerheumatoid arthritis
          2. Systemic lupus erythematosus
          3. Polyarteritis nodosa
          4. Polymyositis
          5. Dermatomyositis
          6. Mixed connective tissue disease
      11. Poisonings
          1. Atropine
          2. Cocaine
          3. Salicylate
          4. Lysergic acid diethylamide
          5. Hydrocarbons
          6. Organophosphates
          7. Tricyclic antidepressants
          8. Amphetamines
          9. Phenothiazines
      12. Other
          1. Spider bites (black widow, brown recluse)
          2. Stevens-Johnson syndrome
          3. Heat-related illness
          4. Serum sickness
          5. Anhidrotic ectodermal dysplasia
          6. Familial dysautonomia
          7. Sarcoidosis
          8. Familial Mediterranean fever
          9. Factitious fever

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

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

1. Infection
   1. Pharyngitis/tonsillitis
      1. Viral
      2. Bacterial
         1. Group A Streptococcus
         2. Other bacteria
   2. Peritonsillar, retropharyngeal, andlateral pharyngeal abscesses
2. Irritants
   1. Excessive dryness
   2. Dust
   3. Smoke
   4. Postnasal drip secondary to allergicrhinitis or sinusitis
3. Trauma
   1. Vocal abuse
   2. Thermal injury
4. Foreign body
5. Caustic substances
6. Psychogenic

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

Respiratory Distress and Apnea: Principal Causes of Respiratory Distress (Neonatal)
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Upperrespiratory tract obstruction
2. Lower respiratory tract disorders
   1. Transienttachypnea of the newborn
   2. Respiratory distress syndrome (hyalinemembrane disease)
   3. Meconium aspiration and other aspirationsyndromes
   4. Pneumonia
   5. Pulmonary air leaks
   6. Pulmonary hemorrhage
   7. Bronchopulmonary dysplasia
   8. Congenital malformations of the lungs,bronchi, diaphragm, and rib cage
      1. Lung agenesis and aplasia
      2. Pulmonary hypoplasia
      3. Pulmonary sequestration
      4. Lobar emphysema
      5. Cystic lung lesions
         1. Bronchogeniccyst
         2. Congenital cystic adenomatoid malformation
         3. Intrapulmonary cysts
         4. Congenital pulmonary lymphangiectasia
      6. Chylothorax
      7. Bronchial malformations
      8. Diaphragm lesions
         1. Congenitaldiaphragmatic hernia
         2. Diaphragmatic eventration
         3. Diaphragmatic paralysis or paresis
      9. Rib cage anomalies
   9. Persistent fetal circulation
3. Cardiac disorders
4. Hematologic disorders
   1. Anemia
   2. Polycythemia
5. Metabolic disorders
   1. Hypothermia
   2. Hypoglycemia
   3. Metabolic acidosis
6. Neurologic and muscle disorders
   1. Braindisorders
   2. Spinal cord injury
   3. Neuromuscular disorders
7. Drugs

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

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

1. Noseand nasopharynx
   1. Congenital
      1. Choanal atresia
      2. Craniofacial anomalies
      3. Midline masses
   2. Infection/inflammation
      1. Rhinitis
      2. Adenoid hypertrophy
      3. Polyps
   3. Trauma
   4. Neoplasm
2. Oropharynx and hypopharynx
   1. Congenital
      1. Micrognathiaand other skull base abnormalities
      2. Macroglossia
      3. Decreased pharyngeal muscle tone
   2. Infection/inflammation
      1. Tonsillarhypertrophy
      2. Abscess
   3. Foreign body
   4. Trauma
   5. Neoplasm
3. Supraglottic
   1. Congenital
      1. Laryngomalacia
      2. Laryngeal cyst and laryngocele
   2. Infection/inflammation
      1. Supraglottitis
      2. Gastroesophageal reflux
      3. Hereditary angioedema
   3. Trauma
   4. Neoplasm
4. Glottic
   1. Congenital
      1. Laryngeal web
      2. Laryngeal cleft
      3. Vocal cord paralysis
   2. Infection/inflammation
      1. Laryngitis
      2. Laryngeal spasm
   3. Foreign body
   4. Trauma
   5. Neoplasm
5. Subglottic
   1. Congenital
      1. Subglottic stenosis
      2. Cysts
   2. Infection/inflammation
      1. Croup
      2. Bacterial tracheitis
   3. Trauma
   4. Neoplasm
6. Tracheobronchial
   1. Congenital
      1. Tracheomalacia
      2. Tracheal web
      3. Tracheal cysts
      4. Tracheal stenosis
      5. Vascular anomalies
   2. Infection/inflammation
   3. Foreign body
   4. Trauma
   5. Neoplasm
      1. Tracheal
      2. Thyroid
      3. Mediastinal masses
7. Psychogenic

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

Cough, barking: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Aspiration of foreign body.Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.

Epiglottiditis.Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.

Laryngotracheobronchitis (acute).Also known as viral croup, laryngotracheobronchitisinitially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.

As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.

Spasmodic croup.Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, productive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Actinomycosis.Actinomycosis begins with a cough that produces purulent sputum. A fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.

Aspiration pneumonitis.Aspiration pneumonitis causes coughing that produces pink, frothy and, possibly, purulent sputum. The patient also has marked dyspnea, a fever, tachypnea, tachycardia, wheezing, and cyanosis.

Bronchiectasis.The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, a recurrent fever, and late-stage finger clubbing.

Bronchitis (chronic).Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.

The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.

Chemical pneumonitis.Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, a fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.

Common cold.When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications include a dry hacking cough, sneezing, a headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, a sore throat, myalgia, and arthralgia.

Lung abscess (ruptured).The cardinal sign of a ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, a fever with chills, dyspnea, a headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient's chest is dull on percussion on the affected side.

Lung cancer.One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, a fever, diaphoresis, wheezing, and clubbing.

Nocardiosis.Nocardiosis causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient's chest is dull on percussion.

North American blastomycosis.North American blastomycosis is a chronic disorder that produces coughing that's dry and hacking or produces bloody or purulent sputum. Other findings include pleuritic chest pain, a fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.

Plague(Yersinia pestis).The pneumonic form of plague may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pneumonia.Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, a high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.

Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Typically, however, a nonproductive cough starts 2 or 3 days after the onset of malaise, a headache, a fever, and a sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles, but generally don't appear seriously ill.

Psittacosis.As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, a fever, a headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.

Pulmonary coccidioidomycosis.Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with a fever, occasional chills, pleuritic chest pain, a sore throat, a headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.

Pulmonary edema.Severe, pulmonary edema, which is a life-threatening disorder, causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include a fever, fatigue, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. As the patient's respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, anxiety, restlessness, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.

Pulmonary embolism.Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.

Pulmonary tuberculosis (TB).Pulmonary TB causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.

Silicosis.A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.

Tracheobronchitis.Inflammation initially causes a nonproductive cough that later—following the onset of chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness—becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.

Other causes

Diagnostic tests.Bronchoscopy and pulmonary function tests (PFTs) may increase productive coughing.

Drugs.Expectorants increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.

Respiratory therapy.Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, nonproductive: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Airway occlusion.Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds.

Anthrax (inhalation).Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic).Aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.

Asthma.Asthma attacks typically occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis.As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.

Avian influenza.Individuals infected with avian influenza may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia.

Bronchitis (chronic).Bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.

Bronchogenic carcinoma.The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.

Common cold.The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and a sore throat.

Esophageal achalasia.In esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia.

Esophageal diverticula.The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion.Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.

Hantavirus pulmonary syndrome.A nonproductive cough is common in patients with Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other findings include a headache, myalgia, fever, nausea, and vomiting.

Hypersensitivity pneumonitis.With hypersensitivity pneumonitis, an acute nonproductive cough, a fever, dyspnea, and malaise usually occur 5 or 6 hours after exposure to an antigen.

Interstitial lung disease.A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.

Laryngeal tumor.A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and an earache may occur.

Laryngitis.In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.

Lung abscess.Lung abscess typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, bloody sputum.

Pleural effusion.A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia.Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 or 3 days after the onset of malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn't appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and a low-grade fever.

Pneumothorax.Pneumothorax is a life-threatening disorder that causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.

Pulmonary edema.Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, a ventricular gallop, and anxiety and restlessness. If pulmonary edema is severe, the patient's respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.

Pulmonary embolism.A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis.With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment, difficulty swallowing, and arrhythmias.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Tracheobronchitis (acute).Initially, tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and, possibly, bronchospasm, with severe wheezing and increased coughing.

Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests.Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough receptors and trigger coughing.

Treatments.Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Fever [Pyrexia]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anthrax, cutaneous.The patient with cutaneous anthrax may experience a fever along with lymphadenopathy, malaise, and a headache. After the bacterium Bacillus anthracis enters a cut or abrasion on the skin, the infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, the lesion develops into a vesicle and then into a painless ulcer with a characteristic black, necrotic center.

Anthrax, GI.Following the ingestion of contaminated meat from an animal infected with the bacterium B. anthracis, the patient experiences a fever, a loss of appetite, nausea, and vomiting. The patient may also experience abdominal pain, severe bloody diarrhea, and hematemesis.

Anthrax, inhalation.The initial signs and symptoms of inhalation anthrax are flulike, including a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours.

Avian influenza.Fever is commonly an initial symptom of avian influenza along with other conventional influenza symptoms, such as muscle aches, sore throat, and cough. Individuals infected with the most virulent avian virus, influenza A (H5N1), may develop pneumonia, acute respiratory distress, and other life-threatening complications.

Escherichia coli O157:H7. A fever, bloody diarrhea, nausea, vomiting, and abdominal cramps occur after eating undercooked beef or other foods contaminated with this strain of bacteria. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop (in which the red blood cells are destroyed), and this may ultimately lead to acute renal failure.

Immune complex dysfunction.With immune complex dysfunction, a fever, when present, usually remains low, although moderate elevations may accompany erythema multiforme. Fever may be remittent or intermittent, as in acquired immunodeficiency syndrome (AIDS) or systemic lupus erythematosus, or sustained, as in polyarteritis. As one of several vague, prodromal complaints (such as fatigue, anorexia, and weight loss), a fever produces nocturnal diaphoresis and accompanies such associated signs and symptoms as diarrhea and a persistent cough (with AIDS) or morning stiffness (with rheumatoid arthritis). Other disease-specific findings include a headache and vision loss (temporal arteritis); pain and stiffness in the neck, shoulders, back, or pelvis (ankylosing spondylitis and polymyalgia rheumatica); skin and mucous membrane lesions (erythema multiforme); and urethritis with urethral discharge and conjunctivitis (Reiter's syndrome).

Infectious and inflammatory disorders.With these disorders fever ranges from low (in patients with Crohn's disease or ulcerative colitis) to extremely high (in those with bacterial pneumonia, necrotizing fasciitis, or Ebola or Hantavirus). It may be remittent, as in those with infectious mononucleosis or otitis media; hectic (recurring daily with sweating, chills, and flushing), as in those with lung abscess, influenza, or endocarditis; sustained, as in those with meningitis; or relapsing, as in those with malaria. A fever may arise abruptly, as in those with toxic shock syndrome or Rocky Mountain spotted fever, or insidiously, as in those with mycoplasmal pneumonia. In patients with hepatitis, a fever may represent a disease prodrome; in those with appendicitis, it follows the acute stage. Its sudden late appearance with tachycardia, tachypnea, and confusion heralds life-threatening septic shock in patients with peritonitis or gram-negative bacteremia.

Associated signs and symptoms involve every body system. The cyclic variations of hectic fever typically produce alternating chills and diaphoresis. General systemic complaints include weakness, anorexia, and malaise.

Kawasaki syndrome.Fever, typically high and spiking, is the primary characteristic of this acute illness. The diagnosis of Kawasaki syndrome is confirmed when fever persists for 5 or more days (or until administration of I.V. gamma globulin if given before the fifth day) and is accompanied by other clinical signs, including conjunctival injection, erythema, lymphadenopathy, and peripheral extremity swelling. This syndrome occurs worldwide, with the highest incidence in Japan. It primarily affects children under age 5, is more prevalent in boys, and can cause serious heart damage and death without prompt treatment with I.V. gamma globulin.

Listeriosis.Signs and symptoms of listeriosis include a fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; symptoms include a fever, a headache, nuchal rigidity, and a change in the LOC.

Monkeypox.Fever is one of the initial symptoms that occurs in almost all patients infected with this rare viral disease. A papular rash that may be localized or generalized appears within 1 to 3 days after the fever begins. Additional symptoms commonly include sore throat, chills, and lymphadenopathy. No treatment is available for monkeypox, but the disease is rarely fatal in developed countries and usually lasts 2 to 4 weeks.

Neoplasms.Primary neoplasms and metastasis can produce a prolonged fever of varying elevations. For instance, acute leukemia may present insidiously with a low-grade fever, pallor, and bleeding tendencies or more abruptly with a high fever, frank bleeding, and prostration. Occasionally, Hodgkin's disease produces an undulant fever or Pel-Ebstein fever, an irregularly relapsing fever.

In addition to a fever and nocturnal diaphoresis, neoplastic disease typically causes anorexia, fatigue, malaise, and weight loss. Examination may reveal lesions, lymphadenopathy, palpable masses, and hepatosplenomegaly.

Plague (Yersinia pestis).The bubonic form of plague (transmitted to man when bitten by infected fleas) causes a fever, chills, and swollen, inflamed, and tender lymph nodes near the bite site. The septicemic form develops as a fulminant illness generally with the bubonic form. The pneumonic form manifests as a sudden onset of chills, a fever, a headache, and myalgia after person-to-person transmission via the respiratory tract. Other signs and symptoms of the pneumonic form include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Q fever.Q fever causes a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Respiratory syncytial virus (RSV).Fever is one of the initial symptoms of this common illness that affects most children by age 2. Healthy adults and children older than age 3 usually develop a low-grade fever along with other common coldlike symptoms of runny nose, cough, and wheezing. Many children younger than age 3 have a high-grade fever that may be accompanied by a severe cough, rapid breathing, and high-pitched expiratory wheezing. Infants with RSV typically exhibit lethargy, poor eating, irritability, and difficulty breathing; severe cases may require hospitalization. To avoid repeated RSV infection, individuals should practice infection-control techniques, such as proper hand-washing and avoiding contact with contaminated surfaces.

Rhabdomyolysis.Rhabdomyolysis results in muscle breakdown and release of the muscle cell contents (myoglobin) into the bloodstream, with signs and symptoms that include a fever, muscle weakness or pain, nausea, vomiting, malaise, or dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidney's attempt to filter myoglobin from the bloodstream.

Rift Valley fever.Typical signs and symptoms of Rift Valley fever include  fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other signs and symptoms include a headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major).Initial signs and symptoms of smallpoxinclude a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Thermoregulatory dysfunction.Thermoregulatory dysfunction is marked by a sudden onset of fever that rises rapidly and remains as high as 107° F (41.7° C). It occurs in such life-threatening disorders as heatstroke, thyroid storm, neuroleptic malignant syndrome, and malignant hyperthermia and in lesions of the central nervous system (CNS). A low or moderate fever appears in dehydrated patients.

A prolonged high fever commonly produces vomiting, anhidrosis, a decreased LOC, and hot, flushed skin. Related cardiovascular effects may include tachycardia, tachypnea, and hypotension. Other disease-specific findings include skin changes, such as dry skin and mucous membranes, poor skin turgor, and oliguria with dehydration; mottled cyanosis with malignant hyperthermia; diarrhea with thyroid storm; and ominous signs of increased intracranial pressure (a decreased LOC with bradycardia, a widened pulse pressure, and an increased systolic pressure) with CNS tumor, trauma, or hemorrhage.

Tularemia.Tularemia, also known as rabbit fever, causes an abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus.Typhus is a rickettsial disease in which the patient initially experiences a headache, myalgia, arthralgia, and malaise. These signs and symptoms are followed by an abrupt onset of a fever, chills, nausea, and vomiting. A maculopapular rash may be present in some cases.

West Nile encephalitis.Signs and symptoms of West Nile encephalitis include fever, headache, and body aches, usually with a skin rash and swollen lymph glands. More severe infection is marked by a high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

Other causes

Diagnostic tests.Immediate or delayed fever uncommonly follows radiographic tests that use contrast medium.

Drugs.A fever and rash commonly result from hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins. A fever can accompany chemotherapy, especially with bleomycin, vincristine, and asparaginase. It can result from drugs that impair sweating, such as anticholinergics, phenothiazines, and monoamine oxidase inhibitors. A drug-induced fever typically disappears after the involved drug is discontinued. A fever can also stem from toxic doses of salicylates, amphetamines, and tricyclic antidepressants.

Inhaled anesthetics and muscle relaxants can trigger malignant hyperthermia in patients with this inherited trait.

Treatments.Remittent or intermittent low fever may occur for several days after surgery. Transfusion reactions characteristically produce an abrupt onset of a fever and chills.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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