MEDICAL SEMEIOTICS: DISEASES OF THE LUNGS Antonio Abbate, MD,PhD

INTRODUCTION TO SEMEIOTICS DISEASES OF THE LUNGS Common symptoms Hypoxia Cough Stridor and Wheezing Dyspnea Crackles and ronchi Chest pain Deformities and asymmetry Common physical signs Breve intro INTRODUCTION TO SEMEIOTICS Date

COUGH: A main indicator of airway disease COUGH – A coordinated (involuntary or voluntary) series of events leading to explosive expiration for clearance of particles from the airway It is about irritation (somewhere in airway, respiratory mechanics, or CNS) It can be productive of sputum in which case it indicates inflammation  a green/brown sputum  infection (bacterial), yellow  inflammation/infection (viral); bloody (hemoptysis)  severe infection (i.e. TB) or cancer or trauma or vasculitis; whereas non-productive cough  inflammation/infection viral, but also other things GERD, compression/invasion by tumor/cancer, but also pulmonary congestion Acute (<1 week) cough  infection; chronic (>4 weeks)  less likely infectious Sax INTRODUCTION TO SEMEIOTICS Date

DYSPNEA from RESPIRATORY DISEASE Dyspnea refers to an uncomfortable feeling associated with breathing. Is dyspnea is a symptom? sign? or syndrome? Triggers for dyspnea: Mechanical  effort Compression Chemical CO2 pH O2 Central (CNS) Dyspnea is different from: Tachypnea Sign, breathing fast Hypoxia Sign, low O2sat Apnea Sign, pauses in breaths Antonio INTRODUCTION TO SEMEIOTICS Date

DYSPNEA from respiratory causes Characteristics of respiratory dyspnea: Generally gradual onset, often chronic Exertional dyspnea (similar to cardiac) Associated symptoms Cough (very very common) Fever (if infection) Altered mental status (if hypoxia or acidosis) Associated signs Exam is rarely normal Tachypnea Stridor, wheezing, ronchi Crackles Abnormal expansion Acute respiratory dyspnea: Asthma attack Pneumothorax Pulmonary embolism Laryngospasm Antonio INTRODUCTION TO SEMEIOTICS Date

DYSPNEA from cardiac causes Characteristics of cardiac dyspnea: Exertional dyspnea Orthopnea, nocturnal cough Paroxysmal nocturnal dyspnea Associated symptoms Angina Fatigue Associated signs Exam can be normal at rest Edema JVD Rales (diffuse end-expiratory wet crackles) Antonio INTRODUCTION TO SEMEIOTICS Date

COUGH: A main indicator of airway disease COUGH – A coordinated (involuntary or voluntary) series of events leading to explosive expiration for clearance of particles from the airway It is about irritation (somewhere in airway, respiratory mechanics, or CNS) It can be productive of sputum in which case it indicates inflammation  a green/brown sputum  infection (bacterial), yellow  inflammation/infection (viral); bloody (hemoptysis)  severe infection (i.e. TB) or cancer or trauma or vasculitis; whereas non-productive cough  inflammation/infection viral, but also other things GERD, compression/invasion by tumor/cancer, but also pulmonary congestion Acute (<1 week) cough  infection; chronic (>4 weeks)  less likely infectious Sax INTRODUCTION TO SEMEIOTICS Date

CHEST PAIN from respiratory causes Pain derives mostly from PLEURAL IRRITATION/INFLAMMATION Characteristics of pleuritic pain: Sharp, acute Worse with respirations Positional Associated symptoms Cough (very common) Dyspnea (common) Fever (sometimes) Associated signs Tachypnea Changes at percussion Pleural rub Causes of pleuritic pain: Pneumonia Pleurisy or pleuritis Pneumothorax Pulmonary embolism Antonio INTRODUCTION TO SEMEIOTICS Date

ANGINA PECTORIS Angina pectoris refers to chest pain that derives from an imbalance in oxygen demand and supply to the myocardium Chest Pain (squeezing, crushing, tightness) Central, radiated to the L arm Brought by exertion, relieved by rest Lasts minutes Worse after a meal, or cold exposure Associated symptoms (dyspnea, fatigue, nausea/vomiting, dizziness) More common in males >50 yrs of age Associated with tobacco use  SUPPLY  DEMAND Antonio Oxygen Causes of increased demand: exertion, fever, pressure overload tachyarrhythmia Causes of impaired supply: coronary artery disease, aortic stenosis, severe comorbidities (such as hypoxia anemia, hypotension) Myocardial hypoxia Adenosine Receptors  Pain ATPADPAMP Adenosine INTRODUCTION TO SEMEIOTICS Date

RESPIRATORY PHYSICAL EXAM The respiratory physical exam, like any exam, starts with a general examination and an analysis of the vital signs. Alterd mental status  poor prognosis, hypoventilation (high CO2?) Distress or lack thereof -- Position and gait  if a patient is sitting laying forward will indicate a different process that one in which he/she is sitting comforably, i.e. in the first case he may be dyspneic and trying to max expand the lun Hypotension  poor prognosis --- Tachycardia  indicated a state of enhanced sympathetic drive Hypoxemia  poor prognosis and suggests either that: large area of lungs affected (bilateral pneumonia, edema) hypoventilation (CNS, trapping, bronchospasm, PNX, mucus) AV shunt (pulmonary embolism, trauma) Fever or hypothermia  suggest infection Pain may indicated the underlying problem Sax INTRODUCTION TO SEMEIOTICS Date

RESPIRATORY PHYSICAL EXAM At difference of the heart, for the lungs, each of 4 steps of the physical exam is essential – because the chest wall is clearly visible and the lungs are full of air, ready to be percussed. Observation – notice size, dimensions, symmetry, deformities of the chest wall, use of accessory muscles [neck/abdomen], retractions in inspirations, cyanosis/pallor  “pink puffer and blue bloater” Palpation – notice discontinuation of the chest wall, position of the trachea, movement/expansion of the apex and base bilat Antonio Percussion – Very important to differentiate between different disease processes. The lung when percussed emit a characteristic resonant sound as they are made by >99% of air. Lack of resonance indicates abnormal consolidation. INTRODUCTION TO SEMEIOTICS

RESPIRATORY PHYSICAL EXAM Auscultation is however where the money is!!! Auscultation – the sound(s) of the air movement as it expands the lung parenchyma are characteristics of the different conditions. At the base of the lungs – Normal Vescicular Sounds On the trachea  Normal Tracheal Sound Abnormal sounds Stridor –a high-pitched inspiratory breath sound resulting from turbulent air flow in the upper respiratory airways  indicates obstruction Wheezing - high-pitched expiratory breath sounds resulting from turbulent air flow in the lower respiratory airways  indicates bronchial obstruction, usually diffuse due to bronchospasm. Ronchi refer to lower pitched inspiratory sounds also related to turbulent flow, can be also expiratory, or w/ expiratory wheezing. Crackles – low-pitched inspiratory breath sounds – very common, often discontinuous – they can be normal if few and cleared by cough, if not they are divided in End-Inspiratory Fine Crackles (or dry crackles) deriving from the expansion of the stiff lung parenchyma or Coarse crackles (or rales) deriving from presence of fluid in the airway as a result of pulmonary edema or bronchitis Antonio INTRODUCTION TO SEMEIOTICS

RESPIRATORY PHYSICAL EXAM Deformities worth reviewing Barrel chest – Acquired changes due to hyperinflation related to air- trapping in emphysema: increase in AP diameter. Kyphosis – Acquired changes in the curvature of the T spine. Pectus excavatum – Congenital deformity of the chest wall Flail chest – Acquired traumatic injury to the chest wall Tracheomalacia  congential or acquired lack of cartilage of the trachea leading to collapse in expiration Antonio INTRODUCTION TO SEMEIOTICS