1. Respiratory Symptoms Zhao Li, M.D.

2. Common symptoms  Cough  Expectoration  Hemoptysis  Chest pain  Cyanosis  Dyspnea

3. Cough (a protective reflex): causes  Respiratory diseases___ the most common causes Airway agents  Bronchitis, bronchiectasis, asthma, endobronchial tuberculosis, tumor, pharyngitis Lung agents  Infection, edema, fibrosis, tumor Pleural agents  Pleurisy, pneumothorax, mesothelioma of pleura  Cardiovascular diseases Cardiogenesis edema, pulmonary embolism  Central nervous system agents Initiative cough, encephalitis, meningitis

4. Cough : manifestations  Characteristics Dry cough (non-sputum: non-infectious) Productive cough (sputum: infectious, edema)  Attack Time season motivation  Tone Hoarseness High pitch Weak Brassy

5. Cough: accompany signs  Fever (infection)  Chest pain (infection, tumor, pleurisy, pneumothorax, pulmo embolism)  Dyspnea  Hemoptysis (bronchietasis, tuberculosis, tumor)  Bulk pus sputum (bronchietasis, lung abscess)  Wheezing (asthma, foreign body)  Clubbing fingers (bronchietasis, lung cancer, chronic lung abscess)

6. Sputum: amount  Bulk frothy sputum Pulmo edema  Bulk serofluid sputum Alveolar carcinoma  Bulk pus sputum Bronchiectasis Lung abscess Layering upper: frothy, middle: mucoid or mucopus, lower: necrosis substance

7. Sputum: consistency  Mucoid sputum Bronchitis (without bacterial infection) Asthma Early stage of pneumonia  Serofluid sputum Pulmo edema  Pus sputum Any bacterial infection  Bloody sputum

8. Sputum: color  White mucoid or serofluid sputum  Yellow general bacterial infection  Green aeruginosus Bacillus infection  Grey or black dust inhalation  Rusty Lobar pneumonia  Pink cardiac edema  Red hemoptysis Grey or black

9. Sputum: foul odor  anaerobic bacterium infection

10. Hemoptysis  Bleeding from lower respiratory tract  The amount varies from blood-strained sputum to several hundreds ml pure blood Mild:  100ml/d Moderate: 100-500/d Severe: >500ml/d, or 100-500/time  Differential diagnosis Bleeding from upper respiratory tract Hematemesis

11. Distinguished hemoptysis from hematemesis HemoptysisHematemesis CausesPulmo or cardiacdigestive system Previous symptomsCough, chest tightnessNausea, vomiting Spit upCough upVomited ColorBright redDark red MixtureSputum, frothy Gastric contents pHalkalityacidity Tarry stools - or ++ Post-bleedingSputum with bloodNo sputum

12. Hemoptysis: causes  Bronchial disorders Bronchiectasis Bronchogenic carcinoma endobronchial TB Chronic bronchitis  Pulmo Disorders Pulmo TB Peumonia Lung abscess Pulmo embolism  Cardiovascular disorders Acute left heart failure Mitral stenosis  Others Hematologic disease, leptospirosis （钩端螺旋体病）， epidemic hemorrhagic fever ， endometriosis （子宫内膜异位症）

13. Hemoptysis: accompany signs  Fever Infection or carcinoma  Chest pain Infection ， Pulmo Embolism ， Carcinoma  Pus sputum Bronchiectasis ， Lung abscess  Clubbing fingers Bronchiectasis ， Lung abscess ， Carcinoma  Hemorrhagic spots Hematologic disease, leptospirosis, epidemic hemorrhagic fever

14. Chest pain: causes  Chest wall herpes zoster, rib fracture  Cardiovascular angina pectoris, myocardial infarction, pericarditis, dissecting aneurysm （夹层动脉瘤）  Respiratory Pleural disorders, pneumothorax, carcinoma  Mediastinal Mediastinitis, mediastinal emphysema, mediastinal tumor  Others esophageal carcinoma, liver abscess, subdiaphragmatic abscess, hiatal hernia （食道裂孔疝）

15. Chest pain: characteristics  location  Referred pain  Level or feature Burning pain, pressing pain, bursting pain, pricking pain  Duration  Influential factors Exertional, respiration, foodintake, administration

16. Chest pain: accompany signs  Cough, sputum and/or fever Respiratory disease  Dyspnea Severe pneumonia, pneumothorax, pleurisy, pulmo embolism  Hemoptysis Carcinoma, pulmo embolism  Shock myocardial infarction, dissecting aneurysm (rupture ), large area pulmo embolism  Dysphagia ( 吞咽困难 ) Esophageal disease

17. Cyanosis  An excess of desaturated hemoglobin causes a blue coloration of the skin or mucosae.  methemoglobinemia ( 高铁血红蛋白血症） Poisoning by nitrite (Methylthioninium Chloride iv, 亚甲兰 )

18. Cyanosis: classification  Central (warm) Deficient oxygenation Right-to-left shunt  Peripheral (cold) Reduced cardiac output Local vasoconstriction  Mixed Heart failure

19. Cyanosis: accompany signs  Dyspnea Severe cardiac or respiratory disorder  Clubbing fingers Congenital heart disease Chronic respiratory disease  Unconsciousness Poisoning, shock, Severe cardiac or respiratory disorder

20. Dyspnea: causes  Respiratory system Obstruction: asthma, COPD, tumor Pulmo Diseases: pneumonia, interstitial lung disease, Chest wall or pleura: pleurisy, pneumothorax, trauma neuro-muscles: poliomyelitis ( 脊髓灰质炎 ), myasthenia gravis ( 重症肌无 力 ) Diaphragma movement disorder: obviously elevated pressure in abdominal cavity  Cardiovascular system Heart failure Pulmo embolism  Poisoning ketoacidosis  Central nervous system cerebral tumor, trauma, abscess, hemorrhage, encephalitis, meningitis  hematological system Severe anemia

21. Respiratory Dyspnea  Inspiratory dyspnea ____ obstruction in large airway Three depression sign  depression in suprasternal fossa, supraclavicular fossa, intercostal space  Expiratory dyspnea ____ obstruction in small airway or alveolar elasticity decreased Prolonged expiratory time Expiratory rhonchi  Mixed dyspnea ____ deficient gas exchange Respiratory rate increased Shallow breathing

22. Cardiac dyspnea ____ Heart failure Mechanism of left heart failure Pulmo edema diffusion capacity decreased Alveolar tension increased stimulating stretch receptor excitation of vagus nerve excitation of respiratory center Alveolar elasticity decreased vital capacity decreased Increased pressure of pulmo circulation stimulating respiratory center

23. Features of left heart failure  Underlying diseases  Mixed dyspnea  Position related dyspnea  Moist crackles or rhonchi in both lungs  Relief of symptoms after digitalis, diuretic, vasodilator agent used

24. Nocturnal paroxysmal dyspnea Characteristics  Awoken due to chest tightness or dyspnea  Forced sitting position or orthopnea  Severe sweat  Tachycardia  Moist crackles or rhonchi in both lungs  Pink frothy sputum

25. Nocturnal paroxysmal dyspnea Mechanism Elevated excitation of vagus nerve Contraction of coronary artery myocardium ischemia Contraction of bronchiole decreased alveolar ventilation Vital capacity decreased in supine position Returned blood volume increased pulmo edema Sensitivity of respiratory center decreased reaction after obvious hypoxia

26. Poisoning dyspnea  Underlying diseases of metabolic acidosis (uremia, diabetic ketoacidosis )  deep breathing (Kussmaul breathing)

27. Dyspnea: accompany signs (1)  Rhonchi Asthma Acute left heart failure (cardiac asthma) Foreign body in large airway Acute laryngeal edema  Chest pain Infection Pneumothorax Pulmo embolism Lung cancer Acute myocardial infarct

28. Dyspnea: accompany signs (2)  Fever Infection  Cough and sputum COPD Infection Left heart failure  Unconsciousness CNS disorder Uremia diabetic ketoacidosis