1. Muhammad Atif Qureshi Associate Professor- Medicine Azra Naheed Medical College

2. Cough Sputum Hemoptysis Dyspnea Chest pain (chest tightness) Wheezing

3. Cough reflex arc

4. 1.Acute (< 3 wks) 2.Subacute (3-8 wks) 3.Chronic (>8 wks)

5. 1.Acute upper respiratory tract infection. 2.Acute lower respiratory tract infection (pneumonia). 3.Acute exacerbation of underlying chronic pulmonary disease. 4.Pulmonary Embolism (PE).

6. 1.Post-infection of upper or lower respiratory tract. 2.Angiotensin Converting Enzyme Inhibitors (ACE-I) medication.

7. 1.Upper airway cough syndrome ( it is related to allergic, non-allergic or vasomotor rhinitis, naso-pharyngitis, & sinusitis. Usually with postnasal drip «PND») 2.Bronchial Asthma 3.Gastroesophageal reflux disease

8. 1.Chronic bronchitis (COPD, eosinophilic) 2.Bronchiectasis 3.Neoplasm 4.Interstitial lung disease (ILD) 5.Lung abscess 6.Obstructive sleep apnea (OSA) 7.Tracheobronchial foreign body or mass 8.Nasal polyps & others……

9. Mediastinal: External tracheal compression ex: enlarged LN Tumors, cysts, masses Cardiac: LVF Severe MS ENT: Acute/chronic sinusitis PND (allergic, or vasomotor rhinitis)

10. Gastrointestinal Tract: GERD Esophageal dysmotility, stricture, or pouch Esophago-bronchial fistula CNS: CVA MS MND Parkinson’s disease

11. Drugs: ACE-Inhibitors Some inhaler preparations can cause cough Others: Idiopathic Ear wax (vagal nerve stimulation) Psychogenic

13. Amount: N amount < 100mls of mucus/day Color: N, clear & white mucus Smell: N, not smelly Ex: chronic large amount of purulent sputum may suggest bronchiectasis while acute one may indicate lobar pneumonia. Ex: foul-smelling purulent sputum may indicate lung abscess with anaerobic infection Ex: pink frothy secretions occurs in pulmonary edema

15. It’s a blood-stained sputum Varies from streaks of blood to massive bleeding (>100 - 600mls /24 hrs) It should be investigated thoroughly Commonest cause is acute infection like exacerbation of copd but other serious causes should be rolled out Other causes: PE, Bronchogenic ca., pul TB, bronchiectasis, lung abscess,

16. Defined as: experience of discomfort in breathing or an awareness of respiratory distress & physiologically its an ↑ in the level & work of breathing. Onset: 1.Instantaneous: pneumothorax, PE 2.Min.s – hrs: * Aw disease: (BA, copd exacerbʼn, UAW obstrcʼn) * parenchymal disease: (pneumonia, pul hage, pul edema..) * pul vascular disease: (PE) * cardiac disease: ( MI,……. ) * metabolic acidosis * hyperventilation syndrome.

18. Subacute (days): * Many of the above plus: * Pl. effusion * lobar collapse * Acute Interstitial pneumonia * SVC obstruct’n * Pul vasculitis Chronic (months-years): * COPD & BA * Diffuse parenchymal dis: (IPF, sarcoidosis, bronchiectasis) * Hypoventilat’n:(neuromuscular weakness, chest wall defor.) * Anemia * Thyrotoxicosis

19. Severity (grading): Dyspnea can be graded from І – IV based on the NYHA classification.

20. 3. Pleura & plural spaces: Pneumothorax Pleuritis & serositis Pleural effusion 4. psychogenic/psychosomatic Wheezing: It’s a continuous whistling, not diagnostic for asthma & can occur in other resp diseases like copd.

21. In general appearance, look for: Respiratory Rate Respiratory distress Use of Accessory muscles of respiration.

22. Hands: 1.Clubbing (check respiratory causes) 2.Tar staining 3.Weakness of hand’s small muscles (abduction) Wrist: 1.Pulse: rate & character 2.Flapping tremors (asterixis) BP:

23. Neck: 1.JVP: ↑ in cor-pulmonale & SVC obstruct’n but not pulsatile. 2.LN: enlargement in CA bronchus or mets Face: 1.Eye: Horner’s syndrome in CA bronchus 2.Tongue : central cyanosis 3.SVC obstruction: plethoric & cyanosed, periorbital edema, injected conjuctvae

24. Inspection: 1.Shape: AP diameter compared to transverse (barrel-chest), pectus excavatum, pectus carinatum, kyphoscoliosis,…. others 2.Symmetry: assessment of upper & lower lobes should be done posteriorly looking for ↓ or delayed chest movement during moderate respirat’n. 3.Scars: from previous operat’n or chest drains or cautery marks or radiotherapy markings. 4.Prominent veins: in case of SVC obstruct’n

40. 1.Trachea: normally central, slight Rt displacement could be N. Check for gross displacement. Tracheal tug means the N distance bet sternal notch & cricoid cartilage is < 3-4 finger breadths & occurs in chest overexpansion as copd. 2.Apex beat : Check for displacement. 3.Chest expansion : N expansion ≥ 5cm 4.Tactile vocal fremitus (TVF): can be done with the palm of one hand.

45. Should be done symmetrically (Lt compared with the Rt), posteriorly (the back), anteriorly (the front) & laterally (the sides). Supraclavicular area, then clavicles should be percussed directly to evaluate the upper lobes. Liver dullness: of the upper edge starting at the 5 th rib MCL, resonant note below this area indicates hyper- inflation (copd, severe asthma) Cardiac dullness: may be ↓ in hyperinfated chest.

47. Using the diaphragm of a stethoscope & comment on the following: 1.Breath sounds (BS): Intensity: N or ↓ as in (consolidation, collapse, pl effusion, pneumothorax, lung fibrosis) Quality: Vesicular or bronchial in consolidation Differentiation between vesicular & bronchial BS: Vesicular: louder &longer on inspiration than expiratory phase & has no gap between the 2 phases Bronchial: louder &longer on exp phase & has a gap between the 2 phases

48. Type: Wheezes or Crackles or friction rub Timing: inspiratory or expiratory WHEEZES: are continuous musical polyphonic sound, heard louder on expiration & can be heard on inspiration which may imply severe AW narrowing. High pitched- wheezes are found in BA due to acute/chronic airflow limitation & low pitched in COPD. Localized monophonic wheeze due to fixed AW obstruct’n in CA bronchus. CRACKLES: interrupted non-musical inspiratory sound coarse medium fine Crackles may be early, late or pan-inspiratory & fine, medium or coarse. Ex: late/pan-insp coarse crackles in bronchiectasis, late/pan-insp medium crackles in pul edema, late/pan-insp fine crackles in pul fibrosis

49. It’s due to thickened or roughened pleural surfaces rub together as lungs expand & contract & give off a continuous or intermittent grating sound. It indicates pleurisy & may be heard in pneumonia or pulmonary infarction. VOCAL RESONANCE: It’s the ability to transmit sounds. Ask patients to say 123 (Urdu) or 99 (English) & listen for the transmitted sound which may be ↓ or ↑ or N (low pitched component of speech heard with booming & high pitched become attenuated).

51. Thank You