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• COUGH:
• Possible Causes of Cough:
• Pulmonary / Mechanical causes: Asthma, Irritants, aspiration
• Infectious: Tuberculosis, Histoplasmosis, Pneumonia
• Temperature: Inhaling cold air
• Pulmonary Embolism, pulmonary edema.
• Non-Pulmonary: external ear canal irritation.
• Details:
• Smoker's Cough usually occurs in morning and is productive.
• Asthmatic Cough usually is non-productive.
• SPUTUM: It is always abnormal.
• PRODUCTIVE COUGHS are seen in:
• Chronic Bronchitis, Smoker's cough
• Bronchiectasis: chronically dilated bronchioles.
• Large volume of sputum, which separates into two or three layers upon standing.
• Tumors: Bronchoalveolar Carcinoma
• Infections: Pneumonia, tuberculosis, Lung Abscess
• Will usually see yellow or green sputum.
• Pulmonary Edema
• HEMOPTYSIS:
• CAUSES:
• Most common: Bronchitis, Bronchogenic Carcinoma, Pneumococcal Pneumonia
• More rare infections:
• Tuberculosis: Age over 60, crackles, few other symptoms
• Coccidiomycosis, Histoplasmosis
• Other Tumors: Weight loss, cigarettes, anorexia
• Rare Immune Disorders: Goodpasture's Syndrome, Wegener's Granulomastosis
• Pulmonary Embolism:
• High V/Q Ratio. Lots of ventilation, poor perfusion. Excessive dead space.
• Friction rub, accentuated P2.
• Pleuritic chest pain.
• MASSIVE HEMOPTYSIS = 600 mL in 24 hrs. Usually associated with bronchiectasis, and may be indicative of lung cancer or pulmonary aspergillosis.
• PLEURITIC CHEST PAIN: Chest pain upon breathing.
• PULMONARY CAUSES: Bronchitis, pneumonia, pulmonary embolism, tuberculosis, lung carcinoma.
• NON-PULMONARY CAUSES:
• Tietze's Syndrome (Costochondritis): Superficial chest pain with local tenderness.
• Tracheitis presents with retrosternal chest pain, made worse by coughing.
• DYSPNEA: Difficult, labored breathing.
• Differential Diagnosis: A laundry list of possible causes
• Pulmonary Disease: COPD, cancer, asthma, chronic or acute bronchitis, emphysema, pneumonia, pulmonary emboli, pneumothorax
• Cystic Fibrosis: Sweat test
• Cardiac causes: CHF, Pulmonary edema, PND
• Hematologic: Anemia, CO-Poisoning
• Metabolic: Ketoacidosis
• Salicylate poisoning
• Symptoms: Dyspnea may be masked by tachypnea (shallow, rapid breathing).
• Hyperpnea is not tachypnea -- it is hyperventilation (not labored breathing) usually caused by metabolic acidosis and is unrelated to dyspnea. Distinguish the two with pulmonary function studies.
• ORTHOPNEA: Dyspnea with onset occurring while lying down, and which is immediately corrected upon restoring upright position.
• Differential Diagnosis: Congestive Heart Failure or COPD
• Also bilateral paralysis of diaphragms.
• PAROXYSMAL NOCTURNAL DYSPNEA (PND): Dyspnea at night, created by lying down, but which does not immediately improve upon standing up. Patient feels acutely air-hungry and frequently wakes up at night. Night sweats common.
• Differential Diagnosis: Acute Pulmonary Edema secondary to congestive heart failure.
• WHEEZING: High-pitched musical breath sound usually heard on expiration, but can be heard on inspiration.
• CAUSED by air rushing past a constricted airway, constricted by secretions, mucous, edema, neurogenic, a tumor, or an aspirated foreign body.
• Asthma: Wheezing is characteristic of asthma.
• Silent Asthma is asthma without wheezing.
• STRIDOR: High-pitched sound occurring with inspiration.
• Stridor portends total airway obstruction, a medical emergency.
• Acute Epiglottitis: H. Influenza infection in kids. Stridor is characteristic. Have a chest-tube nearby before examining epiglottis to prevent (or treat imminent) aspiration.
• CYANOSIS:
• Central Cyanosis: Face, lips, tongue. Results from systemic hypoxia due to poor perfusion or ventilation in the lungs.
• Peripheral Cyanosis: May be found in extremities, ears, cheeks, etc. Can be caused by cold-induced vasoconstriction (Raynaud's Phenomenon) or poor circulation (shock, CHF).
• Differential Diagnosis: Pulmonary hypoventilation, COPD
• Cardiac causes: Shunt (Tetralogy of Fallot), pulmonary edema (cor pulmonale)
• RHINORRHEA: Nasal discharge
• CORYZA: Nasal discharge caused by a viral upper respiratory tract infection.

FAMILY / SOCIAL HISTORY:

• Previous Tuberculosis infection, PPD test.
• Poor dental hygiene is a risk for a lung abscess.
• Environmental exposures revealed in social history
• Travel
• Psittacosis: Exposure to birds
• Legionellosis: Exposure to water, air-conditioners
• Tobacco use

EXTRAPULMONARY EXAMINATION:

• HALITOSIS: Some possible causes
• Campylobacter Pylori colonization of stomach
• Lung abscess or bronchiectasis (foul-smelling, fecal breath-odor)
• Necrotic lesions of mouth or throat
• Zenker's Diverticulum
• Clubbing of fingernails:
• Congenital Heart Disease: Chronic hypoxia of VSD or Tetralogy, in kids.
• Adults: Systemic hypoxia, lung cancer, bronchiectasis, mesothelioma.
• Chemosis: Conjunctival edema. Hyperthyroidism or obstruction of SVC.

BREATHING:

• Bradypnea: Slow breathing rate
• Insulin Coma
• Drug-induced respiratory depression
• Tachypnea: Rapid, shallow breathing, caused by pleuritic chest pain or diseases that immobilize the lung.
• Hyperpnea: Rapid, deep breathing; hyperventilation.
• Diabetic ketoacidosis compensation (to lower PCO₂)
• KUSSMAUL RESPIRATIONS: Central hyperventilation, deep rapid breaths characteristic of Diabetic hyperglycemic coma.
• CHEYNE-STOKES RESPIRATION: Cyclic alternations between apnea and hyperpnea, in which PCO₂ fluctuates and is unstable. It occurs when the respiratory centers of the brain become insensitive to changes in CO₂
• ASSOCIATED DISEASES: Congestive Heart Failure (CHF), Uremia, Meningitis, Pneumonia.
• BIOT'S BREATHING: Ataxic breathing; unpredictable and irregular respirations.
• Caused by meningitis or other cerebral dysfunction.
• SLEEP APNEA: Obesity, leading to airway obstruction at night and chronic fatigue during the day. Treat with CPAP.

INSPECTION:

• BACK SIDE:
• Buffalo Hump: Fatty deposit overlying C7, characteristic of Cushing's Syndrome
• Barrel Chest: Chronically inflated lungs characteristic of COPD.
• Kyphosis: Excessive anterior curvature of spine, as in hunchback.
• Cause: normal or from aging, osteoporosis.
• Scoliosis: Lateral curvature of spine.
• May be detected by patient bending forward and noting uneven paravertebral back muscles.
• Lordosis: Excessive posterior curvature of spine. Bowing of lumbar and cervical spines together.
• Gibbus Deformity: Sharp change of angle of spine instead of gradual change. Characteristic of Pott's Disease, or Vertebral Tuberculosis
• FRONT SIDE
• Pectus Carinatum (Pigeon Chest): Sternum placed forward, increased anteroposterior chest measurement.
• Found in Marfan's Syndrome, Rickets
• Pectus Excavatum (Funnel-Chest): Lower end of sternum is depressed inward. May also be found in Marfan's Syndrome or Rickets.
• Flail Chest: Caused by multiple fractures ribs. One side of chest moves paradoxically relative to the other side of the chest.

PALPATION: Assess chest excursion by placing fingers at costovertebral angle and having patient inhale.

• Subcutaneous Emphysema: Air in subcutaneous space. Can occur in tracheostomy patients, or people with ARDS who have an endotracheal tube.
• Oliver's Sign: Tracheal tug when patient lifts his chin up.
• Indicative of Aortic Aneurysm, pulling trachea downward by pressure of left main bronchus.
• Tactile Fremitus: Vibration on lungs when you have patient say "ninety-nine"
• Increased fremitus is found with pulmonary consolidation in pneumonia.
• Fremitus cannot be heard below the level of fluid in emphysema or pleural effusion, because the fluid stops the sound from being transmitted further.

PNEUMOTHORAX: Trachea will shift toward opposite side as the pneumothorax. The side of the pneumothorax acquires positive pressure, thus trachea deviates to the other side.

• Tracheal Deviation: Tracheal deviation can be caused by other things than pneumothorax.
• Pleural Effusion, Emphysema may also cause trachea to deviate to the opposite side.
• Atelectasis of lung may cause trachea to deviate toward same side as diseased lung.
• Tension Pneumothorax: Medical emergency in which air enters the pleural cavity and is trapped during expiration
• Intrathoracic pressure builds to values higher than atmospheric pressure, compresses the lung, and may displace the mediastinum and its structures toward the opposite side, with consequent disadvantageous effects on blood flow.

PERCUSSION:

• Resonance: Normal breath sound
• Hyperresonance: Increased resonance over thorax.
• May be found in Emphysema or Pneumothorax.
• Tympany: Percussion of gastric air-bubble or air-filled bowel. Increased resonance.
• Dullness: Decreased resonance, normally found over liver, spleen, and below lung.
• Causes: Emphysema, Pneumonia with consolidation, pleural effusion.
• Flatness: Extreme dullness with few or no ringing tones.
• Pleural effusions, massive pulmonary consolidations with tumor, pneumonia.

AUSCULTATION:

• General Properties:
• Stethoscope Sounds: Use the bell side to listen to breath sounds.
• Press lightly: hear low-pitched sounds.
• Press hard: hear high pitched sounds.
• Tracheal Breath Sounds: Loud, harsh, high pitched.
• Bronchial Breath Sounds: Loud, high-pitched with air swishing past.
• Bronchovesicular Sounds: Heard near branching of main bronchi, combination of bronchial and vesicular sounds.
• Vesicular Sounds: Soft, low-pitched, airy, swishing, heard below the level of the bronchi.
• CRACKLES (RALES, CREPITATIONS): Soft, short, high-pitched fine sounds.
• CAUSES: Congestive heart failure, bronchitis, pneumonia, pulmonary edema, bronchiectasis.
• RHONCHUS: Snoring sound, characteristic of Asthma. It indicates fluid or mucus in airways.
• WHEEZE: On expiration, squeaking high pitched sound, often audible to unaided ear.
• Caused by air passing by obstructed airway.
• Characteristic of Asthma, but also found in Emphysema, bronchitis.
• PLEURAL FRICTION RUB: Grating sound heard during breathing that stops when the breath is held. Caused by friction of visceral and parietal pleura.
• PULMONARY CONSOLIDATION: Occurs with late-stage lobar pneumonia.
• BRONCHOPHONY: Increased transmission of sound to the lung periphery. Indicative of pulmonary consolidation.
• WHISPERED PECTORILOQUY: Words being understood better when whispered. Also indicative of pulmonary consolidation.
• EGOPHONY: "E" to "A" sound-changes. Indicative of pulmonary consolidation or pleural effusion.
• HAMMAN'S SIGN: Crunching, crackling sound over chest heard synchronous with the heart beat. Occurs with mediastinal emphysema -- air in the mediastinum.
• CAUSES: Can follow thoracic surgery, trauma.
• Boerhaave's Syndrome: Esophageal rupture causing air in mediastinum. Rare.

LUNG DISEASES:

• Asthma
• Atelectasis: Bronchial plug ------> decreased lung volume ------> higher lung density ------> lung mass is pulled toward chest wall by negative pressure
• Tracheal deviation toward affected side
• crackles, maybe
• no breath sounds
• Bronchiectasis: Chronic bronchial dilation.
• Caused by frequent pulmonary infections or pneumonia.
• Large amounts of sputum will be expectorated when patient lies prone hanging toward floor.
• Bronchitis: Acute (infectious) or chronic (smoker's)
• Bronchiolitis: Common in infants and children.
• Lung Cancer
• Cor Pulmonale
• Croup: Kids under 3 years old. Rapid, staccato coughs.
• Differential Diagnosis is between inflammatory Croup or Spasmodic Croup.
• Cystic Fibrosis
• Pleural Effusion: Dullness on percussion. Decreased fremitus. Reduced breath sounds.
• Emphysema
• Epiglottitis: In kiddies, don't inspect the pharynx without a chest tube nearby.
• Pneumonia

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