Approach & Diagnostic Procedures in Respiratory System

Triwahju Astuti

DATA COLLECTION
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Initial Problem / Diagnosis Differential diagnosis

10 Chief complaint 5

Iterative hypothesis

history Physical examinati on

tests

History Taking of Respiratory System

Presenting (principal) symptom History of presenting illness Past history Social history occupation, education, smoking, alcohol, analgesic use, overseas travel, immunisation, marital status, social support, living conditions Family history Systems review

Detailed history & exploring possible etiologies of cough :

Character ; what is the cough like ? - clearing of the throat : GER & post nasal drip - brassy cough (hard & metallic) : conditions that narrow the trachea or larynx - Barking cough (like a seal) : croup - Hacking cough : pharyngitis, tracheobronchitis, early pneumonia - whooping cough : pertusis - any sputum production ? If so, what collor & how much ( mucus, blood, pus, pink froth) ?

 Onset ; how did it start (sudden versus gradual) ? Intensity : at what time of day is your cough at its worst ? Does it keep you awake at night (asthma and chronic bronchitis may be associated with nocturnal or morning cough ? Duration : how long has it been going on (acute versus chronic versus paroxysmal versus seasonal versus perrenial? If cough is chronic, how has it changed recently ? Is it getting better, worse or staying the same ?

 Event associated : - Pneumonia : fever, chills, rigors, increased sputum production - URTI : malaise, sore throat, rhinorrhe, myalgia, headache, ear pain - tracheitis : retrosternal pain like a hot poker - TB / malignancy : hemoptysis, costitutional symptoms

A simplified overview of the assessment and management of the common causes of acute cough (< 3 weeks)

A simplified overview of the assessment and management of prolonged acute cough (38 weeks)

A simplified overview of the assessment and management of the common causes of chronic cough (> 8 weeks)

Dyspnea
Distressing sensation of difficult, labored, or unpleasant breathing. The word distressing is very important to this definition since labored or difficult breathing may be encountered by healthy individuals while exercising. It does not qualify as dyspnea because it may not be perceived as distressing. The sensation is often poorly or vaguely described by patients.
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Detailed history & exploring possible etiologies of dyspnea :

Character : describe the nature of your breathing difficulty Onset : how did the SOB start ( sudden vs gradual) ?. What were you doing when you became SOB ? Intensity : how severe is your SOB right now, on a scale of 1 to 10 with 1 being mild and 10 being the worst ? Has it gotten worse ? Duration : how long have you been SOB?

 Frequency : Has this ever happened to you before ? If so, how often does it happen ? When was the last time you became SOB ? Palliative factors : Is there anything that makes your SOB better ? if so, what ? Provocative factors : Is there anything that makesyour SOB worse ? If so, what ? Exertion ? Position (sitting up versuslying down)? Exposure to cold air ? Infection ? Allergies

 Frequency : Has this ever happened to you before ? If so, how often does it happen ? When was the last time you became SOB ? Palliative factors : Is there anything that makes your SOB better ? if so, what ? Provocative factors : Is there anything that makesyour SOB worse ? If so, what ? Exertion ? Position (sitting up versuslying down)? Exposure to cold air ? Infection ? Allergies

 Even associated
PE : Hemoptysis, pleuritic chest pain, DVT Pulmonary edema / ACS : Exertional chest pain (CP), PND, orthopnea, and peripheral edema. COPD : Cough, wheeze, and progressively worsening SOBOE Pneumonia, other infections : Fever / chills, rigors, increased sputum production, cough Ascities : Abdominal distension

 Anxiety (diagnosis of exclusion) : Lightheadedness, diaphoresis, trembling, choking sensation, palpitations, numbness or tongling in hands/feet, chest pain, nausea, abdominal pain, depersonalization/derealization, flushes or chills, real of dying, fear of going crazy or doing something uncontrolled Constitutional symptoms: fever, chills, night sweats, weight loss, anorexia, and asthenia.

DIFFERENTIAL DIAGNOSIS OF DYSPNEA(1)

Cardiac Congestive heart failure (right, left or biventricular) Coronary artery disease Myocardial infarction (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Asymmetric septal hypertrophy Pericarditis Arrhythmias
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DIFFERENTIAL DIAGNOSIS OF DYSPNEA(2)

Pulmonary COPD Asthma Restrictive lung disorders Hereditary lung disorders Pneumothorax

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DIFFERENTIAL DIAGNOSIS OF DYSPNEA(3)

Mixed cardiac or pulmonary COPD with pulmonary hypertension and Cor pulmonale Deconditioning Chronic pulmonary emboli Trauma

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DIFFERENTIAL DIAGNOSIS OF DYSPNEA(4)

Noncardiac or nonpulmonary Metabolic conditions (e.g., acidosis) Pain Neuromuscular disorders Otorhinolaryngeal disorders Functional - Anxiety - Panic disorders - Hyperventilation
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GUIDELINES FOR EVALUATING DYSPNEA(1)

Acute dyspnea - A clinical approach is recommended for evaluating acute dyspnea. - It consists of performing history and physical examination and performing laboratory test. - Considering potensial life-threatening conditions first (eg,acute asthma, pulmonary embolism, pulmonary oedema states, pneumonia)
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GUIDELINES FOR EVALUATING DYSPNEA(2)

CHRONIC DYSPNEA COPD, asthma, interstitial lung disease, cardiomyopathy, GERD, other respiratory diseases, and the hyperventilation syndrome. 1. Clinical features 2. Chest radiograph in nearly all patients
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GUIDELINES FOR EVALUATING DYSPNEA(3)

3. Pulmonary function testing
Noninvasive cardiac studies to include ECG, echocardiography, and stress testing Chest CT scan Comprehensive ETT Other more invasive test such as cardiac catheterization and lung biopsy

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GUIDELINES FOR EVALUATING DYSPNEA(4)

Final determination of the cause of dyspnea is made by observing which specific therapy eliminates dyspnea as a complaint. Dyspnea may be simultaneously due to more than one condition Do not stop therapy that appears to be partially successful; rather, sequentially add to it.
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HEMOPTOE/ HEMOPTYSIS
Haima = darah; ptysis= diludahkan DERAJAT BATUK DARAH (PURSEL) 1. Bloodstreak 2. 1-30 cc 3. 30-150 cc 4. 150-500 cc Massive : 500-1000 cc atau lebih

DIAGNOSIS OF HEMOPTYSIS

The diagnostic work-up of hemoptysis involves: History, Physical examination, Complete blood count, Coagulation studies , Electrocardiogram, Chest radiograph, Bronchoscopy

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Comparison of the chest signs in common respiratory disorders

Disorder Mediastinal displacement none Chest wall movement Reduced over affected area Decreased over affected area Percussion Breath sounds Bronchial Added sounds

Consolidation

Dull

Crackles

Collapse

Ipsilateral shift

Dull

Absent or reduced

Absent

Pleural Effusion

Heart displaced to opposite side

Reduced over affected area

Stony dull

Absent over fluid; may be bronchial at upper border

Absent or greatly reduced

Absent, pleural rub maybe found above effusion

Absent

Pneumothorax

Tracheal deviation to opposite side if under tension none

Decreased over affected area

Resonant

Bronchial asthma

Decreased symmetrically

Normal or decreased

Normal or reduced

Wheeze

Interstitial pulmonary fibrosis

none

Decreased symmetrically (minimal)

Normal

Normal

Fine inspiratory crackles over affected lobes

Chest examination

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