Chapter 10: Thoracic and Respiratory Disorders

SIGNS AND SYMPTOMS

Dyspnea

Dyspnea is the uncomfortable awareness of difficult, labored, or unpleasant breathing. Normal resting patients are unaware of the act of breathing. For most patients presenting with dyspnea, there is either a cardiac or pulmonary cause of their symptoms (Table 10.1). Other, less common, causes include psychogenic factors, gastroesophageal reflux disease (GERD), and deconditioning.

SYMPTOMS/EXAMINATION

Look for signs of impending respiratory failure (severe tachypnea, tachycardia, stridor, agitation) and evidence for underlying etiology (eg, rash and hypotension with anaphylaxis).

DIAGNOSIS/TREATMENT

• Conduct a systematic diagnostic and therapeutic evaluation for the cause of dyspnea.

• Obtain a chest x-ray (CXR) at minimum. Obtain other studies (CT-PE, echocardiogram) based on clinical suspicion.

TREATMENT

Treat underlying condition.

Cough

CAUSES

Cough results from stimulation of irritant receptors in the larynx, trachea, and major bronchi. Triggers include mucus, allergens, chemical irritants, gastric acid, and others. Likely etiologies differ depending on whether the cough is acute (< 3 weeks) or more persistent.

Acute Cough

• Acute upper respiratory infection (pertussis, rhinitis, sinusitis)

• Lower respiratory infection

• Asthma/COPD (chronic obstructive pulmonary disease) exacerbation

• Environmental irritants, such as pets, dust, and other allergens

• Airway foreign body

Chronic Cough

• Smoking: Chemical irritant, chronic bronchitis

• Postinfectious postnasal drip

• GERD

• Chronic asthma/COPD

• Angiotensin-converting-enzyme (ACE) inhibitor

• Bordetella pertussis

• Other causes: Bronchiectasis, congestive heart failure (CHF), environmental irritants, and recurrent aspiration

SYMPTOMS/EXAMINATION

• Inquire about postnasal drip symptoms, asthma, GERD, treatment with ACE inhibitors or angiotensin receptor blockers (ARBs), and smoking.

• Determine if cough is productive (infection, bronchiectasis) or bloody (malignancy, infection, Goodpasture syndrome, Wegener granulomatosis).

• The physical examination should focus on the nasal mucosa, lungs, heart, and extremities (for clubbing).