Respiratory System Symptoms (Internal Medicine)

Respiratory System Symptoms (Internal Medicine)

Breathing Pattern:

• Kussmaul Breathing: Deep, slow inspirations followed by expirations (30-second cycle).

• Cheyne-Stokes Breathing: Breathing cycle with: increasing amplitude – decreasing amplitude – apnea.

• Biot Breathing: Irregular breathing, alternating between slow and fast, shallow and deep breaths, with occasional periods of apnea.

• Expiratory Effort: Prolonged expiration, with straining of neck muscles, shoulders, intercostal spaces, and pursed-lip breathing.

• Inspiratory Effort: Signs of retractions of intercostal muscles and supraclavicular area when there is obstruction of large/small airways.

Chest Examination:

• Movement of Costal Angle: Normally, the costal angle opens around 90 degrees, and this angle widens during deep inspiration.

• Chest Ratio:

• Normal: Anteroposterior diameter / lateral diameter ~ 1/2-1/5.

• Barrel Chest: >~1/1.

• Vocal Fremitus:

• Comparison:

• Female: Vocal fremitus is weaker than male.

• Thin: Vocal fremitus is clearer than obese individuals.

• Children: Due to thin chest walls, vocal fremitus is clear even when speaking in a high voice.

• Clinical Examination:

• Increased Vocal Fremitus: May be found in pulmonary consolidation syndrome.

• Decreased Vocal Fremitus: May be found in pleural effusion, pneumothorax, and pneumatocele.

Auscultation of Lungs:

• Tracheal Breath Sounds: During inhalation, airflow through the nose into the trachea creates rough, loud breath sounds, clearly audible over the trachea.

• Tracheal Breath Sounds entering Bronchi: Clearly audible at the sternal notch, clearer during inhalation.

• Alveolar Breath Sounds: Clearly audible in the 1st and 2nd intercostal spaces in the scapular region.

• Vesicular Breath Sounds: Soft, low-pitched breath sounds, with a longer inhalation phase than expiration, sounding soft and gentle, with expiration often inaudible.

Dyspnea:

• Paroxysmal Nocturnal Dyspnea (PND):

• Characteristics: Increased pulmonary capillary pressure due to fluid redistribution from only when lying down, or reduced cardiac output (left ventricle no longer compensating).

• Cause: Sitting up or walking around for a while reduces dyspnea.

• Orthopnea: Increasing shunt between arterioles and venules in the pulmonary circulation leads to increased right-to-left shunting when standing, resulting in decreased blood oxygenation, causing dyspnea.

• Platypnea:

• Cause: Redistribution of peripheral fluid to the lungs, elevation of the diaphragm in obese individuals, abdominal distention, or weak muscles.

• Severity: Evaluated by the number of pillows the patient can lie on.

• Patient Bends Forward to Breathe: Dyspnea due to tracheal obstruction.

• Dyspnea on Expiration, Wheezing, Coughing, Pursed-Lip Breathing. Lung auscultation reveals wheezing and snoring: Dyspnea due to asthma, chronic obstructive pulmonary disease.

• Biphasic Dyspnea, Rapid Shallow Breathing. Lung auscultation reveals crackles and rales: Dyspnea due to bronchopneumonia.

• Rapid Shallow Breathing, Auscultation of Cardiac Abnormalities, Hepatomegaly, Jugular Venous Distension: Dyspnea due to cardiac causes.

MRC (Medical Research Council) Classification of Dyspnea Severity in COPD Patients:

• Grade 1: Dyspnea with severe exertion.

• Grade 2: Dyspnea with brisk walking or walking uphill.

• Grade 3: Dyspnea more than others of the same age when walking on a flat surface, or needing to stop to breathe when walking on a flat surface.

• Grade 4: Dyspnea when walking slowly on a flat surface, approximately 100 meters.

• Grade 5: Dyspnea with even light movements (eating, speaking, bathing, dressing…).

Cough:

• Classification:

• Acute: 3 weeks.

• Subacute: 3-8 weeks.

• Chronic: > 8 weeks.

• Cough Center: Located in the medulla oblongata in the region of the fourth ventricle.

• Nerves Controlling Expiration: (1) Vagus Nerve, (2) Intercostal Nerves, (3) Phrenic Nerve, (4) Diaphragmatic Nerve.

Sputum:

• Mucus: Asthma, tuberculosis, COPD, pneumonia.

• Yellow-Green: Hemophilus.

• Dark Green, Brown: Pseudomonas.

• Rusty: Pneumococcal pneumonia.

• Red Currant Jelly: Klebsiella.

• Foul-Smelling: Anaerobic bacterial lung abscess.

• Sputum Sedimentation: 3 layers: upper layer – foam; middle layer – mucopurulent; lower layer – cloudy pus.

• Excessive Sputum:

• 500 – 1000 ml/24 hours, purulent sputum, sometimes foul-smelling due to anaerobic bacteria: Bronchiectasis.

• Morning sputum in small amounts, with color varying from opaque white, yellow, or green, lasting at least 3 months continuously/year or twice in a year: Chronic bronchitis.

Hemoptysis:

• Origin: Blood originates from the larynx downwards.

• Pathophysiology:

• Vessel rupture or ulceration.

• Red blood cell leakage.

• Allergies.

• Blood disorders.

• Severe: > 100 – 600 ml/ 24 hours.

• Emergency Indication: Patient at risk of suffocation => Death.

• 3 Primary Causes to Consider:

• Pulmonary tuberculosis 81%.

• Bronchiectasis 8.4%.

• Lung cancer, bronchial cancer 3.3%.

Wheezing:

• Upper Airways in the Thoracic Cavity: Tracheal stenosis, foreign body aspiration, tumors, thyroid goiter.

• Lower Airway Obstruction: Asthma, COPD, OAP, pulmonary embolism, Cancer, Bronchiectasis, Pulmonary Embolism,…

Cyanosis:

• Central: Disturbance in one of the four stages of gas exchange:

• Disturbance in ventilation.

• Disturbance in diffusion across the membrane.

• Disturbance in oxygen transport in blood.

• Disturbance in cellular oxygen metabolism.

• Peripheral:

• Shock.

• Reduced cardiac output (especially chronic heart failure).

• Vasoconstriction.

• Thromboembolism – Embolism of blood vessels.

Syndromes:

• Lung Abscess Syndrome – Sputum Stage: Coin-shaped sputum, purulent sputum.

• Clinical Signs of Lung Abscess Syndrome: Coughing up large amounts of purulent sputum, Cavity Syndrome.

• Syndrome of 3 Reductions: Pleural effusion.

• Galliard’s Triad: Vocal fremitus absent, percussion resonant, vesicular breath sounds absent: Pneumothorax.

Clinical Examination:

• Jugular Vein Distension (Internal Jugular Vein): 1. Right heart failure. 2. Pericardial effusion. 3. Pericardial adhesion.

• Right Lower Quadrant Pain – Infectious Fever – Hepatomegaly: Fontan’s Triad => Bacterial liver abscess.

• Ascites: One of the major causes is portal hypertension.

• Hepatic Congestion: Heart failure, constrictive pericarditis, Budd-Chiari syndrome (obstruction of the superior hepatic vein system).