diagnosis & evaluation of respiratory disease

7/28/2019 Diagnosis & Evaluation of Respiratory Disease

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Approach & Diagnostic

Procedures in Respiratory System

Triwahju Astuti


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Chief

complaint

history

Physical

examination tests

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10

5

DATA COLLECTION

Differentialdiag

nosis

Initial Problem / Diagnosis

Iterativehypothesis


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History Taking of Respiratory

System


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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


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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 thatnarrow 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) ?


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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 andchronic bronchitis may be associated with nocturnal

or morning cough ?

Duration : how long has it been going on (acute versuschronic versus paroxysmal versus seasonal versus

perrenial? If cough is chronic, how has it changed

recently ? Is it getting better, worse or staying the

same ?


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Event associated :

- Pneumonia : fever, chills, rigors, increasedsputum production

- URTI : malaise, sore throat, rhinorrhe,

myalgia, headache, ear pain- tracheitis : retrosternal pain like a hot

poker

- TB / malignancy : hemoptysis,costitutional symptoms


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


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A simplified overview of the assessment and management of

prolonged acute cough (38 weeks)


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A simplified overview of the

assessment and

management of the

common causes of chronic

cough

(> 8 weeks)


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Dyspnea

Distressing sensation of difficult, labored, orunpleasant breathing.

The word distressing is very important to this

definition since labored or difficult breathing maybe encountered by healthy individuals whileexercising.

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 breathingdifficulty

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?


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Frequency : Has this ever happened to you before ? Ifso, how often does it happen ? When was the lasttime you became SOB ?

Palliative factors : Is there anything that makes yourSOB better ? if so, what ?

Provocative factors : Is there anything thatmakesyour SOB worse ? If so, what ?

Exertion ?

Position (sitting up versuslying down)?

Exposure to cold air ?

Infection ? Allergies


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Frequency : Has this ever happened to you before ? Ifso, how often does it happen ? When was the lasttime you became SOB ?

Palliative factors : Is there anything that makes yourSOB better ? if so, what ?

Provocative factors : Is there anything thatmakesyour SOB worse ? If so, what ?

Exertion ?

Position (sitting up versuslying down)?

Exposure to cold air ?

Infection ? Allergies


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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


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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 doingsomething uncontrolled

Constitutional symptoms: fever, chills, night

sweats, weight loss, anorexia, and asthenia.


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DIFFERENTIAL DIAGNOSIS

OF DYSPNEA(1)

CardiacCongestive heart failure (right, left orbiventricular)

Coronary artery diseaseMyocardial infarction (recent or past history)CardiomyopathyValvular dysfunction

Left ventricular hypertrophyAsymmetric septal hypertrophyPericarditisArrhythmias

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OF DYSPNEA(2)

Pulmonary

COPD

AsthmaRestrictive lung disorders

Hereditary lung disorders

Pneumothorax

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OF DYSPNEA(3)

Mixed cardiac or pulmonary

COPD with pulmonary hypertension and

Cor pulmonaleDeconditioning

Chronic pulmonary emboli

Trauma

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OF DYSPNEA(4)

Noncardiac or nonpulmonary

Metabolic conditions (e.g., acidosis)

PainNeuromuscular disorders

Otorhinolaryngeal disorders

Functional

- Anxiety

- Panic disorders

- Hyperventilation22


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GUIDELINES FOR

EVALUATING DYSPNEA(1) Acute dyspnea

- A clinical approach is recommended forevaluating acute dyspnea.

- It consists of performing history andphysical examination and performinglaboratory test.

- Considering potensial life-threateningconditions first (eg,acute asthma,pulmonary embolism, pulmonaryoedema states, pneumonia)

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GUIDELINES FOR

EVALUATING DYSPNEA(2)

CHRONIC DYSPNEA

COPD, asthma, interstitial lung disease,

cardiomyopathy, GERD, other respiratorydiseases, and the hyperventilation

syndrome.

1. Clinical features

2. Chest radiograph in nearly all patients

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GUIDELINES FOR


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 cardiaccatheterization and lung biopsy

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GUIDELINES FOR


Final determination of the cause ofdyspnea is made by observing which

specific therapy eliminates dyspnea as acomplaint.

Dyspnea may be simultaneously due tomore than one condition

Do not stop therapy that appears to bepartially successful; rather, sequentiallyadd 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


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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 respiratorydisorders

Disorder Mediastinal

displacement

Chest wall

movement

Percussion Breath

sounds

Added sounds

Consolidation none Reduced over

affected area

Dull Bronchial Crackles

Collapse Ipsilateral shift Decreased over

affected area

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,

pleural rub

maybe found

aboveeffusion

Pneumothorax Tracheal

deviation to

opposite side if

under tension

Decreased over

affected area

Resonant Absent or

greatly

reduced

Absent

Bronchial

asthma

none Decreased

symmetrically

Normal or

decreased

Normal or

reduced

Wheeze

Interstitial

pulmonary

fibrosis

none Decreased

symmetrically

(minimal)

Normal Normal Fine

inspiratory

crackles over

affected lobes


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Chest examination


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TERIMA KASIH

diagnosis & evaluation of respiratory disease

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