(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics

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Accompanying symptoms

  1. Paroxysmal dyspnea with wheezing. It is present in bronchial asthma and cardiac asthma. Paroxysmal severe dyspnea is often seen in acute larynx edema, foreign body in bronchi, massive pulmonary embolism, and spontaneous pneumothorax.


  2. Dyspnea with chest pain. It is frequently observed in lobar pneumonia, pulmonary infarction, spontaneous pneumothorax, acute exudative pleurisy, acute myocardial infarction, and bronchial carcinoma.

  3. Dyspnea with fever. It is commonly noted in pneumonia, lung abscess, pulmonary tuberculosis, pleurisy, acute pericarditis, and nervous system diseases.

  4. Dyspnea with cough and purulent sputum. It is often present in chronic bronchitis, obstructive pulmonary emphysema with infection, purulent pneumonia, and lung abscess; Dyspnea with large amount of foany sputum is often seen in acute left ventricular heart failure and organophosphorus poisoning.

  5. Dyspnea with coma. It suggests cerebral hemorrhage, meningitis, pneumonia with shock, uremia, diabetic ketoacidosis, and acute poisoning.


Chapter 6 Cough and Expectoration

Cough is undoubtedly the commonest of respiratory symptoms. It is a reflex act that may be initiated voluntarily or involuntarily against infection of dust, noxious gases, and may vary in severity from the occasional “clearing of the throat” that everyone performs several times daily to a severe, hacking, harassing paroxysmal cough that may incapacitate the afflicted individual and even threaten life itself. Coughing per se may cause complications, including posttussic emesis, tussic syncope, tussic rib fractures, pneumomediastinum, spontaneous pneumothorax, bullous emphysema, and abdominal hernias. A protracted cough interferes with rest and sleep, aggravates bronchial asthma, and causes irritation to bronchial mucosa and larynx so that the cough tends to become self-perpetuating.

Cough arises from stimulation or irritation of the pharynx, larynx, trachea, or bronchi. The stimuli which produce cough may be inflammatory, mechanical, chemical, or thermal. Occasionally, cough results from pleural irritation in the absence of tracheobronchial disease, and is even reputed to arise from stimulation of the auricular branch of the vagal nerve.


Etiology

The cough reflex can be initiated by a wide variety of stimuli.

1. Respiratory disease: Sensatory points initiating a reflex cough are located in the respiratory tract from the pharynx to the small bronchi, especially in the main carina. The smaller bronchiele and alveoli are relatively insensitive to irritants. The irritation is usually caused by irritating gas inhalation, foreign body, inflammation, tumor, bleeding etc.

2. Pleural disease:

Cough may also be stimulated by impulse resulting from pleurisy or irritation of pleural membrane.

3. Cardiovascular disease:

Left ventricular failure, which causes pulmonary congestion and alveolar transudation of fluid is often associated with cough. Sometimes right-side heart failure and pulmonary embolism also develop cough.

4. Central factor:

Cough can also originate from the cortex (voluntary cough), the impulses are transmitted from cortex to the medulla cough center, which sends impulses to the muscular system of chest and the larynx, and a cough results.

Expectoration:

Ciliary activity carries particles and macrophages on the mucous lining layers of the respiratory epithelium to larger bronchi where the cough reflex is important in their clearance, mucus is propelled upward to the glottis.

Covering the cilis there is a thin layer of secretion the mucous blanket which is produced by the submucosal bronchial glands and to somewhat lesser extent by the goblet cells, mucus can keep the airway membrane moist. An increase in the volume and viscosity of tracheobronchial secretions occurs in association with infection or irritation of the lungs, which induce the congestion of membrane, edema, increase of the permeability of capillary. In the respiratory infection of parasitic lung disease, virus, mycoplasma, pathogenic bacteria, amebia can be detected from the sputum.

In the pulmonary congestion or edema, the escaped blood from pulmonary capillary can initiate cough and expectoration. Frothy, pink watery secretion is characteristic for the pulmonary edema.


Clinical presentation

1. Character of cough.

Cough without sputum is called as dry cough or unproductive. It is usually caused by acute pharyngitis, early stage of acute bronchitis, pleurisy, and mild tuberculosis.

Cough with sputum is called as productive cough. It is caused by pneumonia, chronic pharyngitis, chronic bronchitis, broncheactasis, lung abscess, and cavitious tuberculosis.

2. The duration and pattern of cough:

Cough initiated suddenly is mostly developed by acute upper airway infection or foreign body in the trachea or bronchi. Chronic cough is often associated with chronic bronchitis, bronchial asthma and tuberculosis. Paroxysmal cough is seen in the whooping cough, tuberculous adenopathy or the broncus impressed by tumor. Periodic cough is seen in the chronic bronchitis or bronchiectasis. It is always related to the change of body position. Nocturnal cough particularly associated with asthma, tuberculosis, chronic loft heart failure. It has possible association with the vagal excitation at night.

3. The tone quality of cough:

It means the change of the sound and may suggest the location of the pathology. For example, a "breaking" cough suggests epiglottal disease, a "brassy" cough is associated with tracheal airway, and “Hacking" or "cleaning of throat" is often caused by a postnasal discharge. A “hoarseness" with coughing suggests larynto-tracheal bronchitis or impaired function of the recurrent laryngeal nerve, as from aneurysm of the aorta, left atrial enlargement, or mediastinal malignancy. Inspiratory stridor suggests an upper airway obstruction.

4. The character and volume of sputum:

Clear, white, or gray sputum is characteristically present in cases of chronic bronchitis. In “pure” cases of emphysema, the cough is often nonproductive. Tenacious sticky mucoid sputum, occasionally with bronchial casts, is commonly noted in asthmatics. Foul-smelling purulent sputum suggests bronchiectasis. Expectoration of calcific particles (broncholithoptysis) is diagnostic of broncholithiasis.

Associated hemoptysis also raises the possibility of a malignant process, bronchiectasis, lung abscess, or chronic bronchitis.

(Accompanying symptom)

1. Cough with fever: It is indicative of acute or active infection in the respiratory system such as measles, pneumonia, influenza, lung abscess, tuberculosis, pleurisy etc.

2. Cough with chest pain: It suggests the plural cavity be involved and may be seen is the heart disease and coronary heart disease, such as pneumonia, pleurisy, bronchial carcinoma.

3.Cough with dyspnea

It is often present in the edema of larynx, larynx tumor, chronic obstructive pulmonary diseases, severe pneumonia, tuberculosis, massive pleural effusion,pneumothorax pulmonary congestion, and pulmonary edema.

4. Cough with large amount of purulent sputum

It is commonly noted in bronchiectasis, lung abscess, and bronchi-pleural fistula.

5. Cough with hemoptysis

It suggests pulmonary tuberculosis, bronchiectasis, bronchial carcinoma, lung abscess, or mitral stenosis.

6. Cough with clubbed fingers

It is commonly seen in bronchiectasis, lung abscess, bronchial carcinoma, and thoracic empyema.

7. Cough with wheeze

It is often seen in bronchial asthma, cardiac asthma, and foreign body in trachea and bronchi.



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