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Chapter
c0003
Cardiopulmonary Symptoms
ALBERT J. HEUER*
CHAPTER OUTLINE
Cough
Causes and Clinical Presentation
Descriptions
Sputum Production
Causes and Descriptions
Hemoptysis
Definition
Causes
Descriptions
Hemoptysis versus Hematemesis
Shortness of Breath (Dyspnea)
Subjectiveness of Dyspnea
Dyspnea Scoring Systems
Causes, Types, and Clinical Presentation
of Dyspnea
Descriptions
Chest Pain
Pulmonary Causes of Chest Pain
Descriptions
LEARNING OBJECTIVES
After reading this chapter, you will be able to:
1. Describe the causes and common characteristics of the following symptoms:
2. Cough
3. Sputum production
4. Hemoptysis
5. Dyspnea
6. Chest pain
7. Dizziness and fainting
8. Swelling of the ankles
9. Fever, chills, and night sweats
10. Headache, altered mental status, and personality changes
11. Snoring
12. Gastroesophageal reflux
13. Daytime somnolence (sleepiness)
*Dr. Robert Wilkins, PhD, RRT, and Donna Gardner, MSHP, RRT, contributed much of the content for this chapter as co-editors of the prior edition
of the chapter.
32
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p0010
o0010
o0015
o0020
o0025
o0030
o0035
o0040
o0045
o0050
o0055
o0060
o0065
o0070
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33
KEY TERMS
angina
cough
daytime somnolence
diaphoresis
dyspnea
edema
fetid
fever
frothy
p0080
b0010
gastroesophageal reflux
disease (GERD)
hematemesis
hemoptysis
night sweats
obstructive sleep apnea (OSA)
orthodeoxia
orthopnea
orthostatic hypotension
s0010
Cough
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p0110
o0075
o0080
o0085
p0130
o0090
o0095
o0100
o0105
o0110
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34
t0010
TABLE 3-1
Possible Causes of Cough Receptor Stimulation
Types of Stimulation Possible Causes
Inflammatory
Mechanical
Obstructive
Descriptions
s0020
Q UESTIO NS TO A SK
Cough
Ask the patient to describe the cough in his or her own words; if
unable to give a description, use suggestions of descriptive words.
Can you describe your cough? How long have you had
the cough?
When did the cough start? Did the cough start suddenly? What were you doing when the cough started?
Do you smoke? If so, what do you smoke? How much
and for how many years?
Do you have postnasal drip? Do you wheeze? Do you
have heartburn? Do you notice an acid or bitter taste in
your mouth?
Do you cough up sputum or mucus and, if so, what is
the amount, color, thickness, and odor?
10003-HEUER-9780323100298
b0015
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s0025
t0015
QU E S T ION S TO AS Kc ontd
TABLE 3-2
Cough
Sputum Production
Dry, progressing to
productive
Inadequate, weak
Paroxysmal
(especially night)
Barking
Brassy or hoarse
Inspiratory stridor
Wheezy
Morning
Associated with
position change or
lying down
Associated with
eating or drinking
35
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36
t0020
TABLE 3-3
Q UESTIO NS TO A SK
Sputum
Normal
Ask the patient to describe the sputum in his or her own words; if
unable to give a description, use suggestions of descriptive words
(e.g., green, yellow, white, clear, teaspoon, tablespoon, cup).
Do you usually bring up phlegm or mucus from your
chest first thing in the morning?
Do you usually bring up phlegm or mucus at other
times of the day?
Can you estimate the amount you bring up? About a
cup? About a tablespoon? Has this amount changed?
What color is it? Does it have a foul odor?
Has the sputum changed color recently?
SIMPLY STATED
b0025
Hemoptysis
Definition
s0035
s0040
Causes
seen in certain chronic bronchial infections and bronchiectasis. These characteristics of the sputum may be highly
indicative of the underlying disorder (Table 3-3). Though
sputum culture and sensitivity tests described in Chapter 7
provide for a more in depth microbiologic examination of
sputum, bedside examination can be helpful as an initial
screening tool.
The consistency of sputum may be described as thin,
p0315
thick, viscous (gelatinous), tenacious (extremely sticky),
or frothy. Color depends on the origin and cause of the
sputum production. Descriptions for the color of sputum
include mucoid (clear, thin, and may be somewhat viscid
as a result of oversecretion of bronchial mucus), mucopurulent (thick, viscous, colored, and often in globs with an
offensive odor), and blood-tinged. Copious, foul-smelling
(fetid) sputum that separates into layers when standing
occurs with bronchiectasis and lung abscess when the
patients position is changed.
Morning expectoration implies accumulation of secrep0320
tions during the night and is commonly seen with bronchitis. Nonpurulent, silicone-like bronchial casts are seen
with asthma. Sudden large amounts of sputum production may be indicative of a bronchopleural fistula.
b0020
s0045
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b0105
BOX 3-1
37
t0025
TABLE 3-4
Distinguishing Characteristics of Hemoptysis
and Hematemesis
Characteristic
Hemoptysis
Hematemesis
History
Cardiopulmonary
disease
Coughed up from
lungs/chest
Dyspnea, pain or
tickling sensation
in chest
Alkaline
Sputum
May be present
Bright red
Gastrointestinal
disease
Vomited from
stomach
Nausea, pain
referred to
stomach
Acid
Food
Absent
Dark, clotted,
coffee grounds
As stated by the
patient
Associated
symptoms
Blood: pH
Mixed with
Froth
Color
s0055
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38
important to obtain a detailed sequence of events to determine whether the blood originated in the respiratory tract
and was swallowed and then vomited, or the blood was
vomited, aspirated, and later expectorated.
b0030
QU E S T ION S TO AS K
Hemoptysis
Ask the patient the following questions to help obtain an accurate
and impartial history:
Do you smoke? If so, how much and what do you
smoke?
Do you use smokeless tobacco? If so, how much and
what do you use?
Did you start coughing up blood suddenly?
How long have you noticed the blood?
Do you have a fever? Do you have a cough?
Do you cough up anything else with the blood? Can
you describe what it looks like?
Is the sputum blood-tinged or are there actual clots of
blood?
Have there been recurrent episodes of coughing up
blood?
Do you have chest pain?
What seems to bring on the coughing up of blood? Is it
brought on by vomiting, coughing, or nausea?
Have you felt any unusual sensations in your chest
after you cough up the blood? Before you cough up the
blood? If yes, where? Can you tell me how it feels?
Have you had a recent nosebleed?
Have you been involved in a recent accident or had an
injury to your chest, side, or back?
Have you traveled lately?
Have you ever had tuberculosis? Have you been exposed
to anyone who has had tuberculosis?
Are you HIV positive? Do you have a history of cancer?
Have you had recent surgery?
Have you had night sweats? Shortness of breath? Irregular heartbeats? Hoarseness? Weight loss? Swelling
or pain in your legs?
Is there a family history of coughing up blood? Are you
aware of any bleeding tendency in you or your family?
Have you been exposed to anything at work or hobbies?
Do you take any blood thinners or aspirin? If yes, how
much and how often? Do you take oral contraceptives?
Do you use injection drugs?
s0060
Subjectiveness of Dyspnea
Dyspnea may be difficult to evaluate because it is so subjective. The sensation of dyspnea is made up of the following
components:
1. Sensory input to the cerebral cortex. Multiple sources of sensory information from mechanoreceptors in the upper
airway, thorax, and muscles are integrated in the central
nervous system and sent to the sensorimotor cortex in
the brain. In general, the sensation of dyspnea is related
to the intensity of the input from the thoracic structures and from chemoreceptors. It varies directly with
ventilatory demand such as exercise and inversely with
ventilatory capacity (ability to move gas in and out of
the lung). The more stimulation of the drive to breathe
when ventilatory abnormalities exist, the greater the
dyspnea.
2. Perception of the sensation. Perception relies on interpretation of the information arriving at the sensorimotor
cortex, and interpretation is highly dependent on the
psychological makeup of the person. The emotional
state, distraction, and belief of significance can influence the perception of dyspnea.
A patients perception of dyspnea may have no relation
to the patients breathing appearance. Remember, dyspnea
is subjectivea symptomand what the patient feels. A
patient may have labored and rapid breathing and deny
feeling short of breath. Conversely, a patient may appear to
be breathing comfortably and slowly but may feel breathless. You can never assume that a patient with a rapid respiratory rate is dyspneic. In addition, a patients complaint
of dyspnea must be considered a symptom of a medical
problem and must be taken seriously until proved otherwise. In fact, the onset of dyspnea may be the first clue to
identifying serious problems.
Patients perceptions of dyspnea vary greatly. A healthy
person notices the increased ventilatory demand required
to climb stairs or to exercise but expects it and does not
interpret it as unpleasant. In fact, the athlete may consider
the breathlessness occurring after a sprint to be exhilarating and even a necessary aspect of physical conditioning.
10003-HEUER-9780323100298
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p0525
o0115
o0120
p0540
p0545
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39
t0035
TABLE 3-5
TABLE 3-6
Rating
Intensity of Sensation
0
0.5
1
2
3
4
5
6
7
8
9
10
Nothing at all
Very, very mild/weak
Very mild/weak
Mild/weak
Moderate
Somewhat severe/strong
None
Slight
Moderate
Very severe/strong
Severe
Very severe
0
1
2
3
4
descriptors. This rating scale is showing particular promise in determining the severity of dyspnea in patients who
have asthma.
s0075
p0570
s0080
p0575
o0125
o0130
o0135
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40
t0040
TABLE 3-7
Clinical Types of Dyspnea
Dyspnea
Associated with
Physiologic
Pulmonary
Restrictive
Obstructive
Cardiac
Circulatory
Chemical
t0045
Central
Head injury
Cerebral lesion
Psychogenic
Pain-related dyspnea
Hysterical overbreathing
Sighing dyspnea
If space is also devoid of O2, confusion and unconsciousness may occur before
dyspnea warns of danger
Comfortable at rest
Intensely dyspneic when exertion nears patients limited breathing capacity
Increased ventilator effort
Dyspnea at rest
Breathing labored and retarded, especially during expiration
Orthopnea, paroxysmal nocturnal dyspnea, cardiac asthma, periodic respiration
Dyspnea only with exertion unless anemia is extreme
Air hunger a grave sign
Dyspnea with severe panting caused by acidosis, heart failure, pulmonary edema,
and anemia
Hyperventilation
Intense hyperventilation
Sometimes noisy and stertorous
Biot respiration
Continuous hyperventilation or deep sighing respirations at maximal depth
TABLE 3-8
Causes of Dyspnea by Body System
System
Common Causes of Dyspnea
Respiratory
Cardiac
Hematologic
Neurologic
Metabolic and
endocrine
Psychiatric
Mechanical factors
dyspnea as tightness in the chest. Patients with congestive heart failure (CHF) often describe a sensation of
suffocation or air hunger. Patients with COPD and
interstitial lung disease often complain of increased
effort to breathe, probably because of the increased work
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b0110
BOX 3-2
ACUTE DYSPNEA
Asthma*
Chest trauma
Physical exertion
Pleural effusion
Pneumonia
Pulmonary edema
Pulmonary embolism
Pulmonary hemorrhage
Spontaneous pneumothorax
Cardiac pulmonary edema
Acute interstitial lung disease (e.g., hemorrhage, ARDS)
Upper airway obstruction (e.g., aspirated foreign body,
laryngospasm)
CHRONIC DYSPNEA
(usually progressive)
Asthma*
CHF, left ventricular failure*
Cystic fibrosis
Pleural effusion
Interstitial lung diseases
Pulmonary vascular disease
Pulmonary thromboembolic disease
COPD
Severe anemia
Psychogenic dyspnea
Hypersensitivity disorders
Chest wall abnormalities (e.g., neuromuscular disease,
kyphoscoliosis, diaphragm paralysis)
*Asthma and left ventricular failure represent chronic causes of dyspnea
with paroxysmal exacerbations.
ARDS, acute respiratory distress syndrome; CHF, congestive heart failure;
COPD, chronic obstructive pulmonary disease.
their mouth and in their extremities. They may report having visual disturbances. If they continue to hyperventilate,
they may lose consciousness.
s0085 Acute and Chronic Dyspnea
p0615 Dyspnea may be acute or chronic, progressive, recur-
41
Descriptions
Patients may complain of dyspnea occurring at certain
times of the day, in association with a position, or during
a specific phase of the respiratory cycle. Inspiratory dyspnea is usually associated with upper airway obstruction,
whereas expiratory dyspnea occurs with obstruction of
smaller bronchi and bronchioles.
Paroxysmal nocturnal dyspnea (PND) is the sudden
onset of difficult breathing that occurs when a sleeping
patient is in the recumbent position. It is often associated
with coughing and is relieved when the patient assumes
an upright position. In patients with CHF, PND usually
occurs 1 to 2 hours after lying down and is caused by the
gradual transfer of fluid in the lower extremities to the
lungs.
Orthopnea is the inability to breathe when lying down.
It is often described as two- or three-pillow orthopnea,
depending on the number of pillows the patient must use
to elevate the upper portion of the body and obtain relief.
PND and orthopnea are most commonly associated with
left-sided heart failure and occur when reclining causes
fluid to collect in the lungs.
Trepopnea is dyspnea caused by lying on one side that
does not occur when the patient turns to the other side.
Trepopnea is most often associated with disorders of the
chest that occur on only one side such as unilateral lung
disease, unilateral pleural effusion, or unilateral airway
obstruction.
Platypnea, the opposite of orthopnea, is dyspnea
caused by upright posture and relieved by a recumbent
position. Orthodeoxia (ortho, positional; deoxia, decrease
of oxygen) is arterial oxygen desaturation (hypoxemia) that
is produced by assuming an upright position and relieved
by returning to a recumbent position. Orthodeoxia and
platypnea are seen in patients with right-to-left intracardiac shunts from congenital heart disease and in patients
with venous-to-arterial shunts in the lung related to severe
lung disease or chronic liver diseases such as cirrhosis.
Simply stated, when these patients are upright, there is an
increased amount of blood being shunted from the right
side of the heart to the left without being adequately oxygenated. When orthodeoxia is severe, patients experience
increasing dyspnea (platypnea) while standing. Orthodeoxia also may occur after a pneumonectomy (removal of a
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s0090
p0630
p0635
p0640
p0645
p0650
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42
t0050
TABLE 3-9
Terms Commonly Used to Describe Breathing
Medical Term
Definition
Apnea
Dyspnea
Eupnea
Bradypnea
Tachypnea
Hypopnea
Hypernea
Orthopnea
Trepopnea
Platypnea
Orthodeoxia
Hyperventilation
Hypoventilation
Air hunger
Q UESTIO NS TO A SK
b0035
Shortness of Breath
Ask the patient to describe the shortness of breath in his or her
own words; if unable to give a description, then give suggestions
of descriptive words (e.g., smothering? hard to catch your breath?
suffocating? chest tightness? hard to take a deep breath?).
What do you do when you experience breathlessness?
Can you continue to do what you were doing or do
you have to sit down or lie down? Can you continue to
speak?
Does the difficult breathing alter your normal activities
during the day? Does it make it hard for you to sleep at
night? What makes it better? What makes it worse?
Are you always short of breath or do you have attacks of
breathlessness? (The onset of dyspnea may be gradual
or sudden or intermittent.)
What relieves the attacks? Relaxing? Changing location?
Changing position? Taking medication?
Does a body position, time of day, or certain activity
affect your breathing?
Do the attacks cause your lips or nail beds to turn blue?
How many stairs can you climb or how many blocks can
you walk before you begin to feel short of breath? Do
activities like taking a shower, getting dressed, or shopping make you feel short of breath?
When you feel breathless, do you feel any other symptoms like sweating, cough, or chest discomfort?
Do you make any sounds like wheezing, whistling, or
snoring?
Does the shortness of breath seem to be getting better
or worse or staying the same?
Have you ever had exposure to asbestos? Sandblasting?
Pigeon breeding?
Have you ever been exposed to anyone with tuberculosis?
Have you started taking any new medications or has the
dose or frequency changed for current medications?
Do you have any known allergies to food, insects, or
latex? (Anaphylaxis)
Do you have any weakness in your arms or legs, difficulty speaking, or swallowing? (Neuromuscular diseases)
Do you have any numbness or tingling in your fingertips? Do you feel a sense of fear or doom? Do you have
panic attacks or anxiety disorder?
Have you ever lived near the San Joaquin Valley in
California (coccidioidomycosis) or in the Midwest or
southeastern United States (histoplasmosis)?
Chest Pain
s0095
The causes of chest pain vary greatly and can range from a p0755
self-limited orthopedic injury such as a pulled chest muscle
to much more serious conditions including cardiac ischemia (low blood supply to the myocardium) or inflammatory disorders affecting thoracic or abdominal structures or
organs. As a result, it is important to promptly and correctly
determine the cause of a patients chest pain. However,
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43
TABLE 3-10
Causes and Characteristics of Shortness of Breath
Type of
Associated
Cause
Dyspnea
Symptoms
Acute or Recurrent Dyspnea
Asthma
Acute dyspnea
Episodic
Cough indicates
asthmatic
bronchitis
Dyspnea may be
exertional and/or
worse at night
Sudden, sharp
pleuritic pain
Pneumothorax
Acute onset
Foreign-body
aspiration
Acute dyspnea
Pulmonary
emboli
Acute onset
Chest pain,
faintness, loss of
consciousness
Pulmonary
edema
Hyperventilation
and anxiety
Acute onset
Episodic
Acute dyspnea,
sighing
respiration
Dyspnea on exertion
Orthopnea, PND
Lightheaded,
palpitations,
paresthesias
(especially around
mouth and
extremities)
Poor physical
conditioning
Dyspnea on
minimal
exertion
Chronic Dyspnea
Congestive heart Chronic dyspnea
failure
with gradual
onset, PND
Chronic
bronchitis
Emphysema
Dyspnea not
necessarily
presenting
symptom
Progressive,
usually no
dyspnea at
rest
Precipitating and
Aggravating Factors
Patient
Characteristics
Allergies, noxious
fumes, exercise,
recumbency,
respiratory tract
infection
Exposure to cold or
use of certain types
of -blockers
Spontaneous, COPD,
trauma, cystic
fibrosis
Most common
cause of
recurrent
dyspnea in
children
Bilateral wheezing,
prolonged expiration
Often a prior
history of similar
episode, may be
familial
Most common in
children and
intoxicated or
semiconscious
people during
eating
Postoperative,
phlebitis,
postpartum,
arrhythmia
(atrial fibrillation
and flutter)
Decreased or absent
breath sounds
Tracheal shift if tension
pneumothorax
Tachypnea, inspiratory
stridor, localized or
unilateral wheeze,
suprasternal
retraction with
respiration
Tachypnea, crackles,
low blood pressure,
wheezing pleural
friction rub
Prolonged
recumbency;
women using
birth control pills,
especially those
who smoke
Stress panic
Usually anxious
Obese, physically
inactive
Edema, dyspnea
Exercise, recumbency, Older patients,
nocturnal
remains long after
trauma, anesthesia,
dyspnea relieved
exercise is stopped
shock, hemorrhage,
by sitting
calcium channel
blockers or
-blockers
Persistent,
productive cough
Infection, exertion
Overweight
Weak cough
Exertion
Malnourished
AP, anteroposterior; COPD, chronic obstructive pulmonary disease; PND, paroxysmal nocturnal dyspnea.
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uncovering the root cause can be challenging for many reasons, including the complexity of the nerve structure of the
chest, which can result in pain from other locations being
referred to the chest and pain from the chest being referred
to other sites. For example, pain from indigestion is often
referred to the chest. Pain from a dissecting aneurysm of the
thoracic aorta may start just below the sternum (anterior
substernal location) but then migrates or tears toward the
back. Despite such challenges, by investigating the characteristics of a patients chest pain, the RT can assist in making a correct diagnosis and optimizing patient care.
p0760
Chest pain can also occur from musculoskeletal disorders, trauma, drug therapy, indigestion, and anxiety. It can
range in character from sharp or stabbing to a vague feeling of heaviness or discomfort. It may be steady or intermittent, mild or acute. It may be caused or aggravated by stress,
exertion, deep breathing, coughing, moving, or eating certain foods. The precise cause of chest pain cannot always be
determined by taking a history, but it is usually possible to
determine whether the origin is from the chest wall, the pleurae, or viscera and whether emergency care is needed. History
taking and the patient interview are key to evaluating chest pain.
For example, chest pain is the cardinal symptom of
p0765
heart disease. In its classic presentation, a patient may
report viselike chest pain radiating down the arms, most
often the left, which may spread to the shoulders, neck,
jaw, or back. This type of chest pain is known as angina
and signals a medical emergency. Intervention to open a
clogged coronary artery and reestablish blood flow to the
heart muscle should occur within about 90 minutes from
the onset of pain, or else irreversible damage to the heart
muscle is likely. Unfortunately, not all heart pain presents
with this classic picture. In fact, in some people, there is
only a weak relationship between the severity of the chest
pain and the importance of the underlying cause. Therefore, all chest pain must be taken seriously.
b0040
SIMPLY STATED
Cardiac chest pain in men is most often located in the
center of the chest and may radiate to the arm, jaw, or
back; in women, it is located across the center of the chest,
may radiate to the back and down the legs, and may be
accompanied by nausea and dizziness.
p0775
structures) causes aching, oppressive retrosternal sensations that may be severe. Chronic disorders of the large airway, such as tracheal or bronchial tumors or ulcers, usually
do not cause pain. But the inflammation of tracheobronchitis may induce substernal discomfort that changes to a
tearing, rasping, and sharp substernal pain with coughing.
Pleuritic pain, often described as inspiratory pain, is the p0785
most common symptom of disease causing inflammation
of the pleura (pleurisy). It is sharp, often abrupt in onset,
and severe enough to cause the patient to seek medical
help (often within hours of onset). It increases with inspiration, a cough, a sneeze, a hiccup, or laughing. Pleuritic
pain is usually localized to one side of the chest, frequently
the lower, lateral aspect. It may be only partially relieved by
splinting and pain medication. Pleuritic pain increases with
pressure and movement but not to the same degree as pain
originating from the outer chest wall. In contrast, the lung
parenchyma and the visceral pleura that cover the lungs are
relatively insensitive to pain; therefore, pain with breathing
usually indicates involvement of the parietal pleura.
Chest wall pain may originate from the intercostal and p0790
pectoral muscles, ribs, and cartilages or from stimulation
of a neural pathway (neuralgia) anywhere along a dermatome (skin area innervated by a particular spinal cord segment). It is usually described as a well-localized, constant
aching soreness that increases with direct pressure on
the area of tenderness and with any arm movement that
stretches the thoracic muscles.
Descriptions
s0105
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45
TABLE 3-11
Causes and Characteristics of Chest Pain
Condition
Location and Characteristics
Chest Wall Pain
Myalgia
Dermatome distribution
Superficial tingling to deep burning
pain
Etiology/Precipitating Factors
Associated Findings
Tumors
Sharp, tearing
Sudden onset
Increased by inspiration
May be localized or diffuse
Constant, sharp, boring, or dull
Pulmonary
hypertension
(primary)
Cardiac Pain
Angina pectoris
Myocardial
infarction
Pericardial pain
Unknown
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46
TABLE 3-11
Causes and Characteristics of Chest Paincontd
Condition
Location and Characteristics
Mediastinal Pain
Esophageal
Dissecting aortic
aneurysm
Tracheobronchitis
Other causes
Etiology/Precipitating Factors
Associated Findings
Esophagitis aggravated by
bending over, lying down,
smoking, ingestion of coffee,
fats, large meals
Esophageal spasm
Esophageal tear
Hyperventilation syndrome
b0045
Hematemesis, shock
QU E S T ION S TO AS K
Chest Pain
Ask the patient the following questions to help obtain an accurate and impartial history:
Where is the pain?
Did the pain start suddenly or gradually? Is it more severe now than when it started?
Have you ever had a pain like this before? What did you do to relieve the pain? Did you take medication to relieve the pain?
What medicine did you take?
How would you describe the pain? (Let the patient describe the character of the pain in his or her own words; if unable to
give a description, then use suggestions of descriptive words.) Would you describe the pain as aching? Throbbing? Knifelike?
Sharp? Constricting? Sticking? Burning? Dull? Shooting? Tearing?
Can you rate your pain on a scale of 0 to 10, with 10 being the worst pain you have ever felt?
How long have you had the pain?
Do you have recurrent episodes of pain? How often do you get the pain? How long does the pain last?
What makes the pain worse? Breathing? Lying flat? Moving your arms or neck?
Is the pain associated with coughing? Shortness of breath? Palpitations? Coughing up blood? Nausea or vomiting? Leg pain?
Dizziness? Weakness? Headache? Muscle fatigue?
Does the pain occur at rest? Exercise? While sleeping? With stress? After eating?
What do you do to make it better?
Have you ever had a heart attack? Has anyone in your family had heart disease? At what age?
Have you had a recent respiratory infection? Do you have pulmonary disease?
Have you had trauma to your chest? A hip or leg fracture? Been involved in an accident?
What medications are you taking? Have you recently changed the dose or how you take them?
Do you take any other type of legal or illegal drugs? If so, what are the drugs, how much and and how often do you take such
drugs?
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s0115
BOX 3-3
Definition
Causes of Syncope
47
b0115
hypotension. Elderly patients are more prone to orthostatic hypotension because of dehydration.
Carotid sinus syncope is associated with a hypersensi- p0920
tive carotid sinus and is seen more commonly in elderly
people. Whenever a patient with carotid sinus syncope
wears a tight shirt collar or turns the neck in a certain way,
there is an increased stimulation of the carotid sinus. This
slows the pulse rate and causes a sudden fall in systemic
pressure, resulting in syncope.
Cough (tussive) syncope is the transient loss of con- p0925
sciousness after severe coughing. It occurs most commonly
in middle-aged men with underlying COPD who are outgoing and moderately obese and have a great appetite for
food, alcohol, and smoking. It rarely occurs in women. The
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48
cough may be chronic and is usually dry and unproductive. Typically, there is a tickle in the patients throat
precipitating a coughing paroxysm; then the patients face
becomes red, vision dims, the eyes become fixed, and the
patient suddenly loses consciousness. The attacks usually
last only a few seconds, but the patient may fall or slump
in a chair as the muscles relax completely. Some patients
have reported more than 20 episodes a day. Cough syncope
is usually a benign symptom, and patients return to their
previous activity with little recall of the episode. However,
deaths and serious injury have been reported when the syncope occurred while driving.
s0125 Descriptions
p0930 A precise description of the syncopal event should include
b0050
QU E S T ION S TO AS K
Dizziness and Fainting
Ask the patient the following questions to help obtain an accurate
and impartial history:
What do you mean when you say you were dizzy? Felt
faint? Did you lose consciousness?
What were you doing just before you fainted? Did you
have any warning that you were going to faint?
Have you had recurrent fainting spells? If so, how often
do you have these attacks?
What position were you in when you fainted?
Was the fainting preceded by any other symptom? Nausea? Chest pain? Palpitations? Confusion? Numbness?
Hunger? Cough?
s0130
s0135
Causes
s0140
Descriptions
s0145
Patients may report that when they press on their swollen p0985
ankles or when they remove their shoes and socks, they
notice a depression that remains in place for at least several
minutes. When compression of an edematous area produces a depression that does not fill immediately, pitting
edema is present. In the medical history, pitting edema
is usually described in general terms such as the patient
denies pitting edema or the patient reports pitting edema
in both ankles that remains for at least 5 minutes after leg
elevation. When the history and physical examination are
reported together, pitting edema may be recorded using
the scale shown in Table 3-12.
Peripheral edema is a sign and a symptom. The exam- p0990
iner may find edematous ankles that the patient had not
noticed. The presence of edema is such an important
factor that the history of the edema should be traced.
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publication.
TABLE 3-13
1+ Trace
2+ Mild
3+ Moderate
4+ Severe
Rapid
10-15 sec
1-2 min
>2 min
Fever, pyrexia
High-grade fever
Low-grade fever
Intermittent fever
Remittent fever
Precipitating and alleviating factors and associated symptoms should be documented with the history of present
illness.
b0055
QU E S T ION S TO AS K
Swelling of the Ankles
Ask the patient the following questions to help obtain an accurate
and impartial history:
When did you first notice the swelling? Where else does
it occur?
Does it occur only when you have been standing or sitting for a long time? Or is it present when you first get
up in the morning? How does it change throughout the
day?
If you press on the swelling, does it leave a fingerprint in
the tissue? How long does the indentation remain?
What happens to the swelling when you sit with your
legs elevated?
What makes it worse? What makes it better?
Is the swelling associated with any other activities such
as exercise or when you eat food that has a lot of salt?
Do you have any other symptoms when you have the
swelling? [use the following suggestive cues when the
patient is unable to answer] Like cough? Difficulty
breathing? Pain?
s0150
t0070
TABLE 3-12
Slight
0-0.6 cm (0- in)
0.6-1.3 cm (- in)
>1.3 cm (> in)
temperature above the normal range resulting from disease. Fever may be described as sustained (continuously
Relapsing fever
Hyperthermia
Mild hyperthermia
Moderate
hyperthermia
Critical hyperthermia
Malignant
hyperthermia
Fever of unknown
origin (FUO)
Hypothermia
49
Causes
s0160
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50
t0075
TABLE 3-14
Common Causes and Characteristics of Fever
Type
Nature of Fever/Patient
Associated Symptoms
Clinical Findings
Acute
Upper Respiratory Infection (URI)
Viral
Usually <101.5F orally
Any age
Bacterial
Often high temperature, >101 F
More common in children
Oropharynx infected
Exposure to URI
Pharyngotonsillar exudates
Pulmonary findings
Children are restless
Muscle aches
Minimal
Drug reaction
Chronic
Infectious
Usually low grade
mononucleosis Teenagers, young adults
Tuberculosis
Hepatitis
s0165
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QU E S T ION S TO AS K
Fever, Chills, and Night Sweats
Ask the patient the following questions to help obtain an accurate
and impartial history:
How long have you had fever? How did you measure
your temperature? What readings did you get?
Has there been any pattern to the fever? Did it start
gradually or suddenly? Did it rise, then disappear, then
reappear?
Have you had other symptoms with the fever such as
chills, headache, fatigue, cough, diarrhea, or pain?
Has your neck felt swollen? Have you had a sore throat
or earache?
Do you have pain when you take a deep breath or
cough? Where is the pain?
Have you had an infection recently? Can you recall a recent
exposure to someone who may have had an infection?
Have you had a recent wound? How did it heal? Is the
area still painful?
Have you traveled to an area where you may have been
bitten by a tick? Insect? Spider? Animal?
Have you been exposed to high temperatures for a prolonged period of time such as playing sports or working
out in the heat? How long were you out in the heat?
How much water did you drink while you were working
or playing?
Have you had any unusual physical or emotional stress
lately? Injury? Anesthetic? Surgery? Blood transfusion?
Have you taken any new medications in the last few weeks?
Are you taking thyroid medication? Antidepressants?
Amphetamines or diet pills? Medications that keep
you from sweating, such as anticholinergics, phenothiazines, monamine oxidase (MAO) inhibitors?
Have you ever been told that you have pneumonia?
HIV? Cancer?
51
SIMPLY STATED
b0065
s0170
b0070
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52
s0175
SIMPLY STATED
Clinical Presentation
Patients who snore and who have OSA or sleep disordered p1225
breathing will complain of excessive daytime somnolence
(sleepiness) (EDS). If EDS is not present in the patient who
snores, the snoring may be relevant only to the spouse or
significant other. The EDS associated with OSA is related
to the poor quality of sleep that occurs. Upper airway narrowing increases with the effort to breathe and eventually
results in total obstruction and apnea. The apnea continues until the patient arouses somewhat (fragmenting
the sleep), and the upper airway muscle tone increases in
response to the arousal. The patient then is able to breathe
until the deeper stage of sleep returns and the pattern
cycles again. These cycles may occur hundreds of times
each night of sleep. The result is a night of poor-quality
sleep in which the deeper stages are not sustained. The
patient awakens feeling fatigued and experiences EDS.
EDS often results in serious consequences, such as occu- p1230
pational accidents, motor vehicle crashes, loss of employment, and social dysfunction. In many cases, there is no
association made between daytime sleepiness and snoring
by the patient, the family, or the patients family physician.
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SIMPLY STATED
Patients with loud snoring and excessive daytime sleepiness
should be evaluated for obstructive sleep apnea (OSA).
s0190
Gastroesophageal Reflux
b0085
KEY POINTS
53
KEY POINTScontd
Orthopnea is present when the patient complains of shortness of breath when lying down.
Chest pain is the cardinal symptom of heart disease. In its
classic presentation, the viselike pain of a heart attack is
referred down the arms, most often the left, and may radiate
into the shoulder, neck, jaw, or back. This type of chest pain is
known as angina and signals a medical emergency.
Syncope is a temporary loss of consciousness caused by
reduced blood flow and therefore a reduced supply of oxygen and nutrients to the brain.
Cough (tussive) syncope is the transient loss of consciousness following severe coughing.
Bilateral peripheral or dependent edema suggests pulmonary hypertension, heart failure, or venous insufficiency.
Fever (hyperthermia, pyrexia) is an elevation of body temperature above the normal range resulting from disease.
Patients with snoring and sleep disordered breathing will
complain of EDS.
CASE STUDY
A 66-year-old woman is brought to the emergency
department (ED) complaining of rapid onset of SOB,
stating, I cannot catch my breath. She also admits to
coughing up a tablespoon of yellowish sputum every 30
minutes to 1 hour, sweating, and feeling warm, although
she has not taken her temperature.
Questions
Answers
1. The interviewer should ask the patient if she has chest
pain, nausea, dizziness, or blood in her sputum, or a
history of lung disease or cigarette smoking.
2. The pulmonary problems suggested at this point
include pneumonia, acute bronchitis, asthma, and
acute exacerbation of COPD.
3. The sweating is significant because it is consistent with
a fever that may be caused by an infection. If a fever is
present, it may be contributing to the patients SOB
because of an increase in oxygen consumption and an
increase in the drive to breathe.
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54
CASE STUDY
b0095
Questions
1. What questions should the interviewer ask the patient
about his chest pain?
2. What other symptoms should the interviewer ask the
patient about?
3. What clinical problems may explain the chest pain?
Answers
1. The interviewer should ask the patient to point to the
position of the chest pain on his chest. The patient
should also be asked to describe the characteristics of
the chest pain; if it radiates to the jaw, shoulder, or back;
and if it increases with a deep breath.
2. The patient should be asked about nausea, fever, pedal
edema, shortness of breath, cough, and dizziness. The
patients smoking history is important to obtain at
some point.
3. If the patient has pain in the center of his chest that
radiates to his shoulder or jaw and is accompanied by
nausea and/or dizziness, it would be consistent with
myocardial ischemia, and the patient may be having a
heart attack. If the pain is sharp and located peripherally
on the chest, the pain may be related to pleural disease
or lung infection.
CASE STUDY
b0100
Questions
1. What questions should the interviewer ask of the patient
about his condition?
2. What clinical problems may explain the daytime
sleepiness?
3. What further studies would you recommend?
Answers
1. The interviewer should ask if the patient believes he fell
asleep while driving. Beyond this and more importantly,
the patient should be asked about alternations in
sleeping habits or medications, day-time sleepiness, and
other changes, such as difficulty concentrating.
ASSESSMENT QUESTIONS
See Appendix A for answers.
1. Which of the following factors may lead to a weak
cough?
a. Reduced lung recoil
b. Bronchospasm
c. Weak inspiratory muscles
d. All of the above
2. A cough described as being persistent for more
than 3 weeks would be called which of the
following?
a. Acute
b. Paroxysmal
c. Chronic
d. Nocturnal
3. Which of the following problems is associated with
hemoptysis?
a. Tuberculosis
b. Lung carcinoma
c. Pneumonia
d. All of the above
4. A patients complaint of breathlessness or air hunger
would be defined as which of the following?
a. Hemoptysis
b. Wheezing
c. Dyspnea
d. Cyanosis
5. What term is used to describe shortness of breath in
the upright position?
a. Orthopnea
b. Platypnea
c. Eupnea
d. Apnea
6. Which of the following is least associated with causing
dyspnea?
a. An increase in the work of breathing
b. A decrease in the ventilatory capacity
c. An increase in the drive to breathe
d. An increase in lung compliance
7. What term is used to describe difficult breathing in
the reclining position?
a. Apnea
b. Platypnea
c. Orthopnea
d. Eupnea
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s0195
u0635
o0230
o0235
o0240
o0245
o0250
o0255
o0260
o0265
o0270
o0275
o0280
o0285
o0290
o0295
o0300
o0305
o0310
o0315
o0320
o0325
o0330
o0335
o0340
o0345
o0350
o0355
o0360
o0365
o0370
o0375
o0380
o0385
o0390
o0395
o0400
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55
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