INVESTIGATING RESPIRATORY DISEASES--22�

(Basic Respiratory Tract Functional Anatomy Done)

By Dr Danjuma Sulai, OON

MB BS, MSc. Com Hlth(Lon), FRCP(Lon),FMCP(Nig)

COMMON SYMPTOMS OF RESPIRATORY DISEASE

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Major

• Cough
• Chest pains
• Difficulty in Breathing

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Minor

• Sore Throat
• Recurrent Catarrh, sneezing
• Snoring
• Change in voice

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General

• Fevers
• Weight Loss/Gain

Clinical History

• Detailed Clinical History Vital
• Onset, Duration, Severity
• Recurrence
• Be detailed on the symptom in terms of Site, variation, Aggravating and relieving factors

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• Determine Exposure History
• Previous related ill health
• Current Medications
• Recent Contact with the Sick
• Recent hospitalizations, travels
• The level of inactivity etc
• Occupation

3. Medical History

• Previous related ill health
• Current medications
• Recent hospitalizations
• Recent travels
• Level of activity

CLINICAL EXAMINATION

1. General outlook
1. Level of distress (unable to speak in sentences ).Accessory muscles use
2. Wasting, Obesity, Anaemia, Central Cyanosis
3. Finger Clubbing, Oedema, pyrexia
4. Blood pressure, Kyphosis, Scoliosis
5. Noisy ventilation, Types of Resp.
6. Chest movement symmetry/asymmetry

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CLINICAL EXAM contd

2. Inspection and localization of areas of pain, swelling, discomfort, etc.

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3. From the symptoms and general examination do mental classification of possible site:-

URT-nostrils, paranasal sinuses, pharynx, larynx, trachea

LRT ie (Pulmonary) –tract and or parenchyma would have started to emerge

CLINICAL EXAM cntd.

3a. URT

• Inspection of the Nostrils, Pharynx, the inside

ears

Use of torch, Spatula, Auroscope, nasal Speculum etc Mandatory

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• For Larynx, Glotis and Epiglottis use of Laryngo

scope (requires more skills, therefore ENT Clinic)

• Therefore Tonsils, Uvula, Adenoids, Pharynx, Nasal turbinates, Ear drums examined.

3b. LRT (Pulmonary, pleura)

On Exam Couch in most Comfortable position for the patient do check…

• Chest expansion as inspiration done. Symmetry; in drawing of xiphisternum and inter-costal spaces. Crico-sternal notch narrow
• Determine tracheal deviation and apex shift

JVP, Odema-Legs and Sacrum

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• Percussion (Front and Especially Back) Resonance, Hyper-resonance, Dullness, reduced resonance
• Palpate liver Surface and edge
• Where Dull do Tactile and vocal fremetus
• Auscultation for Breath sounds(BS) with mouth semi –open Breathing in and out. Normal and Deep Breath, may ask to cough

(Note normal BS, added BS like Crepts, Rhonci Diminished/Absent BS) , Enhanced BS like Bronchial BS, Tubular/Amphoteric

Clinical Impression-Diagnosis

• The Mental analysis of the symptoms, clinical history, the signs elicited will enable you arrive at your clinical impression/diagnosis

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However you will contend with differential diagnosis for: Infection;- Microbes-,type of Pathology in the;:- Resp. tract, Pleura, Interstitium, the Cage; Cause of Obstruction, Consolidation, Fibrosis ,Fluids in pleura, interstitium etc.

INVESTIGATION TESTS

• To Refine the Diagnosis (ie Reduce Differential Diagnosis to Zero)

5.1. Bed- Side/Side-lab

• Inspect the Sputum pot content- Its Nature, Color, Consistency, Volume ,odour
• Grams,-Rods Cocci ,Diplo,Cluster,Strands. ZN Stains
• Urine Protein
• Pulse oxymeter measure pO2
• Peak Flow metre(PEFR)-- changes with Bronchodilator Inhalation ie Reversability Test5.
• 5.1a. Full Blood Count--ESR

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5.2. Radiological

• Chest x-Ray, Basic PA and Lateral will show Lungs and Mediastinum and Pleura
• Do have an idea of what you are looking out for..

a. eg High BP, Cough……………………….

b. Purulent Sputum, Fever…………………….

c. Painful Rt Chest, RTA, Dyspnoea………………………

d. Apex normal position, Trachea Shift to RT with reduced resonance on the RT upper zone…………………………..

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e Incidental.

Rounded Shadows with/ without Cavity

f. Hyper inflated/resonance ……………

g. Reduce Chest space with gurgling Noise on auscultation……………………..

h. Lymphadenopathy hilar and weight

loss……………………

i. Post surgery, Bed ridden,

Acute Breathlessness……………….

2. CAT/MRI

High resolution details in Fibrosing

alveolitis (Cryptogenic, Allergic..organic and inorganic causes)

Lymph nodes, Tumor

Bronchiectasis

PET CAT enhances resolution -for staging and early diagnosis of Ca. and follow up eg larynx, fibrosis on Rx

5.3 Laryngoscopy

the Vocal cords, Epiglottis visualized. Paralysis Hemi/Bilat, Inflamned/ Growth--Polyps

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5.4 Bronchoscopy (Fibroptic)

visualizes trachea, Bronchi

for Tumor, Foreign Body, Mucus Plug,

Taking tissue biopsy for histology; aspirate for cytopathology, culture ,special stains microscopy, ,Gene- expert

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5.5 Blood Gas Analysis

pO2, pCO2, Serum Bicarbonate, pH ie >than pulse oxymetry

Checks Falling and Rising Value

5.6 Spirometry (Lungs Function Test)

Vitalograph

Peak Flow Meter-PEFR

FEV 1, FVC, FEV1/VC, CO Transfer Factor

5.7 Reversability Test

5.8 Allergens Sensitivity Skin Test

Inhalation Challenge

5.9 Body Plethysmograph

5.8 Micro Biological/Histology

i. Sputum –

Microscopy-basic/special stains, Culture, Virus, Fungi, Gene-expert

ii. Pleural Aspirate

Biochem, Microscopy/ Histology, Culture

iii. Biopsy – Needle/open,Bronchoscopic, Culture

and histology

iv. Serological Test

Microbes , immune factors eg Precipitins (pigeons Birds Farmers Organic Allergic Alveolitis, SLE, RH Factor

ii FBC incl.Diff, ESR

5.9 Miscellaneous Tests

a. Ventilation Perfusion Isotope Scan –V/Q

a2. Carbon Monoxide Transfer Factor

b. ECG-12Lead, Exercise, Ambulatory/Hotler

c.Ultrasound Scan

c. Angiography, Venography