Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 
Next
Diseases » Whooping Cough » Tests
 

Diagnostic Tests for Whooping Cough

Contents
  1. Whooping Cough: Introduction
  2. Symptoms of Whooping Cough
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Failure to Diagnose
  6. Alternative Diagnoses
  7. Misdiagnosis
  8. Complications

Whooping Cough Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Whooping Cough:

Whooping Cough Diagnosis: Book Excerpts

Diagnosis of Whooping Cough: medical news summaries:

The following medical news items are relevant to diagnosis of Whooping Cough:

Diagnostic Tests for Whooping Cough: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Whooping Cough.

COUGH: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.

Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H 2 antagonist may also be diagnostic.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

STRIDOR: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests may include a CBC; sedimentation rate; smear and culture of material from the nose, throat, and sputum; x-ray of the chest and sinuses; and, in adults, an EKG. In adults also it might be wise to order a chemistry panel, thyroid profile, and VDRL test, depending on the clinical picture. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. In addition, fiberoptic bronchoscopy may be valuable. A Tensilon test may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. If there are neurologic signs, a neurologist should be consulted.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

WHEEZING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The CBC, sedimentation rate, chest x-ray, EKG, sputum analysis and culture, and pulmonary function testing will usually assist with the clinical diagnosis. Bronchoscopy may be needed also, especially when there is hemoptysis .

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Cough, barking: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, nonproductive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed;  anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as a cough. Ask the patient at risk for TB — one born in another country, in contact with acute TB, or with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Cough, productive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes. (See Productive cough: Common causes and associated findings, page 168.)

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Stridor: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Wheezing [Sibilant rhonchi]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 599.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds.)  

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Introduction: Respiratory Disorders: Assessment
(Professional Guide to Diseases (Eighth Edition))

Assessment of the respiratory system begins with a thorough patient history. Ask the patient to describe his respiratory problem. How long has he had it? How long does each attack last? Does one attack differ from another? Does any activity in particular bring on an attack or make it worse? What relieves the symptoms? Always ask whether the patient was or is a smoker, what and how often he smoked or smokes, and how long he smoked or has been smoking. Record this information in “pack years”—the number of packs of cigarettes per day multiplied by the number of smoking years. Remember to ask about the patient’s occupation, hobbies, and travel; some of these activities may involve exposure to toxic or allergenic substances.

If the patient has dyspnea, ask if it occurs during activity or at rest. What position is the patient in when dyspnea occurs? How far can he walk? How many flights of stairs can he climb? Has his exercise tolerance been decreasing? Can he relate dyspnea to allergies or environmental conditions? Does it occur only at night, during sleep? If the patient has a cough, ask about its severity, persistence, and duration; ask if it produces sputum and, if so, what kind. Have the patient’s cough habits and character of sputum changed recently?

Physical examination

Use inspection skills to check for clues to respiratory disease, beginning with the patient’s general appearance. If he’s frail or cachectic, he may have a chronic disease that has impaired his appetite. If he’s diaphoretic, restless, or irritable or protective of a painful body part, he may be in acute distress. Also, look for behavior changes that may indicate hypoxemia or hypercapnia. Confusion, lethargy, bizarre behavior, or quiet sleep from which he can’t be aroused may point to hypercapnia. Watch for marked cyanosis, indicated by bluish or ashen skin (usually best seen on the lips, tongue, earlobes, and nail beds), which may be due to hypoxemia or poor tissue perfusion.

Assess chest shape and symmetry at rest and during ventilation. Increased anteroposterior diameter (“barrel chest”) characterizes emphysema. Kyphoscoliosis also alters chest configuration, which in turn restricts breathing. Assess respiratory excursion and observe for accessory muscle use during breathing. The use of upper chest and neck muscles is normal only during physical stress.

Observe the rate and pattern of breathing because certain disorders produce characteristic changes in breathing patterns. For example, an acute respiratory disorder can produce tachypnea (rapid, shallow breathing) or hyperpnea (increased rate and depth of breathing); intracranial lesions can produce Cheyne-Stokes and Biot’s respirations; increased intracranial pressure can result in central hyperventilation and apneustic or ataxic breathing; metabolic disorders can cause Kussmaul’s respirations; and airway obstruction can lead to prolonged forceful expiration and pursed-lip breathing.

Also observe posture and carriage. A patient with COPD, for example, usually supports rib cage movement by placing his arms on the sides of a chair to increase expansion and leans forward during exhalation to help expel air.

Palpation of the chest wall detects areas of tenderness, masses, changes in fremitus (palpable vocal vibrations), or crepitus (air in subcutaneous tissues). To assess chest excursion and symmetry, place your hands in a horizontal position, bilaterally on the posterior chest, with your thumbs pressed lightly against the spine, creating folds in the skin. As the patient takes a deep breath, your thumbs should move quickly and equally away from the spine. Repeat this with your hands placed anteriorly, at the costal margins (lower lobes) and clavicles (apices). Unequal movement indicates differences in expansion, seen in atelectasis, diaphragm or chest wall muscle disease, or splinting due to pain.

Percussion should detect resonance over lung fields that aren’t covered by bony structures or the heart. A dull sound on percussion may mean consolidation or pleural disease. (See Characterizing and interpreting percussion sounds.)

Auscultation normally detects soft, vesicular breath sounds throughout most of the lung fields. Absent or adventitious breath sounds may indicate fluid in small airways or interstitial lung disease (crackles), secretions in moderate and large airways (rhonchi), and airflow obstruction (wheezes).

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Cough, barking: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, nonproductive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when his cough began and whether any body position, time of day, or specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has any pain associated with coughing, breathing, or activity, when did it begin and where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also ask about recent changes in his appetite, weight, exercise tolerance, or energy level; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

Cultural Cue: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB—those born in another country, those in contact with acute TB, and those with high-risk behaviors—about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note wheezing or “crowing” noises that occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough, productive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Stridor: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Wheezing [Sibilant rhonchi]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma and recent changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a specimen for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 766.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds. See also Differential diagnosis: Wheezing, pages 826 and 827.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Cough: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

 B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

Testing

A. Clinical laboratory tests. Most acute presentations of cough do not require blood, urine, or other laboratory tests. White blood count with differential and blood cultures are indicated for pneumonia. Gram’s stain and culture of sputum are rarely practical in the office. A purified protein derivative (PPD) test should be placed early if TB is suspected, unless the patient is known to be anergic or thought to have overwhelming active TB disease. Systemic causes require testing specific to the disease in question.

B. Radiologic tests. A chest x-ray study is not indicated for upper respiratory causes or bronchitis. It is only useful when pneumonia, TB, COPD, CHF, or cancer (primary or metastatic) are being considered. Computed tomography of the sinuses is more sensitive and specific than PE to differentiate sinusitis from other causes of cough.

C. Pulmonary function tests. The simple peak flow meter used with a therapeutic trial of bronchodilators will identify most cases of asthma. This important test should be supervised by the physician or an experienced nurse. Additional testing is suggested for COPD and pulmonary fibrosis.

D. Invasive tests. Bronchoscopy is useful for foreign body aspiration, cancer, or chronic interstitial lung disease. Esophageal pH monitoring will most likely confirm suspected GERD.

Diagnostic assessment

A thorough history is vital to accurate diagnosis. Acute cough is likely to be infectious. A pertinent observation is that physicians overtreat acute bronchitis with antibiotics. The literature suggests that most cases are viral in origin and antibiotics are ineffective. Chronic cough has a longer list of differential diagnoses. Asthma tends to be underdiagnosed in adults and children. Smoking-related causes should prompt educational intervention and workup, especially in older patients. GERD is a diagnosis often missed because it is not considered. Often, more than one office visit is needed to unravel the cause of chronic cough. Up to 80% of cases have multiple causes (5). Making an accurate diagnosis is essential to successful treatment. Of cough presentation, 90% can be adequately managed in the family physician’s office, although it can take 3 to 5 months to arrive at a correct diagnosis in some cases (2). Referral to a pulmonary specialist is needed only in complicated cases (e.g., cancer, occupational and connective tissue diseases, and failed therapy).


References

1. Weiss BD. 20 common problems in primary care. New York: McGraw-Hill, 1999.

2. Lawler WR. An office approach to the diagnosis of chronic cough. Am Fam Physician 1998;58(9):2015–2022.

3. Heath JM. Chronic bronchitis: primary care management. Am Fam Physician 1998;57(10):2365–2372, 2376–2378.

4. Irwin RS. Managing cough as a defense mechanism and as a symptom. A consensus report of the American College of Chest Physicians. Chest 1998;114:133S–181S.

5. Irwin RS. Silencing chronic cough. Hosp Pract 1999;34:53–60.>

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Stridor: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Focused physical examination (PE)

1. The PE should include vital signs, notably temperature and respiratory rate, and pulse, with emphasis on general appearance and examination of the head and neck, including ears, nose, and throat.

2. Signs of respiratory distress may be present, including dyspnea, tachypnea, chest retractions, nasal flaring, and stridor. If cyanosis is present, this is an ominous sign (2,4) (Chapter 8.2).

B. Additional physical examination may reveal:

1. A toxic-appearing child with high fever, drooling, severe respiratory distress, and preference for a sitting and forward-leaning position (1,4)

2. Varying degrees of anxiety, which will increase during examination, cause a worsening of stridor (1,4)

Testing

A. The best test is a lateral neck x-ray study to assist with a diagnosis that is mostly made on clinical grounds. Films of the larynx and trachea in anteroposterior and lateral neck views may show narrowing of the trachea or extrinsic pressure on the tracheobronchial airway. Acutely, lateral neck radiographs showing the classic swollen glottis described by some as a thumbprint, assist with the diagnosis of acute supraglottitis and eminent respiratory collapse. Chest x-ray studies are of little value. Films showing hyperinflation or bronchial thickening may help to make a diagnosis of asthma rather than stridor. Additionally, foreign body aspiration or mass will be elucidated in x-ray studies (2).

B. Tomograms or computed tomography (CT) of the neck may provide additional information, especially in chronic stridor (2).

C. Blood tests (e.g., complete blood count) can be useful in the acutely ill patient, especially if viral or bacterial infection is suspected.

D. With suspicion that the stridor is a result of a laryngomalacia or laryngeal lesions such as papilloma, direct laryngoscopy is the test of choice for accurate diagnosis. Direct observation via fiberoptic bronchoscope positioned in the pharynx would provide diagnostic views of the larynx (2,4).

Diagnostic assessment

In making the diagnosis of stridor, two key elements exist: acute onset in a toxic-appearing patient, versus chronic stridor in a relatively stable patient.

A. Acute stridor

 1. The most likely cause of acute stridor in the febrile child with the additional features of barking cough and antecedent coryza is laryngotracheobronchitis or croup. Acute stridor is a non–life-threatening condition accounting for 90% of stridor cases. Classically, it improves with exposure to moist air. It has a viral cause, usually from one of the following: respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza virus, and influenza virus. Generally, this diagnosis is made on clinical grounds (1). The child is less ill and, although often febrile, not toxic appearing. The entire illness usually abates in 5 days. Hospitalization, unlike with epiglottitis, is rarely needed (2).

2. In the toxic patient with fever, respiratory distress, sore throat, or drooling, especially in the younger age group, consider epiglottitis—a medical emergency. As use of the Haemophilus influenzae vaccine has increased in recent years, acute epiglottis is becoming increasingly rare. H. influenzae is the most common bacterial cause of stridor, although streptococcus, staphylococcus and viral agents are also possible causes.

 3. The patient with a history of suspected foreign body aspiration will have similar symptoms without fever. Foreign body aspiration is common in the 1- to 2-year age groups, although it does occur in adults. It can be a cause of chronic stridor (3).

 4. Additionally, an acute allergic reaction can cause stridor. The history should herald a possible offending agent and, although respiratory collapse may be eminent, the patient will not be toxic, as no infectious agent is involved.

 5. Trauma can also cause laryngeal damage; however, the history will assist with this diagnosis.

 B. Chronic stridor. For the most part, these causes of stridor occur in early childhood. With the exception of laryngeal papillomas, tumors, and subglottic stenosis after instrumentation as in intubation (there is a congenital form also), foreign body aspiration with partial obstruction and hysterical stridor can occur at any age. Laryngomalacia and laryngeal lesions are caused by webs, hemangiomas, and cysts; they are usually identified early in life (1–3).


References

1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–112.

2. Behrman RE, Kliegman RM, Arvin AM. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1996:241, 1173, 1198, 1238.

3. Behrman RE, Vaughan VC. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1983:1031–1032, 1076–1077.

4. Tintinalli JE, Ruiz E, Krome RL. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 1996:247–251.

5. Campbell AGM, MacIntosh N. Textbook of pediatrics. London: Pearson Ltd., 1998:
508–513, 563.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Wheezing: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Vital signs. A full set of vital signs is essential to the assessment of the wheezing patient. The respiratory rate and the pulse are a more objective, and often more accurate, assessment of the severity of wheezing than the auditory volume of the wheezing itself. Fever suggests a concurrent respiratory infection. Hypotension is an ominous sign that points to a decompensating patient.

 B. Lung examination. During auscultation, note the location, intensity, and duration of wheezing. Wheezing caused by asthma, chronic obstructive pulmonary disease (COPD), or interstitial disease should be diffuse and symmetric and present during expiration. The expiratory phase will be prolonged. Focal obstruction (e.g., tumors and foreign bodies) can give asymmetric findings and inspiratory wheezing. Mucus plugging will change with cough. Rhonchi and crackles suggest a concurrent infectious process. Percussion and egophony can be present with consolidation.

Testing

A. Pulmonary function. A peak flow meter is a valuable initial assessment of airway obstruction and can be done quickly and cheaply in the office. It is also an excellent measure of progression of disease or success of treatment. Pulse oximeter is another quick, noninvasive office technique to assess the severity of both chronic disease and acute respiratory distress. Full spirometry, although not available in all primary care offices, gives additional diagnostic information that can differentiate among asthma, COPD, and fixed airway obstruction.

B. Chest x-ray study. Plain chest films will identify consolidation, masses, mediastinal shifts, and hyperaeration.

C. Clinical laboratory tests. A complete blood count may demonstrate signs of an acute bacterial infection. Polycythemia is a sign of chronic hypoxia (Chapter 16.5). Eosinophilia can indicate asthma or allergic disease (Chapter 16.2). Angiotensin-converting enzyme levels are elevated in sarcoidosis. A tuberculin skin test should be considered in all patients with wheezing or chronic cough.

Diagnostic assessment

The history and physical examination are the key elements to an acute diagnosis. A consistent exposure or reaction history, coupled with an elevated serum IgE or eosinophilia, indicates allergic disease. Wheezing in the setting of acute bronchitis or sinusitis is not true asthma and the patient can be reassured that this is not the beginning of a chronic disease. Inspiratory wheezing, or stridor, indicates upper airway obstruction or psychogenic wheezing. A normal, or nearly normal, peak flow is reassurance that good air exchange is occurring, regardless of the loudness of the wheezing. The pulse oximetry will differentiate between severe obstruction and poor cooperation with the peak flow testing. When confusion still exists, spirometry will clarify the diagnosis in most cases. The diagnosis and treatment of most cases of wheezing is within the scope of practice of the primary care physician.


References

1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–111.

2. Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995;50:701–710.

3. Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J 1995;8:1942–1948.

4. Goldman J. All that wheezes is not asthma. Practitioner 1997;241:35–38.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Wheezing: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

A wheeze is a continuous musical sound produced by vibration of airway walls when they are near closure. A wheeze consisting of a single musical note indicates small airways disease, usually asthma. Polyphonic wheezes (multiple musical notes) are produced by dynamic compression of large central airways.

Stridor signifies central airway obstruction, and is an ominous portent of impending complete airway closure. Causes such as an aspirated foreign body or bronchogenic cancer should be suspected when the onset of wheezing is sudden and focal, allergic markers and specific triggers are absent, and response to bronchodilator is poor. A history of aspiration, or smoking and clubbing are also helpful.

Nocturnal wheezing could be the result of congestive heart failure (paroxysmal nocturnal dyspnea) or gastric aspiration with reflux.

Dyspnea on exertion correlates with an FEV1 below 50% predicted, and dyspnea at rest with FEV1 below 25% predicted. Forced expiratory time (FET) is measured by ausculting over the trachea, and timing until airflow is no longer heard. FET of 9 seconds predicts an FEV1/FVC ratio of 70%. Stridor indicates that the airway diameter is less than 5 mm.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.

Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.

A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Cough, barking: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Observe the child for signs of respiratory distress. Note use of sternal or intercostal retractions or nasal flaring. Observe his skin for cyanosis and diaphoresis. Take his vital signs, noting respiratory rate and depth. Although stridor can be heard without a stethoscope, auscultate his lungs. Decreased breath sounds and crackles may be present.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, nonproductive: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE:Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB — those born in another country, those in contact with acute TB, and those with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, and signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough, productive: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Stridor: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Wheezing: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 655.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds, pages 720 and 721.)

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Cough: Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • In manycases history and physical exam are diagnostic.
  • Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities.

    • Age of Child and Duration of Cough

  • In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.
  • In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).
  • Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.
  • Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.
  • In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.
  • Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems.

    • Periodicity and Quality of Cough

  • Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.
  • Recurrent viral URIs and asthma causeepisodic coughing.
  • Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.
  • Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.
  • Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.
  • Neuromuscular disorders produce a weakand feeble cough.
  • Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease.

    • Timing of Cough

  • If coughdisappears while asleep, it usually has psychologic basis.
  • Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.
  • Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis.

    • Nature of Sputum Production

    Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.

    Associated Findings

  • Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.
  • Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.
  • Cough associated with stridor indicatesairway obstruction.

    • Evaluation

  • Etiologyof cough can usually be determined or at least suspected from historyand physical exam.
  • Chest radiography shows pattern andextent of disease and is confirmatory in many instances.
  • With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.
  • If TB is suspected, intermediate-strengthPPD should be placed.
  • Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.
  • With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.
  • Another useful test is sweat test inchildren with recurrent or chronic cough.
  • With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Wheezing: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • History,physical exam, and chest radiograph are diagnostic in most casesof wheezing.
  • Age of child; timing and duration ofwheezing; presence of fever, stridor, or cough; and family historyof asthma or other atopic disorders help distinguish various causesof wheezing.
  • Asthma, bronchiolitis, and pneumoniaare most frequent causes of acute wheezing, whereas asthma is mostcommon cause of recurrent or persistent wheezing.
  • Other useful tests in children withhistory of wheezing are sweat test (cystic fibrosis), pH probe andendoscopy (gastroesophageal reflux disease), video swallowing study(swallowing disorders with aspiration), bronchoscopy (foreign bodyaspiration, tracheal or bronchial stenosis, tracheomalacia), andflexible laryngoscopy (vocal cord dysfunction). Further investigationsdepend on suspected diagnosis.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Respiratory Distress and Apnea: Diagnostic Approach: Respiratory Distress
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • In preterminfants, most common cause of respiratory distress is respiratorydistress syndrome. In term infants, transient tachypnea, meconiumaspiration, pneumonia, and pneumothorax are most common lower respiratorytract disorders causing respiratory distress. Other nonpulmonarycauses of respiratory distress in neonates are congenital heartdisease, persistent fetal circulation, and septicemia. In infancyand childhood, most common causes of respiratory distress are bronchiolitis,croup, asthma, pneumonia, foreign body aspiration, and congenitalor acquired heart disease with cardiac failure.
  • History and physical exam suggest mostlikely cause for respiratory distress. Oxygen saturation in roomair indicates degree of hypoxemia. Certain tests should be considereddepending on clinical circumstances:

  • Airway radiography or endoscopy for upperairway obstruction
  • Chest radiography for lower respiratorydisorders or cardiac disease
  • CBC for anemia
  • Serum electrolytes and creatinine;blood urea nitrogen; and venous/capillary pH for metabolicacidosis
  • ECG and 2-D echocardiography for cardiacfailure
  • Chest CT for any airway, lung, or mediastinal mass

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Stertor, Stridor, and Airway Obstruction: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Stertorand stridor are signs of upper airway obstruction. With seriousairway obstruction, establishing control of the airway and maintainingventilation are the most important immediate priorities. In absenceof life-threatening airway obstruction, prompt but thorough investigationis essential.
  • Age of onset is useful in diagnosis.Onset of stridor at birth or during neonatal period suggests laryngomalacia,laryngeal web, vocal cord paralysis, or vascular ring. In infancyand childhood, onset of acute stridor suggests croup, supraglottitis,or foreign body. Most common cause of persistent stertor in children2–8 yrs of age is adenoid or tonsillar hypertrophy.
  • Phase of respiration in which stridoroccurs, pitch of the sound, character of voice or cry, and changein position help in assessing degree of obstruction and its localization.

  • The phaseof respiration associated with different levels of airway obstructionhas already been described.
  • Variation in pitch depends on leveland degree of obstruction. Coarse low-pitched snoring sounds (stertor)localize lesion to nose, nasopharynx, or oropharynx. Harsh inspiratorystridor may occur with supraglottic, glottic, or subglottic lesions.Stridor associated with deep barking cough signifies subglotticor tracheal obstruction, whereas stridor associated with hoarsenessor change in character of voice or cry signifies glottic lesion.
  • When infants with laryngomalacia orinnominate artery compression are placed in prone position withneck extended, stridor decreases.
  • After history and physical exam, othertests may be useful depending on suspected diagnosis. These includeneck and chest radiography and flexible laryngoscopy. If resultsof these tests are normal, upper GI radiographic series with attentionto the pharynx and esophagus should be considered. With suspectedobstruction below glottis, bronchoscopy is necessary. Usefulnessof esophagoscopy, CT, and MRI depends on suspected diagnosis.
  • Histologic diagnosis is necessary forany suspected neoplasm except perhaps hemangioma, which can usuallybe recognized clinically.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Cough, barking: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, nonproductive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

    As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

    Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

    Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, productive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

    Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds—rhonchi, crackles, or wheezes.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Stridor: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

    Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or cough?

    Then examine the patient's mouth for excessive secretions, foreign matter, inflammation, andswelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient's chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Wheezing [Sibilant rhonchi]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient isn't in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

    Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

    Examine the patient's nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect the patient's chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 597.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds, pages 650 and 651.)

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough - Case 4-2: 7-Week-Old Boy: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 37.3°C; RR, 54/min; HR, 153 bpm; BP in right upper extremity, 93/59 mm Hg; BP in left upper extremity, 87/62 mm Hg; BP in right lower extremity, 94/63 mm Hg; SpO 2, 95% in room air
    Weight, 4.5 kg
    Initial examination revealed a well-developed infant in moderate respiratory distress. The physical examination was remarkable for nasal flaring, intercostal retractions, and intermittent grunting. He had good aeration and scattered rales at both lung bases. Cardiac examination revealed a normal first heart sound (S 1) and a prominent second pulmonary sound (P2). A II-III/VI systolic murmur was appreciated at the left sternal border. The liver edge was palpated 4 cm below the right costal margin. The remainder of the physical examination was normal.

    IV. Diagnostic Studies

    Laboratory analysis revealed a peripheral blood count of 8,400 WBCs/mm3, with 35% segmented neutrophils, 60% lymphocytes, and 5% eosinophils. The hemoglobin was 11.4 g/dL, and there were 203,000 platelets/mm 3. Electrolytes, blood urea nitrogen, and creatinine were all within normal limits. Antigens of respiratory viruses were not detected by immunofluorescence of nasopharyngeal washings.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Cough - Case 4-3: 7-Month-Old Girl: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 40.6°C; RR, 60/min; HR, 168 bpm; BP, 102/55 mm Hg; SpO2, 99% in room air
    Weight, 50th percentile; height, 75th to 90th percentile
    Initial examination revealed an alert baby who was crying but consolable. She appeared slightly pale. Physical examination was notable for an erythematous right tympanic membrane and bilaterally injected conjunctiva with yellow discharge. She had moderate rhinorrhea and some notable buccal thrush. Her oropharynx was mildly erythematous. The chest examination was remarkable for an elevated respiratory rate, but there were no retractions. She had fine expiratory wheezes bilaterally, with decreased breath sounds at both bases. Her skin exhibited a fine, erythematous, blanching maculopapular rash on her face and torso (Fig. 4-3) and, to a lesser degree, on her extremities. Her palms and soles were spared. The rash appeared confluent in her perineal area and torso. The remainder of her physical examination was unremarkable.

    IV. Diagnostic Studies

    Laboratory analysis revealed a peripheral blood count of 10,900 WBCs/mm3, with 41% segmented neutrophils, 50% lymphocytes, 8% monocytes, and no band forms. The hemoglobin was 10.6 g/dL, and there were 290,000 platelets/mm 3. A urinalysis was normal, and a chest roentgenogram revealed mild hyperinflation and right middle lobe atelectasis with some peribronchial cuffing.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Cough - Case 4-6: 4-Month-Old Boy: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 37.2°C; RR, 27 to 40/min; HR, 138 bpm; BP, not obtained; SpO2, 96% in room air and decreasing to 93% with feeds
    Weight, 25th percentile
    On examination, he was alert with moderate respiratory distress and frequent episodes of coughing. His chest examination was significant for grunting with substernal, intercostal, and supraclavicular retractions. Rales were appreciated on the right with good aeration throughout. No wheezes were heard. The remainder of his physical examination was within normal limits.

    IV. Diagnostic Studies

    The complete blood count revealed 25,400 WBCs/mm3, with 51% lymphocytes, 17% atypical lymphocytes, 25% segmented neutrophils, and 6% monocytes. The hemoglobin was 12.3 gm/dL, and the platelet count was 494,000/mm 3.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Jaundice - Case 15-1: 14-Day-Old Boy: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 36.4°C; RR, 48/min; HR, 140 bpm; BP, 83/50 mm Hg
    Weight, 2.7 kg
    Physical examination revealed a 2-week-old term boy who was listless but arousable. His skin demonstrated a yellow-green jaundice but no petechiae, rash, or bruising. He was nondysmorphic and normocephalic, with an open, flat fontanel. His pupils were equal, round, and reactive with red reflexes present bilaterally. Mucous membranes were yellow-pink and slightly dry. His respirations were slightly rapid but otherwise unlabored with clear breath sounds bilaterally. The heart examination was normal. The abdomen was soft and nondistended, with a smooth, firm liver edge palpable 3 cm below the right costal margin. Examinations of the genitalia and extremities were normal. His tone, power, and primitive reflexes all appeared to be within normal limits.

    IV. Diagnostic Studies

    A complete blood count revealed the following: white blood cells (WBCs), 9,400/mm 3 (1% band forms, 41% segmented neutrophils, and 45% lymphocytes); hemoglobin, 16.0 g/dL; and platelets, 66,000/mm 3. PT and PTT were markedly prolonged at 50 and 112 seconds, respectively. Fibrinogen was 127 mg/dL, and fibrin split products were negative. Serum bicarbonate was 17 mEq/L, but the remainder of the serum electrolytes, calcium, magnesium, and phosphorus were normal. Serum glucose was 52 mg/dL. A hepatic function panel revealed the following: alanine aminotransferase (ALT), 115 U/L aspartate aminotransferase (AST), 126 U/L; alkaline phosphatase, 730 U/L; γ-glutamyl transferase (GGT), 55 U/L; and albumin, 3.5 mg/dL. The unconjugated bilirubin concentration was 13.1 mg/dL, and the conjugated bilirubin was 5.9 mg/dL.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Seizures - Case 19-1: 8-Day-Old Girl: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 39.0°C; RR, 20/min; HR, 180 bpm; BP, 86/45 mm Hg; SpO2, 100% in room air
    Weight, 25th percentile; head circumference, 50th percentile
    Examination revealed a mechanically ventilated infant. She was sedated but withdrew in response to painful stimuli. The fontanel was bulging. There were no head lacerations or skull depressions. The sclerae were anicteric, and the pupils were 1.5 mm and symmetrically reactive. There were no cardiac murmurs, and the femoral pulses were weakly palpable. The lungs were clear to auscultation. The abdomen was soft, and the umbilical stump was well healed without erythema or discharge. There were two pustules in the perineal area.

    IV. Diagnostic Studies

    Laboratory results were as follows: sodium, 132 mEq/L; potassium, 3.3 mEq/L; chloride, 99 mEq/L; bicarbonate, 23 mEq/L; glucose, 73 mg/dL; calcium, 8.9 mg/dL; and magnesium, 2.1 mg/dL. The complete blood count revealed 8,000 WBCs/mm 3, including 33% band forms, 18% segmented neutrophils, 35% lymphocytes, and 10% monocytes. The hemoglobin and platelet count were normal. On cerebrospinal fluid (CSF) examination, there were 879 WBCs/mm 3 (48% segmented neutrophils, 19% lymphocytes, and 33% monocytes) and 1,739 red blood cels/mm 3; no organisms were seen on Gram staining. The CSF glucose concentration was 36 mg/dL, and the protein concentration was 400 mg/dL. CSF was sent for bacterial culture and detection of HSV by polymerase chain reaction (PCR). There were no abnormalities on chest radiograph.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Seizures - Case 19-2: 10-Day-Old Boy: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 37.5°C; RR, 40/min; HR, 124 bpm; BP, 75/45 mm Hg; SpO2, 100% in room air
    Weight, 50th percentile; length, 25th percentile; head circumference, 25th percentile
    The infant appeared alert. There were no vesicles on the scalp or skin. His anterior fontanel was open and flat. His conjunctivae were pink and anicteric. Red reflex was present bilaterally. There was no murmur on cardiac examination, and femoral pulses were strong. The spleen tip was just palpable, and there was no hepatomegaly. The Moro reflex was symmetric. The remainder of the examination was also normal.

    IV. Diagnostic Studies

    A complete blood count revealed 8,800 WBCs/mm3 (16% segmented neutrophils, 70% lymphocytes, 11% monocytes, and 3% atyptical lymphocytes); hemoglobin, 13.4 g/dL; and platelets, 511,000/mm 3. Serum chemistry values included sodium, 139 mmol/L; potassium, 5.5 mmol/L; chloride, 104 mmol/L; and bicarbonate, 28 mmol/L. The blood urea nitrogen and creatinine concentrations were normal. Serum alanine and aspartate aminotransferases were normal. Serum albumin was 3.3 g/dL. Examination of the CSF revealed the following: WBCs, 12/mm 3; red blood cells, 1,834/mm3; glucose, 45 g/dL; and protein, 124 g/dL. There were no bacteria on Gram staining.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Home Testing and Whooping Cough

    Rate This Website

    What do you think about the features of this website? Take our user survey and have your say:

    Website User Survey

    Medical Tools & Articles:

    Next articles:

    Tools & Services:

    Medical Articles:

    Forums & Message Boards
     
    HONcode We subscribe to the HONcode principles

    By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

    Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

    Copyright © 2010 Health Grades Inc. All rights reserved. Last Update: 8 February, 2010 (23:31)