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7/28/2019 Diagnosis & Evaluation of Respiratory Disease
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Approach & Diagnostic
Procedures in Respiratory System
Triwahju Astuti
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Chief
complaint
history
Physical
examination tests
15
10
5
DATA COLLECTION
Differentialdiag
nosis
Initial Problem / Diagnosis
Iterativehypothesis
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History Taking of Respiratory
System
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Presenting (principal) symptom
History of presenting illness Past history
Social history
occupation, education, smoking, alcohol,analgesic use, overseas travel, immunisation,
marital status, social support, living conditions
Family history Systems review
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Detailed history & exploring possible etiologies of
cough :
Character ; what is the cough like ?- clearing of the throat : GER & post nasal drip
- brassy cough (hard & metallic) : conditions thatnarrow the trachea or larynx
- Barking cough (like a seal) : croup
- Hacking cough : pharyngitis,tracheobronchitis, early pneumonia
- whooping cough : pertusis
- any sputum production ? If so, what collor &how much ( mucus, blood, pus, pink froth) ?
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Onset ; how did it start (sudden versus gradual) ?
Intensity : at what time of day is your cough at its
worst ? Does it keep you awake at night (asthma andchronic bronchitis may be associated with nocturnal
or morning cough ?
Duration : how long has it been going on (acute versuschronic versus paroxysmal versus seasonal versus
perrenial? If cough is chronic, how has it changed
recently ? Is it getting better, worse or staying the
same ?
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Event associated :
- Pneumonia : fever, chills, rigors, increasedsputum production
- URTI : malaise, sore throat, rhinorrhe,
myalgia, headache, ear pain- tracheitis : retrosternal pain like a hot
poker
- TB / malignancy : hemoptysis,costitutional symptoms
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A simplified overview of the assessment and management of thecommon causes of acute cough (< 3 weeks)
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A simplified overview of the assessment and management of
prolonged acute cough (38 weeks)
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A simplified overview of the
assessment and
management of the
common causes of chronic
cough
(> 8 weeks)
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Dyspnea
Distressing sensation of difficult, labored, orunpleasant breathing.
The word distressing is very important to this
definition since labored or difficult breathing maybe encountered by healthy individuals whileexercising.
It does not qualify as dyspnea because it may not
be perceived as distressing. The sensation is often poorly or vaguely
described by patients.
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Detailed history & exploring possible etiologies of
dyspnea :
Character : describe the nature of your breathingdifficulty
Onset : how did the SOB start ( sudden vs gradual) ?.
What were you doing when you became SOB ? Intensity : how severe is your SOB right now, on a
scale of 1 to 10 with 1 being mild and 10 being the
worst ? Has it gotten worse ?
Duration : how long have you been SOB?
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Frequency : Has this ever happened to you before ? Ifso, how often does it happen ? When was the lasttime you became SOB ?
Palliative factors : Is there anything that makes yourSOB better ? if so, what ?
Provocative factors : Is there anything thatmakesyour SOB worse ? If so, what ?
Exertion ?
Position (sitting up versuslying down)?
Exposure to cold air ?
Infection ? Allergies
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Frequency : Has this ever happened to you before ? Ifso, how often does it happen ? When was the lasttime you became SOB ?
Palliative factors : Is there anything that makes yourSOB better ? if so, what ?
Provocative factors : Is there anything thatmakesyour SOB worse ? If so, what ?
Exertion ?
Position (sitting up versuslying down)?
Exposure to cold air ?
Infection ? Allergies
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Even associated
PE : Hemoptysis, pleuritic chest pain, DVT
Pulmonary edema / ACS : Exertional chest pain
(CP), PND, orthopnea, and peripheral edema.
COPD : Cough, wheeze, and progressively
worsening SOBOE
Pneumonia, other infections : Fever / chills, rigors,
increased sputum production, cough
Ascities : Abdominal distension
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Anxiety (diagnosis of exclusion) : Lightheadedness,
diaphoresis, trembling, choking sensation,
palpitations, numbness or tongling in hands/feet,
chest pain, nausea, abdominal pain,
depersonalization/derealization, flushes or chills,
real of dying, fear of going crazy or doingsomething uncontrolled
Constitutional symptoms: fever, chills, night
sweats, weight loss, anorexia, and asthenia.
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DIFFERENTIAL DIAGNOSIS
OF DYSPNEA(1)
CardiacCongestive heart failure (right, left orbiventricular)
Coronary artery diseaseMyocardial infarction (recent or past history)CardiomyopathyValvular dysfunction
Left ventricular hypertrophyAsymmetric septal hypertrophyPericarditisArrhythmias
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DIFFERENTIAL DIAGNOSIS
OF DYSPNEA(2)
Pulmonary
COPD
AsthmaRestrictive lung disorders
Hereditary lung disorders
Pneumothorax
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DIFFERENTIAL DIAGNOSIS
OF DYSPNEA(3)
Mixed cardiac or pulmonary
COPD with pulmonary hypertension and
Cor pulmonaleDeconditioning
Chronic pulmonary emboli
Trauma
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DIFFERENTIAL DIAGNOSIS
OF DYSPNEA(4)
Noncardiac or nonpulmonary
Metabolic conditions (e.g., acidosis)
PainNeuromuscular disorders
Otorhinolaryngeal disorders
Functional
- Anxiety
- Panic disorders
- Hyperventilation22
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GUIDELINES FOR
EVALUATING DYSPNEA(1) Acute dyspnea
- A clinical approach is recommended forevaluating acute dyspnea.
- It consists of performing history andphysical examination and performinglaboratory test.
- Considering potensial life-threateningconditions first (eg,acute asthma,pulmonary embolism, pulmonaryoedema states, pneumonia)
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GUIDELINES FOR
EVALUATING DYSPNEA(2)
CHRONIC DYSPNEA
COPD, asthma, interstitial lung disease,
cardiomyopathy, GERD, other respiratorydiseases, and the hyperventilation
syndrome.
1. Clinical features
2. Chest radiograph in nearly all patients
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GUIDELINES FOR
EVALUATING DYSPNEA(3)
3. Pulmonary function testing
Noninvasive cardiac studies to include ECG,
echocardiography, and stress testing
Chest CT scan
Comprehensive ETT
Other more invasive test such as cardiaccatheterization and lung biopsy
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GUIDELINES FOR
EVALUATING DYSPNEA(4)
Final determination of the cause ofdyspnea is made by observing which
specific therapy eliminates dyspnea as acomplaint.
Dyspnea may be simultaneously due tomore than one condition
Do not stop therapy that appears to bepartially successful; rather, sequentiallyadd to it.
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HEMOPTOE/ HEMOPTYSIS
Haima = darah; ptysis= diludahkan
DERAJAT BATUK DARAH (PURSEL)
1. Bloodstreak
2. 1-30 cc
3. 30-150 cc
4. 150-500 cc
Massive : 500-1000 cc atau lebih
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DIAGNOSIS OF HEMOPTYSIS
The diagnostic work-up of hemoptysis
involves:
History, Physical examination,
Complete blood count, Coagulation
studies , Electrocardiogram, Chest
radiograph, Bronchoscopy
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Comparison of the chest signs in common respiratorydisorders
Disorder Mediastinal
displacement
Chest wall
movement
Percussion Breath
sounds
Added sounds
Consolidation none Reduced over
affected area
Dull Bronchial Crackles
Collapse Ipsilateral shift Decreased over
affected area
Dull Absent or
reduced
Absent
Pleural Effusion Heart displaced to
opposite side
Reduced over
affected area
Stony dull Absent over
fluid; may be
bronchial at
upper border
Absent,
pleural rub
maybe found
aboveeffusion
Pneumothorax Tracheal
deviation to
opposite side if
under tension
Decreased over
affected area
Resonant Absent or
greatly
reduced
Absent
Bronchial
asthma
none Decreased
symmetrically
Normal or
decreased
Normal or
reduced
Wheeze
Interstitial
pulmonary
fibrosis
none Decreased
symmetrically
(minimal)
Normal Normal Fine
inspiratory
crackles over
affected lobes
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Chest examination
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TERIMA KASIH