Cough and dyspnoea

Chapter 24 Cough and dyspnoea



Case 24.1



1. What is the most likely cause of this patient’s symptoms?

An upper respiratory tract infection (URTI).


2. Name other disorders which may present with this type of symptomatology.
• Early stages of some systemic infections (especially viral) may present with these types of symptoms. Examples include influenza and measles.

• Allergies.

3. What is the relationship between the colour of the nasal discharge and the aetiological agent?

• A clear discharge usually indicates an allergic response, a viral infection, or discharge of cerebrospinal fluid.

• A white discharge may indicate a viral infection.

• A yellow or green discharge usually indicates a bacterial infection.


Case 24.2



1. What is the most likely cause of this patient’s current presentation?

Bronchopneumonia.


2. What is his underlying chronic condition?

Chronic bronchitis


3. Name some of the possible predisposing factors which can make an individual more susceptible to this disease.

Possible predisposing factors are:


• pre-existing lung disease

• pre-existing systemic disease (eg: diabetes mellitus)

• any immunodeficiency state

• poor nutrition

• debilitated individuals

• being elderly or an infant

• post-surgery.


Case 24.3



1. What is the most likely underlying, chronic condition?

Chronic bronchitis.


2. What is the most likely cause of this patient’s current presentation?

Acute bronchitis.


3. Can you determine from this information, the most likely aetiological agent for his problem?

The yellow-green colour of the sputum indicates it is a bacterial agent.


4. In a patient with no underlying lung disease, would this disorder generally cause dyspnoea?

Generally not.



Case 24.4



1. With no other information, what is your differential diagnosis?

Dyspnoea and occasional palpitations suggest the following possible causes:


• anxiety

• anaemia

• an arrhythmia.

2. Based on this additional information, can you now narrow your diagnosis?

Most likely to be anaemia.


3. What do you need to do now?

Refer her to a medical practitioner in order for her to have a full blood count. This is needed to:


• confirm actual haemoglobin level

• determine mean cell volume, and thus determine if she has a microcytic, normocytic or macrocytic anaemia.

A microcytic anaemia is most commonly due to iron deficiency, a macrocytic anaemia most likely due to folate or vitamin B12 deficiency, and a normocytic anaemia may indicate a chronic disease process. Other causes of each type also exist.


Following this test, further investigations can be selected based on the results (eg: iron studies, folate levels).



Case 24.5



1. What is the most likely cause of John’s 25-year history of cough and sputum?

Chronic bronchitis.


2. What extra questions do you need to ask John?

A full history should be taken. Most pertinent questions include:


• Has he coughed up any blood? Any loss of weight? Any changes in appetite? (to explore the possibility of an underlying malignancy)

• Any dyspnoea prior to the episode this week? Chronic bronchitis getting worse? Any heart failure? Possible malignancy?

• Any dyspnoea related to posture? Worse when in bed? (possibility of pulmonary oedema)

• Any swelling of ankles? (possibility of right heart failure)

• Any changes in the sputum prior to this episode? Any wheezing?

• Any other episodes of chest pain (of any type)?

3. What is your differential diagnosis for his current presentation? Why?

Pneumonia, possibly lobar. Reasons include:


• Yellow—green sputum indicates a bacterial infection

• The pain described is ‘pleuritic’ in nature, which indicates irritation of parietal pleura or the pericardium. Lobar pneumonia always involves the pleura, whereas bronchopneumonia less commonly. Acute bronchitis does not cause this type of chest pain.

• Acute respiratory infections are reasonably common in individuals with an underlying chronic respiratory disorder.

4. What do you need to examine in this patient?

Full examination should be performed, but most pertinent includes:


• vitals: especially pulse rate and temperature

• respiratory system: percussion note, breath sounds, adventitious sounds.

5. What information can you obtain from these findings? Can you narrow your differential diagnosis?

The respiratory signs localise the pathology to the base of the left lung, and are indicative of an increase in tissue density in that area of the lung fields. They support the diagnosis of lobar pneumonia, as suggested in question 3.


6. Explain the significance of the following signs, in context of your differential diagnosis.
a dullness to percussion at the left base

Exudate from the pneumonia fills the alveolar spaces, displacing the air, thus increases its density. Percussion thus produces a dull sound.


b decrease in vesicular breath sounds at the left base

Vesicular breath sounds represent air moving in and out of the alveoli. If the air has been replaced by fluid, there is no movement, thus no breath sound.


c presence of bronchial breath sounds at the left base

The fluid in the alveoli provides a medium in which sound travels better, as compared to air. Thus, the sound of air moving through the large airways is transmitted to the consolidated area, and is perceived as ‘bronchial breath sounds’.


d increased vocal fremitus and resonance at the left base

The explanation given to question 6c also explains this sign. In this case, it is the sound of the voice which is transmitted through the lung fields.


e pulse rate of 98

A tachycardia will generally occur with an infection, which he almost certainly has. It may also be related to his pain.


f temperature of 39.2

This is a result of pyrogens released as part of the infective process, which reset the hypothalamic thermostat at a higher level.


g blood pressure of 140/90

This may be a response to pain, or due to the effect of cigarettes on blood pressure. Contributing to this may be the ageing factor.


7. Why was the patient examined for the presence of clubbing?

Clubbing may occur in patients with bronchogenic carcinoma. As he is a smoker, and has had an episode of pneumonia, the presence of an underlying malignancy should be considered.

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Cough and dyspnoea

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