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COMMON SYMPTOMS

COMMON SYMPTOMS. What do they mean? ACUTE- < 3 weeks. PERSISTENT/ CHRONIC- > 3 weeks CHAPTER 2. COUGH. ACUTE In healthy adults, most cases of acute cough are due to viral respiratory infections.

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COMMON SYMPTOMS

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  1. COMMON SYMPTOMS What do they mean? ACUTE- < 3 weeks. PERSISTENT/ CHRONIC- > 3 weeks CHAPTER 2

  2. COUGH ACUTE • In healthy adults, most cases of acute cough are due to viral respiratory infections. • Chronic medical conditions can cause acute cough during exacerbations: asthma, CHF, allergic rhinitis. • Cough from a viral respiratory infection CAN persist beyond 3 weeks.

  3. COUGH ACUTE • Dyspnea does not typically accompany acute cough in a viral resp infection, and • Cough + Dyspnea- requires a work-up: CXR, ABGs, PFTs, Cardiovascular eval.

  4. COUGH PERSISTENT • In the absence of respiratory infections, therapy w/ ACE inhibitors, or abnormalities on CXR, 90% of cases of persistent cough are due to: • 1) Postnasal drip (allergies). • 2) Asthma. • 3) GERD.

  5. COUGH PERSISTENT • OTHER CAUSES: • Lung cancer, TB - both can present w/ fever, night sweats, weight loss. • Chronic bronchitis / COPD. • Other chronic infections (crypto, coccy, etc.) • Interstitial lung disease- pulmonary fibrosis, sarcoidosis, etc. • Psychogenic.

  6. COUGH DIAGNOSTIC STUDIES • ACUTE COUGH- CXR should be done in the patient with: abnormal vital signs (tachycardia, tachypnea); physical exam findings suggestive of pneumonia (rales, consolidation), decreased pulse-ox. • PERSISTENT COUGH- CXR, empiric Rx for postnasal drip, GERD, asthma for 2-4 weeks; if no better, PFTs, referral.

  7. DYSPNEA • The perception of uncomfortable breathing. 3 BROAD CATEGORIES: • 1) MECHANICAL- COPD, myasthenia gravis • 2) COMPENSATORY- hypoxemia, acidosis. • 3) PSYCHOGENIC- anxiety / panic attack. • Dyspnea commonly accompanies a multitude of acute and chronic medical conditions.

  8. DYSPNEA • Acute dyspnea as the chief complaint warrants urgent evaluation, looking for: • P.E., pneumothorax, asthma, COPD. • Pneumonia, cardiac disease such as MI, CHF, valvular dysfunction (rupture of chordae tendonae), arrhythmias. • Metabolic acidosis (DKA eg), methemoglobinemia, carbon monoxide poisoning, cyanide toxicity (such as from smoke inhalation).

  9. DYSPNEA • Can distinguish mechanical from compensatory from psychogenic with arterial blood gas (ABG) evaluation. EXCEPT for: cyanide toxicity and carbon monoxide poisoning. • MECHANICAL- respiratory acidosis, w/ or w/out hypoxemia. • COMPENSATORY- respiratory alkalosis w/ or w/out hypoxemia or metabolic acidosis. • PSYCHOGENIC- respiratory alkalosis.

  10. ACID-BASE REVIEW CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3‾ (H2CO3 = CARBONIC ACID, HCO3‾ = “BICARB”) HENDERSON HASSELBACH EQUATION pH = pKa + log([HCO3‾] / 0.03[CO2]) OR, SIMPLIFIED pH = -log10(H+)

  11. ACID-BASE REVIEW • Remember to consider what is the disease and what is the compensatory response • The disease: • RESPIRATORY ACIDOSIS: CO2 IS RETAINED, pH goesdown • RESPIRATORY ALKALOSIS: CO2 IS EXHALED, pH goes up • METABOLIC ACIDOSIS: DECREASE IN HCO3, pH goes down • METABOLIC ALKALOSIS: INCREASE IN HCO3-, pH goes up

  12. ACID-BASE REVIEW • The compensation: • SHORT TERM: respiratory, by altering amount of CO2 exhaled. • LONG TERM: by the kidney, by altering amount of H+ excreted, thereby changing HCO3-.

  13. ACID-BASE REVIEW • For review of Acid-Base Metabolism: • http://www.nda.ox.ac.uk/wfsa/html/u13/u1312_01.htm • http://www.acid-base.com/index.php • For interpretation of ABGs • http://www.health.adelaide.edu.au/paed-anaes/javaman/Respiratory/a-b/AcidBase.html

  14. DYSPNEA – THE DDx BASED ON Sxs • If dyspnea is sudden in onset and severe, and absence of other Sxs, think: P.E., pneumothorax, increased LVEDP (as in CHF, silent MI). • W/ chest pain, think: M.I., P.E., pneumo, pleurisy, pericarditis. Need to dig deeper into the pain- was it acute in onset, chronic, pleuritic, exertional. • W/ fever and cough think infection. • Dyspnea w/ no other Sxs, think non-cardiopulmonary causes of impaired O2 delivery: anemia, carbon monoxide, methemoglobinemia, PE, metabolic acidosis. • W/ wheezing, think: asthma, COPD, foreign body.

  15. DYSPNEA – THE PHYSICAL EXAM • Inspect- breathing pattern, resp rate, pursed lips (emphysema), barrel chest (chronic bronchitis), use of accessory muscles (asthma), asymmetrical excursion of the chest and/or diaphragm (pneumo). • Head & Neck- JVD (CHF). • Lungs- the usual- breath sounds, crackles and wheezes • Heart- the usual- murmurs, rubs, location of PMI, etc. • Extremities- edema (CHF), evidence of DVT (P.E.).

  16. DYSPNEA – DIAGNOSTIC STUDIES • “Causes of dyspnea that can be managed without a chest X-ray are few: ingestions causing lactic acidosis, methemoglobinemia, and carbon monoxide poisoning.” • “In the absence of physical examination evidence of COPD or CHF, the major remaining causes of dyspnea include P.E., upper airway obstruction, foreign body, and metabolic acidosis.” • CXR, ABG’s, EKG. • V / Q SCAN – to r/o P.E. (Ventilation/Perfusion Scan =V/Q) • Blood tests- CBC, carboxyhemoglobin & methemoglobin levels.

  17. EDEMA DIFFERENTIAL Dx • CHRONIC VENOUS INSUFFICIENCY. • VENOUS THROMBOSIS. • CELLULITIS. • MUSCULOSKELETAL DISORDERS. (ruptured Baker’s cyst). • LYMPHEDEMA. • SYSTEMIC DISEASE- CHF, cirrhosis, renal failure, nephrotic syndrome. • MEDICATION- Ca channel blockers.

  18. EDEMA CHRONIC VENOUS INSUFFICIENCY • By far the most common cause of edema. • 2% of the population. • Due to incompetence of the valves in the veins of the leg; also a complication of DVT. • Results in leakage of not only fluid but leukocytes and other inflammatory components, resulting in lymphatic obstruction and worsening edema. • PRESSURE IS A DISEASE- ultimately results in impaired arterial supply, tissue necrosis, ulceration.

  19. EDEMA CHRONIC VENOUS INSUFFICIENCY • PHYSICAL FINDINGS: shiny, atrophic skin, lack of hair, increased pigmentation; pitting; redness & warmth when inflamed; stasis ulcer most commonly over the medial malleolus; • Can be unilateral or bilateral.

  20. EDEMA D.V.T • The most life-threatening cause of edema. • Unilateral. • Risk factors: recent immobilization from surgery; bed-rest, air travel; OCP / estrogen use; pregnancy and the puerperium; obesity; malignancy; less commonly genetic deficiencies of Protein S, Protein C, or Anti-thrombin III; Mutant Factor V (the “Leiden” mutation).

  21. EDEMA D.V.T MANIFESTATIONS: • Pain, swelling, muscle tenderness (calf/gastrocs) • Many cases of DVT are asymptomatic. • Most common sites: venous sinuses in the soleus muscle, and in the posterior tibial and peroneal veins. • HOMAN’S SIGN: pain in the calf on dorsiflexion of the foot.

  22. EDEMA WHEN EDEMA IS BILATERAL • THINK SYSTEMIC DISEASE. • CHF. • NEHROTIC SYNDROME & CIRRHOSIS, DUE TO DECREASED INTRAVASCULAR OSMOTIC PRESSURE FROM HYPOALBUMINEMIA. • THESE PATIENTS WILL ALSO HAVE THE OTHER FEATURES OF THOSE CONDITIONS.

  23. EDEMA DIAGNOSIS / DIAGNOSTIC STUDIES • History, physical exam. • Assess for risk factors for DVT. • Unilateral or bilateral. • Other physical findings to suggest systemic disease? • Color duplex ultrasonography. The “Doppler” study. Use liberally to R/O DVT as DVT is hard to exclude on clinical grounds. • Measure D-dimers of fibrin degradation products in the serum

  24. EDEMA TREATMENT OF VENOUS INSUFFICIENCY • 1) ELEVATION. • 2) COMPRESSION. • Consider referral to a vascular surgeon, as some patients w/ chronic venous insufficiency will also have peripheral artery disease, which can be worsened with compression.

  25. FEVER • Most commonly due to infections. • In adults: 25-40% infections, 25-40% malignancy. • In children: infection 30-50% of the time.

  26. FEVER • FUO - fever of unknown origin – “unexplained cases of fever exceeding 38.3° C. on several occasions for at least 3 weeks in patients without neutropenia or immunosuppression.” • CAUSES OF FUO: 1) INFECTION 2) NEOPLASMS 3) AUTOIMMUNE DISORDERS 4) MISCELLANEOUS 5) 10-15% UNDIAGNOSED CAUSES

  27. FEVER CAUSES OF FUO • 1) INFECTION- TB, endocarditis, fungi, occult abscesses, osteomyelitis, UTI, and other “exotic” infections such as malaria, toxoplasmosis, CMV, etc. • 2) NEOPLASMS- most commonly lymphomas and leukemias. • 3) AUTOIMMUNE DISORDERS- most common are Juvenile RA (Still’s Disease), Lupus, Polyarteritis Nodosa.

  28. FEVER CAUSES OF FUO • 4) MISCELLANEOUS- thyroiditis, sarcoidosis, recurrent PE, alcoholic hepatitis, Crohn’s, drug fever, etc. • 5) 10-15% UNDIAGNOSED CAUSES- of these, 75% will abate without treatment, the rest will eventually manifest their underlying disease.

  29. FEVER EVALUATION • “Uncommon presentations of common diseases are more common than common presentations of uncommon diseases.” • So look for the common stuff, most commonly infection. • History & physical. Lab as appropriate. • Ask about travel, diet, drugs. • For FUO, I would refer the patient to an internal medicine specialist, who may refer the patient to an infectious disease specialist, who may refer the patient to a rheumatologist, who may……

  30. INVOLUNTARY WEIGHT LOSS • Loss of 5% or more of usual body weight over 6-12 months. • Often indicates serious physical or psychological illness. • MOST COMMON CAUSES: 1) CANCER- 30% 2) GI DISORDERS- 15% 3) DEMENTIA, DEPRESSION, ANOREXIA- 15%.

  31. INVOLUNTARY WEIGHT LOSS THE WORK-UP • History and physical. Psychological eval. • LAB- CBC, Chem profile, TSH, UA, Hemoccult. • RADIOGRAPHS- CXR, UGI. • These usually reveal the cause. • If not, Phase II- GI endoscopy, tests for malabsorption, Mammogram, PSA. • In 15-25%, no cause is found. F/U req.

  32. FATIGUE • 1-3% of visits to generalists. • “Fatigue of unknown cause or related to psychiatric illness exceeds that due to physical illness, injury, medications, drugs, or alcohol.” • My take on “unknown cause” is it’s due to an interplay of life-style and emotional factors. • IMPORTANT CAUSES: thyroid disease, CHF, infection (endocarditis, hepatitis), COPD, sleep apnea, anemia, autoimmune disease, cancer.

  33. FATIGUE • OTHER CAUSES: • Alcoholism, recreational drugs, side effects from medication (sedatives, beta blockers). • PSYCHOLOGICAL- depression, insomnia, somatization disorders. • PSYCHIATRIC- depression, dysthymia, somatoform disorders, anxiety disorders, panic attack. • Irritable bowel syndrome.

  34. CHRONIC FATIGUE SYNDROME • Diagnosis of exclusion. • No confirmatory physical finding or lab tests. • Etiology unknown, no single pathogenic mechanism, likely a heterogeneous abnormality. • There is a greater prevalence of past and current psychiatric diagnoses in patients w/ this syndrome, esp. affective disorders.

  35. CHRONIC FATIGUE SYNDROME DIAGNOSTIC CRITERIA • Work-up/lab is/are normal/negative. • Criteria for severity of fatigue are met. • 4 or more of the following are present for > 6 months: • Impaired memory or concentration. • Sore throat. • Tender cervical or axillary lymph nodes. • Muscle pain. • Multijoint pain.- Unrefreshing sleep. • New headaches.- Postexertional malaise.

  36. CHRONIC FATIGUE SYNDROME THE WORK-UP 1) History and physical. 2) Mental status exam. 3) Lab- CBC, Chem profile, ESR, TSH, UA. 4) Other tests as indicated by the Hx and PE. 5) Possibly- HIV; ANA, Rheumatoid factor, if joint symptoms present.

  37. CHRONIC FATIGUE SYNDROME TREATMENT • No single drug helpful. No cure, but recovery is possible. • Comprehensive, multidimensional approach. • Current treatment of choice: Cognitive- behavioral therapy combined with graded exercise. • Sympathetic ear.

  38. DYSURIA • Painful urination. • Common. Common. Common. DIFFERENTIAL Dx • Acute cystitis – Dx’d 50-60% of the time. • Acute pyelonephritis. • Vaginitis (Candida, trichomonas). See next slide. • Urethritis. Cervicitis.

  39. DYSURIA SYMPTOMS AND THE Dx • Dysuria, frequency, urgency WITHOUT vaginal discharge or itching → increased likelihood of cystitis. • Dysuria, frequency, urgency WITH vaginal discharge or itching → decreased likelihood of cystitis. • W/ fever, back/flank pain, N/V → think pyelo.

  40. DYSURIA SYMPTOMS AND THE Dx • If the patient has dysuria, frequency, and urgency, w/out vaginal discharge, itching, fever, or flank pain, you can treat for cystitis w/ out a fancy-schmancy evaluation or even a UA. • If any of the other Sxs are present, need to evaluate w/ PE including vaginal exam, wet prep, KOH, UA. • Always need to R/O upper tract infection / pyelo as this can progress to sepsis and septic shock, esp in the older patient.

  41. DYSURIA SYMPTOMS AND THE Dx HEMATURIA • Can be consistent w/ the Dx of cystitis (hemorrhagic cystitis), but need to also consider urolithiasis and malignancy • If upper tract disease is suspected, especially stones, consider imaging studies- IVP, ultrasound, helical CT. • Remember: children and the elderly do not always have “typical” presentations, esp fever in the elderly.

  42. DYSURIA TREATMENT • Acute, uncomplicated cystitis in the otherwise healthy patient (not immunosuppressed, not pregnant, etc) can be treated by a 1-3 day course of antibiotics- macrodantin, trim-sulfa. • Phenazopyridine- an OTC drug for symptomatic relief. • If fever, tachycardia, and hypotension are present, hospitalization should be considered.

  43. RED FLAGS • Hemoptyis • Hematemesis • Central chest pain lasting >20 mins • Shock • Convulsions • Headaches requiring emergent neuro-imaging

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