COMMON PRESENTING COMPLAINTS



Cough is “the watchdog of the lungs.” It is pro­voked by mechanical or chemical stimulation of the airways. The cough is preceded by a deep breath followed by glottic closure. Then active compression causes a rapid rise in intrathoracic pressure until sudden opening of the glottis al­lows rapid decompression. The high flow velocity achieved serves to clear the airway of secretions or foreign bodies. Cough may be caused by the presence of secretions, viral infection of the air­way epithelium, or stimulation of parenchymal receptors by pulmonary edema or fibrotic lung disease or may be the sole manifestation of bronchospasm. Chronic cough at night can often be ascribed to the presence of postnasal drip, re­flux esophagitis, or aspiration. Recent alteration in the character of a chronic cough may be due to bronchial carcinoma. The cause of chronic iso­lated cough can usually be elucidated without re­course to invasive measures.

Hemoptysis requires immediate evaluation. A bleeding site in the upper airway should be ex­cluded. Blood-streaked sputum is commonly seen in bronchitis, bronchiectasis, pneumonia, and tu­berculosis, but in the absence of infection, per­sistent or intermittent hemoptysis usually indi­cates the presence of tumor. Massive hemoptysis is a medical emergency and unless promptly treated the patient may asphyxiate. Unexplained hemoptysis requires a complete evaluation, in­cluding a chest x-ray, and fiberoptic bronchos­copy may eventually be required.

Breathing is an automatic, unconscious act. Dyspnea indicates an awareness of increased dif­ficulty in breathing. Its pathophysiology is un­clear but may be due to a disproportion between the perceptive demand for ventilation and that achieved. This may result from a change in the relationship between respiratory center drive and minute ventilation or the work of breathing. Clar­ification of the predisposing factors is important in the diagnosis of its origin. Episodic dyspnea associated with wheezing at rest or following ex­ercise may indicate bronchospasm. Dyspnea caus­ing arousal from sleep may be due to nocturnal asthma, pulmonary edema, sleep apnea syn­drome, or aspiration. Dyspnea on exertion may be cardiac or pulmonary in origin, and differentia­tion often requires exercise testing.

Chest pain originates in the chest wall, the par­ietal pleura, the large airways, and the structures located within the mediastinum, as the lung par­enchyma and visceral pleura are insensitive to painful stimuli. Pleuritic pain is distinctive, being sharp and knifelike and exacerbated by breathing and coughing. It must be differentiated from per­icardial pain, involvement of the intercostal nerves by herpes zoster, and inflammation of the costochondral junctions (Tietze’s syndrome). Dis­ease involvement of the diaphragmatic pleura may cause referred pain to the shoulder, because the phrenic nerve supply arises from the cervical roots (C3, 4, 5).
Careful review of the remainder of the history is important. Prior episodes of respiratory infec­tion may indicate acquired or congenital abnor­malities of pulmonary clearance mechanisms. Similar findings in family members may suggest an inherited disorder such as immotile cilia syn­drome. Attention should be paid to occupation, travel, habits (smoking), and hobbies (pets).