Topic Discussion
We have six symptoms that are exhibited by the patient, those are cough, wheezing, fever, wet rhonchi, sneezing, and runny nose. This LTM we will be discussing the diagnosis of cough, wheezing, and fever and also the possible differential diagnosis regarding the respiratory system diseases posed by each of the symptoms. (1)
A. Cough
Cough is one of the most often medical complaints reported. Cough is an innate reflex of our body to protect itself against foreign materials. This symptom is correlated with numerous respiratory diseases, to some extent, its etiologies. Even though coughing is a common sign of underlying diseases, there is no objective tool to measure or quantify a cough. Nonetheless, coughing should still be evaluated. (2)
Acute and subacute should be treated symptomatically unless there is a suspicion about more sinister pathology. Radio-photography may be appropriate to determine the severity of the disease. Chronic cough requires a thorax x-ray and further evaluation by the pulmonologist. Often times single etiology cannot be established because the chronic cough is a result of multiple diseases. Bronchoscopy with visualization of the airways may be required to rule out any lesion or mass in the vocal cord or endotracheal. Biopsy may also be required to acquire samples for cytological and microbiological analysis. A CT scan may be required for further anatomical analysis. If the cough mostly occurred at night and the signs suggest obstructive sleep apnea, the patient may be ordered for a sleep study. (2)
Differential diagnosis of cough is numerous and can be categorized into acute, subacute, and chronic. Acute ones are several inflammatory diseases such as acute bronchitis, rhinosinusitis, and rhinitis. Other ones are asthma, pertussis, pneumonia, and obstructive pulmonary disorder. Subacute differential diagnoses are the secondary irritation of cough receptors by resolving or ongoing sinus or bronchial inflammation caused by viral upper respiratory infection. Chronic diseases are including but are not limited to chronic bronchitis and sinusitis, GERD, malignancy, intolerance to ACE-Inhibitor medications, obstructive sleep apnea, and psychosomatic cough. (2)
Sputum production is caused by the inability of the mucociliary mechanism to deal with the infection. The increased production of tracheobronchial secretion also causes the cough. In the acute phase, these symptoms are self-limiting. In chronic coughing, however, is caused by bronchial asthma, and intra and extra-thoracic pathologic condition. (3)
Nocturnal coughing can tell a lot about the condition of the patient. Nocturnal coughing needs to be assessed by severity, intensity, frequency, and sensitivity. Clues in the assessment of nocturnal cough are including cough worsening when in a supine position suggesting chronic bronchitis, post-nasal drip, bronchiectasis, and heart failure. The presence of clear sputum suggests a hypersensitivity mechanism. Purulent sputum suggests bronchiectasis and sinusitis, which also ruled out TB. Blood-tinged sputum suggests TB, bronchiectasis, and malignancies. Non-productive cough suggests ACE-inhibitor therapy. (4)
B. Wheezing
Wheezing is a symptomatic manifestation of any obstructive airway disease. It is a high-pitched sound coming from the larynx up to the bronchioles during both inspiration and expiration. Evaluation of wheezing can be done by auscultation of the chest. Nowadays we can use waveform analysis to characterize the wheeze as a sinusoidal waveform, with frequency from 100Hz to 5000Hz with the dominant frequency being 400Hz, and lasts around 80 milliseconds. (5)
Further procedures may be done for the patient with wheezing because it is an abnormal sound. The first imaging test is an X-ray to find the foreign body or mass in the central airway. In the non-acute condition, asthma is suspected. The next step is to do an airway challenge test with a bronchoconstrictive drug such as methacholine if the wheezing resolves with the administration of a bronchodilator, a tumor or mass is likely not considered. If there is no resolution then a mass or tumor may be suspected, and CT and bronchoscopy are needed to confirm the possible malignancy. (5)
Other lung sounds may be mistaken for wheezing. Those are stridor and rhonchi. Stridor is higher pitched and has a higher amplitude due to turbulent airflow in the upper airway because of obstruction. The sound is far more audible during auscultation on inspiration. Rhonchi have a similar characteristic to wheezing but have a lower frequency, fewer than 200 MHz. The sound may be described as a snoring-like sound. (5)
Differential diagnoses of wheezing include but are not limited to anaphylaxis, asthma, bronchiectasis, allergies, chronic obstructive pulmonary disease, obstructive sleep apnea, emphysema, and vocal cord dysfunction. Non-respiratory diseases may include heart failure, GERD, and drugs. (5)
C. Fever
Fever is a complex body response to injury or infection or both. The main feature of fever is the temporary changes in body core temperature by resetting the body’s thermostat setpoint. The temperature increases result in a profound effect on immune function, cell apoptosis, and recovery. (6)
Fever is often defined as a condition where the body temperature exceeds 38 degrees Celsius. The measurement can be done on several sites on the body such as the axilla, rectum, skin, ear, and mouth. Event though rectal is considered to be the most accurate among them. Axilla can be alternative due to its practical and reasonable accuracy. The gallium-in-glass thermometer is suggested to be an alternative to the digital thermometer because it may be more accurate but has to be maintained in its position for 5 minutes.
Tympanic infrared is suggested but not as accurate. Forehead non-contact infrared is emerging but has to be proven first. (6,7)
Fever is the body's response when there is an infection so if the disease in the respiratory tract is due to infection, it can trigger fever. There is a lot of infectious disease in the respiratory system. Those are include but not limited to lower respiratory infections (bronchitis, bronchiolitis, and pneumonia), epiglottitis, and laryngotracheitis. (7)
Conclusion
The patient from the trigger is suffering from a disease or disease that exhibits several symptoms. Those include recurrent and nocturnal cough, phlegm vomiting, fever, and wheezing. A diagnosis of each symptom is needed to make a diagnosis and differential diagnosis. Fever, cough, and wheezing suggest that the patient may suffer from an infectious disease that attacks the lower respiratory tract and worsen by the condition of the patient that may be hypersensitive to certain conditions.
References
Figure 1. Image taken from: https://us.123rf.com/450wm/yatate10/yatate102002/yatate10200200026/1 41268752-sick-cute-boy-is-coughing-as-symptom-for-cold-on-white- background-flu-symptoms-.jpg?ver=6
1. Kasper DL, editor. Harrison’s principles of internal medicine. 19th edition/editors, Dennis L. Kasper, MD, William Ellery Channing, Professor of Medicine, Professor of Microbiology, Department of Microbiology and Immunobiology, Harvard Medical School, Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts [and five others]. New York: McGraw Hill Education; 2015. 1 p.
2. Sharma S, Hashmi MF, Alhajjaj MS. Cough. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Apr 30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK493221/
3. Farzan S. Cough and Sputum Production. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations [Internet]. 3rd ed. Boston: Butterworths; 1990 [cited 2020 Apr 30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK359/
4. Singh DP, Jamil RT, Mahajan K. Nocturnal Cough. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Apr 30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532273/
5. Patel PH, Mirabile VS, Sharma S. Wheezing. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Apr 30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482454/
6. Hasday JD, Shah N, Mackowiak PA, Tulapurkar M, Nagarsekar A, Singh I. Fever, Hyperthermia, and the Lung: It’s All About Context and Timing. Trans Am Clin Climatol Assoc. 2011;122:34–47.
7. Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS. Fever in Children: Pearls and Pitfalls. Children (Basel) [Internet]. 2017 Sep 1 [cited 2020 Apr 30];4(9). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5615271/
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