Introduction to Pharmacy

Practice and Simulation

PHAR456
Beirut Instructors: Dr. Marwan Akel; Dr. Jihan Safwan; Dr.
Ahmad Dimassi; Dr. Maya Khoury; Dr. Siham Kanaan
Bekaa Instructor: Dr. Rasha Jbara
Lebanese International University
School of Pharmacy
Spring 2020-2021
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 5.A NOSE
5.B EARS
5.C THROAT
5.D COUGH

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 Learning Objectives
• Identify the most likely etiology when patients present with a runny
nose, sore throat, earache, or cough, through history, diagnostic tests,
and patient findings on examination, to enable the pharmacist to
recommend effective treatment or refer the patient to an appropriate
provider
• Perform appropriate physical assessment for the ears, nose, and
throat

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5.A NOSE

5.B EARS

5.C THROAT

5.D COUGH
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 Runny/Stuffy Nose
• Patients presenting with the chief complaint of a runny nose or stuffy
nose are most commonly diagnosed with:
1. Common cold or Flu (two common viral infections)
2. Allergic rhinitis
3. Vasomotor rhinitis
4. Bacterial sinusitis
DIAGNOSTIC SCHEMATA FOR RUNNY/STUFFY NOSE
• Allergic Rhinitis • Upper Respiratory Tract Infection (Common • Bacterial Sinusitis
• Vasomotor Cold)
Rhinitis • Upper Respiratory Tract Infection (Flu or
Super Virus)
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 Common Cold (Upper Respiratory Infection)
Causes • Most common: rhinoviruses or coronaviruses
Subjective • Onset: “Feel cold coming on” slow onset (12 to 48 hours)
symptoms that progressively worsen and last 5 to 9 days
• Nose: Inflamed, red swollen nasal mucosa
• Nasal discharge: initially clear and thin but progresses to
mucoid, then to green tinged after 3 to 5 days (indicative of
a viral not bacterial infection as previously thought)
• Associated symptoms: Minimal sneezing, feverish (no or
low grade), cough usually worse at night, dry mild sore
throat esp. in AM
• Dry cough and sore throat may be attributable to post-
nasal drip, sore throat often resolves after eating

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 Flu/Super Virus (Upper Respiratory Infection)
Definition • Influenza is a much more severe seasonal respiratory disorder
in which runny nose, sore throat, and earache are not the
predominant symptoms
• Cold and Flu are viral infections (antibiotics are ineffective)
that occur predominantly in the late fall and winter months

Causes • Respiratory syncytial virus, adenovirus, or coronaviruses

Subjective • Onset: acute and rapid onset (quicker onset/progression than
cold)
• Nose/Nasal Discharge: similar to cold
• Associated Symptoms: Fever, myalgia, arthralgia, looks sick,
cough more than cold (may be productive), and sore throat
may be more bothersome
• Lasts several days longer than the common cold
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 Cold vs. Influenza (FLU)
Signs and Symptoms Influenza Common Cold
Symptom onset Abrupt Gradual
Fever Abrupt onset; commonly 37.78 to 38.89 °C lasting 3-4 days Rare
*
Not everyone will have fever, especially elderly
Muscle Aches Common often severe Rare
Chills Common Slight
Fatigue/weakness Common; may last 2 to 3 weeks, especially in elderly Sometimes; usually mild
Extreme exhaustion Common Never
Sneezing Sometimes Common
Stuffy Nose Sometimes Common
Sore throat Sometimes Common
Chest discomfort or cough Common; may be severe Common; mild to moderate hacking
cough
Headache Common Rare
Complications Pneumonia; worsening of chronic underlying conditions, Sinus congestion, earache
secondary bacterial infection, encephalopathy, myocarditis,
myositis; can be rapidly progressive and life-threatening
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 Allergic Rhinitis
Definitio • Inflammation of the nasal membranes that is characterized by sneezing,
n nasal congestion, nasal itching, and rhinorrhea, in any combination

Causes • Often outdoor airborne allergens such as pollen/usually in spring and

lasting until fall
• Some patients have allergy symptoms year round, due to moderate
winters, or they may have an allergy to one or more indoor allergens,
such as house dust mites, cockroaches, or indoor molds
Subjecti • Nasal discharge: copious, clear, and watery
ve • Nose: Swollen, pale, boggy nasal mucosa
• Onset: usually sudden, and it can wax and wane, depending on the
exposure to the airborne allergen
• Nasal congestion can be the most troublesome symptom
• Associated Symptoms: Sneezing, itchiness (nose and the palate of the
throat may itch) and itchy watery red eyes (allergic conjunctivitis)
• If the allergic rhinitis is chronic or perennial, patients may have allergic
shiners (dark areas on their face below the eyes near the nose due to the
vasodilation associated with the chronic nasal congestion), a nasal crease,
and Dennie’s lines
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 Allergic Rhinitis
History • Many people are aware they have allergies or may
and have a history or a family history of allergic rhinitis,
Objectiv atopic dermatitis, and/or asthma
e • Careful history regarding asthma and its symptoms,
including early morning cough or a family history of
asthma, should be noted since a significant percentage
of patients have concurrent asthma
• Auscultation of the lungs should be performed to
determine whether or not the expiratory wheezing
typical of asthma is present
Treatme • Avoiding exposure to the allergen, if known, as well as
nt taking an antihistamine will decrease the frequency
and severity of the symptoms
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 Vasomotor Rhinitis
Definition • Vasomotor rhinitis is an irritant rhinitis, not an immune-mediated disease such
as allergic rhinitis (AR)
Causes • Irritants in the environment such as perfumes, odors, smog, or secondhand
smoke
• Changes in the weather, particularly dry weather
• Viral infections such as those associated with a cold or flu
• Hot or spicy foods or drinks
• Medications such as aspirin, ibuprofen, or beta-blockers
• Overuse of nasal decongestant sprays
Subjective • Setting: During dry, windy, dusty conditions
• Onset and nasal discharge: similar to AR
• Associated symptoms: Sneezing and itching are much less common than AR, dry
red eyes (not watery)
Objective • The primary way to distinguish it is by examining the nasal mucosa: in vasomotor
rhinitis, the nasal mucosa is dry but the normal pink-red color, not pale
• Patients will fail to respond to antihistamines and do not have allergic shiners,
and other physical findings of AR 11
 Acute Bacterial Sinusitis
Definition • It is an infection of both your nasal cavity and sinuses
• Bacterial sinusitis is uncommon in patients with nasal symptoms
Causes • Bacteria that colonize the upper respiratory tract, most
commonly Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis
• Secondary to a viral URI or active allergic rhinitis
Subjective • Onset: patient has a viral URI or an exacerbation of allergic
rhinitis and starts to get better after a week, but then symptoms
suddenly worsen
• Associated symptoms: High fever, unilateral facial pain, looks
sick, maxillary toothache (sign of maxillary sinus infection)
• Bending over makes facial pain worse
• Cough is infrequent: usually nonproductive and worsens at night
• Nasal discharge: purulent, opaque, foul tasting/smelling, and/or
blood tinged, brown to dark yellow throughout the day

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 Acute Bacterial Sinusitis
Objective • Ask patient about the color of the discharge during the afternoon or after they have been
awake and ambulatory for at least 6 hours
• Why?
• Most patients have opaque, yellowish brown discharge in the morning due to
evaporation of moisture during the night
• However, if this persists throughout the day, it is more consistent with true bacterial
sinusitis
• Patients may present with pain on palpation or percussion of the maxillary and frontal sinuses
(palpate gently first, and percuss only if there is no pain on palpation)
• Patients may also have unequal, decreased, or absent transillumination of the maxillary sinus
• If afebrile, make sure fever is not masked with analgesics such as acetaminophen and NSAIDs
which are also antipyretics
• Failure of a decongestant favors bacterial infection but watch out for tachyphylaxis (decreased
effect) if patient has used decongestants continually
Treatment • Antibiotics to kill the infecting bacteria
• Pain medicines
• Rinsing the nasal passages with saline to make them feel better 13
 Transillumination test: A light is
shined against the sinuses. Normally

Sinus Assessment the sinus appears hollow and the

light shines through giving a reddish
glow. When inflamed and blocked
with secretions and mucus the light
fails to sine through and
the sinus appears opaque.

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 Summary NOSE
A. DIAGNOSTIC SCHEMATA FOR RUNNY/STUFFY NOSE
•Allergic Rhinitis •Upper Respiratory Tract Infection (Common Cold) Bacterial Sinusitis
•Vasomotor Rhinitis •Upper Respiratory Tract Infection (Flu or Super Virus)
B. DIFFERENTIAL DIAGNOSIS OF STUFFY/RUNNY NOSE
SUBJECTIVE Cold Allergic Rhinitis Vasomotor Rhinitis “Flu”/Super Virus Bacterial Sinusitis
Location N/A N/A N/A N/A N/A
Onset “Feel cold coming on” slow onset (12 to Relatively sudden onset. May be off and Similar to allergic rhinitis Acute onset—quicker onset/progression Cold lasts >7 days. Starts to get better or
48 hours) symptoms that progressively on than cold plateau, then gets worse or allergic
worsen rhinitis active in spite of antihistamines/
intranasal corticosteroids

Quantity Varies Usually copious Usually copious Varies Varies

Quality Nasal discharge that is initially clear and Nasal discharge that is clear and watery Nasal discharge that is clear and watery Nasal discharge like cold Nasal discharge is purulent, opaque, foul
thin but progresses to mucoid, then to tasting/smelling, and/or blood tinged,
green tinged after 3 to 5 days brown to dark yellow throughout the day

Setting September-March “others have it” March-September (may be year round) During dry, windy, dusty conditions September-March “others have it” After a cold or allergic rhinitis

If seasonal, exposure to allergen

History of allergy
Associated symptoms Minimal sneezing, feverish, cough Sneezing, itchiness Sneezing and itching are much less Fever, myalgia, arthralgia, looks sick, High fever, unilateral facial pain, looks
usually worse at night, dry mild sore Itchy, watery red eyes common than AR, dry red eyes cough more than cold, may be sick, maxillary toothache
throat esp in AM productive
Modifying factors None Antihistamines or removal of allergen None None Bending over makes facial pain worse
makes it better. Further exposure to Failure on decongestants
allergen makes it worse
OBJECTIVE Cold Allergic Rhinitis Vasomotor Rhinitis “Flu”/Super Virus Bacterial Sinusitis
Fever Usually mild to no fever No fever No fever High fever Fever
Nasal examination Inflamed, red swollen nasal mucosa with Swollen, pale, boggy nasal mucosa with Dry irritated but otherwise normal Same as cold Purulent, dark yellow-brown or blood
mucoid discharge clear watery discharge appearing nasal mucosa with clear tinged nasal discharge
May be green tinged after 3 to 5 days watery discharge Unequal decreased or absent maxillary
sinus transillumination

Lung A&P Clear Normally clear Clear Usually clear, may have occasional clear
May have expiratory wheeze if asthma scattered rhonchi that clear with
coughing
Other None Allergic shiners, nasal crease, Dennie’s None None Pain on palpation/percussion of frontal/
lines, elevated levels of serum IgE maxillary sinuses
Upper tooth pain if maxillary
Usual causative agents Rhinovirus, coronavirus Indoor and outdoor allergens None Respiratory syncytial virus (RSV), some Streptococcus pneumoniae
coronavirus, adenovirus, parainfluenza Haemophilus influenzae
Moraxella catarrhalis
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5.A NOSE

5.B EARS

5.C THROAT

5.D COUGH
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 Ear Pain/Discharge
• Multiple causes for ear pain, purulent discharge, and possible acute
hearing loss:
1. Acute otitis media
2. Serous otitis media (aka otitis media with effusion)
3. Otitis externa
4. Chronic suppurative otitis media
5. Cerumen impaction
• Some causes of ear pain that are not caused by ear problems:
1. Temporomandibular joint (TMJ) disorders (AKA TMJ pain dysfunction syndrome
and TMJ syndrome)
2. Dental disorders
3. Streptococcal pharyngitis

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Ear Anatomy

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 Tympanic Membrane Eustachian Tube

Jones, Rhonda M., and Raylene M. Rospond. Patient Assessment in Pharmacy Practice. 2nd ed.,
Wolters Kluwer, 2009.

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 Acute Otitis Media (AOM)
Definition • Presence of fluid in the middle ear with accompanying conductive
hearing loss and without concomitant symptoms or signs of acuity
• Development of middle ear infections requires the transit of
colonizing bacteria or viruses from the nasopharynx or oropharynx,
up into the (dysfunctional) eustachian tube
Pathophysiology • Eustachian tube dysfunction/closure can be caused by swelling or
enlargement of posterior pharyngeal lymphoid tissue due to cold
(viral URI) or upper respiratory manifestations of allergies
Epidemiology • AOM occurs mostly in children under 6 years of age who have
relatively short straight eustachian tubes
• By 6 years of age, the eustachian tube is considerably longer and is
curved, making the retrograde transit of microorganisms difficult
Causes • Half are caused by respiratory viruses and the remaining are caused
by the respiratory tract bacteria, Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis

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 Acute Otitis Media (AOM)
Subjective • Children will be fussy, irritable, pulling their ear (due to pain)
• Onset of symptoms is preceded by a 2-3 day history of viral URI or allergic
rhinitis
• Associated symptoms: Fever, purulent discharge on the pillow if tympanic
membrane (TM) ruptures and decreased hearing
• Natural course of AOM leads to increasing pain and pressure, finally resulting
in a pinpoint perforation in the TM with immediate cessation of severe pain
due to the release of pressure
Objective • Ear examination (through otoscope):
• Ear canal normal, may have purulent discharge if TM ruptures
• Red, bulging TM with loss of landmarks (light reflex, malleus, short
process)
• TM-reduced mobility
Treatment • Over two-thirds of AOM cases resolve spontaneously without sequelae
(virtually in all viral cases and many bacterial cases)
• Current guidelines recommend that for most children 2 yrs or over, only
analgesic/antipyretics be given for 48 hours
• Almost 75% will resolve without antibiotic therapy 21
Otitis Media With Effusion (OME)
Definition • Characterized by a nonpurulent effusion of the middle ear that may be either mucoid or serous
• In children who have had AOM, more than 60% will have some effusion remaining up to 8
weeks later (follow up visit is important post AOM to check for possible OME)
Pathophysiology • Like AOM, eustachian tube dysfunction is required to develop OME
Subjective • OME is painless unless there are changes in atmospheric pressure as occurs during takeoff and
landing of an aircraft
• Patients may notice a sensation of fullness, decreased hearing, and ear popping when yawning
Objective • Ear (otoscopic) examination:
• Ear canal normal
• TM normal OR retracted against the middle ear bones with prominent short process and
malleus (in severe cases)
• Fluid-air levels or air bubbles behind TM
• TM-reduced mobility
• TM may be somewhat bluish in appearance

FYI: Video about OME

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https://www.ypo.education/ent/ear/otitis-media-with-effusion-t485/video/
 Otitis Media With Effusion (OME)
Treatment • Usually OME resolves spontaneously without sequelae
• OME does not require antibiotic therapy
• The efficacy of decongestants or corticosteroids is controversial
• In some cases the inflammation creates bubbles of CO2 in the fluid, which diffuse out into the blood
stream, creating a vacuum that pulls the TM back against the middle ear bones, causing them to touch
each other
• Untreated, this can eventually cause permanent hearing loss when the bones fuse
• Treatment of severe OME with a retracted TM requires the placement of pressure equalization tubes (PE
tubes) through the TM
• The tubes function to equalize the pressure, relieving the retraction induced contact with the bones
of the middle ear, while allowing the inflammation to run its course

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 Chronic Suppurative Otitis Media (CSOM)
Definition • Perforated tympanic membrane with persistent drainage from the middle ear for more than 2-
6 weeks
Pathophysiology • Requires the presence of a large central perforation in the TM
• Bacteria migrate through the central perforation, often facilitated by water from swimming or
showering
• Once inside the middle ear, they infect tissue and with accompanying inflammation, cause
a purulent discharge
• If untreated, this process can destroy important middle ear tissue, and invade the mastoid
and other bony structures of the cranium
• In chronic cases, a whitish cyst made up of epithelial tissue called a cholesteatoma may form
• This tissue can enlarge, become infected, and eventually destroy middle ear bones

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 Chronic Suppurative Otitis Media (CSOM)
Causes • Causes: Trauma, placement of PE tubes, high fever, and repeated episodes of AOM with
perforation
• Pathogens come from the flora of the external canal with Staphylococcus species and
Pseudomonas aeruginosa predominating as causative agents (other gram negative can be
involved)
Subjective • The two major symptoms of CSOM are decreased hearing and a purulent discharge for
>14 days
• Pain is generally not a prominent feature except in more widespread disease
Objective • Otoscopic examination:
• Ear canal normal unless discharge
• Large central TM perforation with pus
• Red middle ear tissue
• Cholesteatoma (in long standing disease)
Treatment • Patients with suspected CSOM should be referred to an otorhinolaryngologist, as soon as
possible, for definitive treatment (Abx)
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 Otitis Externa (Swimmer’s Ear)
Definition • Infection of the external ear canal
Causes • Risk factors: Trauma from cleaning ears with foreign objects, wearing earpieces
chronically, constant moisture from sweat (especially while wearing earphones),
frequent immersion of head in water (swimming)
• Common pathogens include normal external ear canal flora including
Staphylococcus sp, Pseudomonas aeruginosa, and multiple fungi
Subjective • Pain/discomfort and a purulent discharge, potentially decreased hearing if canal
mostly occluded (depending on the amount of swelling and debris)
• Yawning and laying on the ear may worsen pain
Objective • Ear examination:
• Pain with a firm pull on the earlobe (pinna) or pressure on the tragus (the
cardinal diagnostic finding not found in other diseases)
• External canal red swollen with purulent discharge, with fungal infections
picturesque growths with colorful spores or hyphae may be seen
• TM normal (swelling, debris, and especially pain in the external canal may
prevent complete visualization of the TM)
• Peri- or post-auricular lymphadenopathy may occur
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 Ear Pain With a Normal Otoscopic Examination
• Think of referred pain from a dental problem, pharyngitis, or TMJ pain
dysfunction syndrome
• Specific problems may include a tooth abscess or streptococcal pharyngitis
• A normal otoscopic examination in this setting warrants a mouth and
throat examination by applying pressure on each tooth with a tongue
depressor to detect abscessed teeth
• Also palpation over the TMJ and observation of the mouth opening
should be conducted

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 TMJ Pain Dysfunction
Syndrome
Definiti • Temporomandibular joint dysfunction (TMD, TMJD) is
on an umbrella term covering pain and dysfunction of the
muscles of mastication (the muscles that move the
jaw) and the temporomandibular joints (the joints
which connect the mandible to the skull
Causes • Can cause pain in the area of the ear due to muscle
spasms caused by grinding the teeth (bruxism), or
structural and/or functional abnormalities of the TMJ
Subject • Patients may complain of ear pain, headache, or
ive tinnitus
• Jaw may temporarily lock when opening mouth wide
• Patients may admit to a grinding, clicking, popping,
snapping sensation or noise when they open and close
their mouth

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 TMJ Pain Dysfunction
Syndrome
Objectiv • Ask if they grind their teeth at night and how frequently
e they chew gum, as both are typical in TMJ pain
dysfunction syndrome
• Examination:
• Press gently against the TMJ (just in front of the
ears) and have the patient open their mouth slowly.
Any clicking, grinding, popping sensations palpated
may indicate TMJ problems
• Palpable muscle spasms may be felt over the joint,
which is typical
• Watch the opening of the mouth carefully. If it does
not open smoothly straight up and down, there may
be TMJ problems
• Check for dental malocclusions especially an
underbite
• Patients suspected of TMJ problems should be
initially referred to a dentist for further evaluation
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 Summary EAR
A. DIAGNOSTIC SCHEMATA FOR EAR PAIN/DISCHARGE
•Acute Otitis Media •Chronic Suppurative Otitis Media •TMJ Pain Dysfunction Syndrome
•Otitis Media With Effusion (Serous Otitis Media) •Otitis Externa (Swimmer’s Ear)
B. DIFFERENTIAL DIAGNOSIS OF EAR PAIN/DISCHARGE
SUBJECTIVE Acute Otitis Media Otitis Media With Effusion (Serous Otitis Chronic Suppurative Otitis Media Otitis Externa (Swimmer’s ear) TMJ Pain Dysfunction Syndrome
Media)
Location N/A N/A N/A N/A N/A
Onset Typically get URI for 2 to 3 days, then notice ear s Usually occurs post- None Occurs after periods of excessive moistu Variable with severity of TMJ disorder a
ymptoms or allergic rhinitis symptoms for several AOM or when allergic rhinitis symptoms re and/or trauma to the external canals nd presence of modifying factors
days prominent
Quantity Severe discomfort, although infants may just be f Painless unless changes in atmospheric Severity varies from significant to none Pain varies but can be severe Severity of discomfort varies depending
ussy or irritable and toddlers, young children ma pressure on severity of TMJ disorder and other m
y just pull at ear odifying factors
Pain disappears if TM ruptures
Quality Varies Fullness in ear Varies Varies Ache to muscle spasm
Setting Requires eustachian tube dysfunction and the pa Requires eustachian tube dysfunction None Lots of moisture in the ear due to head None
ssage of viruses or bacteria from the nasopharyn sets, earphones, swimming
x Picks at ear with foreign object, e.g., Q-
tip, bobby pin
Associated sy Purulent discharge on the pillow if TM ruptures Ear popping when yawns Purulent discharge on the pillow Purulent discharge on the pillow Headache, grinding or popping noise wh
mptoms Decreased hearing Decreased hearing Decreased hearing Potentially decreased hearing if canal m en open mouth. Jaw may temporarily lo
May have perennial allergic rhinitis and i ostly occluded ck when opening mouth wide
ts symptoms
Modifying fac None None None Yawning, laying on the ear may worsen Grinding teeth at night, chewing gum m
tors pain akes it worse
OBJECTIVE Acute Otitis Media Otitis Media With Effusion (Serous Otitis Chronic Suppurative Otitis Media Otitis Externa (Swimmer’s ear) TMJ Pain Dysfunction Syndrome
Media)
° °
Fever Mild to moderate (38 C to 40 C) None Usually none Usually none None
Ear examinati Ear canal normal, may have purulent discharge if Ear canal normal.TM normal to retracte Ear canal normal unless discharge Pain on pinna traction or tragus pressur Normal
on TM ruptures d with prominent short process and mal Large central TM perforation with pus, r
e
Red, bulging TM with loss of landmarks (light refl leus ed middle ear tissue, or cholesteatomaExternal canal red swollen, with purulen
ex, malleus, short process) Fluid-air levels or air bubbles behind TM t discharge, picturesque growths
TM-reduced mobility TM-reduced mobility TM normal if visualized
Other Palpation of TMJ reveals crepitus when
opening mouth and/or muscle spasm
Underbite or other malocclusion
Mouth does not open straight vertically
Usual causati Viral, Streptococcus pneumoniae, H. influenzae, None usually Staphylococcus sp, Pseudomonas, fungi Staphylococcus sp, Pseudomonas, fungi None
ve agents Moraxella catarrhalis 30
5.A NOSE

5.B EARS

5.C THROAT

5.D COUGH
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 Sore Throat/Hoarseness
• Bacterial Pharyngitis: Streptococcus pyogenes (Group A β-hemolytic strep or
GABHS) also known as strep throat is the most common
• Viral Pharyngitis
• Mononucleosis
• Herpangina
• Hand, Foot, and Mouth Disease (HFMD)
• Post-nasal Drip due to Allergic Rhinitis/URI (PND)

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Posterior Pharynx/Pharyngitis

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 Streptococcal Pharyngitis
Definition • Infection of the back of the throat including the tonsils caused by group
A streptococcus (GAS)
Epidemiology • Occurs most frequently in elementary school-age children (ages 5 to 11) and those in
contact with them
• Occurs primarily during school year in fall/winter
Causes • Strep throat is caused by a Group A β-hemolytic strep (Streptococcus pyogenes)
Complications • Accurate diagnosis is needed to prevent nonsuppurative (autoimmune) inflammatory
sequelae (acute rheumatic fever) in untreated patients
• Acute rheumatic fever occurs between 2 and 5 weeks after the sore throat and
presents with fever, carditis, migratory polyarthritis, and/or chorea
• The carditis can result in permanent valvular damage and risk for developing
bacterial endocarditis
• Scarlet fever (a possible manifestation):
• Occurs in small number of patients, caused by strep, treat ASAP
• Skin rash comprised of fine red papules on the trunk that spread to the extremities
but not the palms and soles of the feet
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 Streptococcal Pharyngitis
Subjecti • Onset: sudden/rapid onset of severe symptoms lasting 72
ve hours
• Symptoms: fever (38.4-40 oC) , severe sore throat, severe
pain with difficulty swallowing all day, may have referred ear
pain
• Acidic (citrus juices) or carbonated drinks make pain worse
• Cough and nasal symptoms are uncommon
• Malaise is common, but arthralgias and myalgias are not
• Gastrointestinal symptoms including nausea, vomiting, and
abdominal pain may occur, but are more common in children
• Symptoms lasting longer than or not markedly improved
after 72 hrs should raise the suspicion of other causes such
as viral pharyngitis and mononucleosis
• A recent history of exposure to someone with a severe sore
throat or diagnosed strep throat is common

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 Streptococcal Pharyngitis
Objective • Throat examination: Beefy red posterior pharynx with swollen Rapid antigen
tonsils with exudate (pus) on tonsils or posterior pharynx, fetid detection test (RADT
(foul smelling) breath
• Painful anterior cervical adenopathy is typical
• For examination or rapid antigen test: use tongue depressor or have
patients open their mouth wide, sticking their tongue out
• Throat culture: 48 hours needed for results
• Rapid antigen detection test (RADT): preferred, result is available in
minutes
• Relatively high rate of false-positive (as many as one-fourth of
patients are carriers of β-hemolytic Streptococcus)
• A significant number of false negatives (poor sampling
technique)
• Clinical diagnosis needs a combination of typical features plus
bacteriologic confirmation (additional positive serologic test is
needed for carriers)
• If one tonsillar pillar or the uvula is swollen and displaced and the
patient has difficulty opening their mouth without pain, suspect the
suppurative complication peritonsillar abscess, which requires
immediate referral 36
Streptococcal Pharyngitis

37
 Viral Pharyngitis
Definition • Viral pharyngitis can be caused by numerous viruses
• Acute pharyngitis is an inflammatory syndrome of the pharynx and/or
tonsils caused by several different groups of microorganisms
Epidemiolo • Occurs in all ages, usually milder symptoms
gy
Causes • Common causes: Rhinovirus, adenovirus, coronavirus, herpes simplex,
parainfluenza and RSV (similar to URI)
Subjective • Symptoms and degrees of severity depend on the specific virus
• Symptoms: slower onset, longer duration (5-10 days) , and less pain than
strep throat, usually low grade fever
• Most have additional symptoms such as nasal symptoms, cough, and
conjunctivitis that are very uncommon in patients with strep throat
• In some cases, viral pharyngitis can mimic streptococcal pharyngitis in
every aspect except the positive bacteriological findings
Objective • Throat examination: Variable from mild to severe inflammation

38
 Mononucleosis (Kissing Disease)
Definition • A contagious infectious illness that’s usually caused by the Epstein-Barr virus
(EBV)
• It’s also called mono or “the kissing disease”
Epidemiology • Occurs most frequently in adolescents and young adults
Causes • Most commonly caused by Epstein-Barr virus
• Spread:
• Spread most commonly through bodily fluids, especially saliva (Kissing) but
can also spread through blood and semen during sexual contact, blood
transfusions, and organ transplantations
• Can be spread also by sharing drinks, food, or personal items, like
toothbrushes, with people who have infectious mononucleosis
• Patients can be contagious for weeks before getting symptoms
• EBV stays in the body forever in an inactive (latent) state, and usually gets
reactivated when there is weakened immune system
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 Mononucleosis (Kissing Disease)
Subjective • The onset of the sore throat is slow and it lasts 5 to 7 days with mild to
moderate pain lasting all day (onset may be preceded by fatigue/malaise)
• Most experience significant fatigue and malaise that may last for 4 to 8 weeks
(sometimes it is the primary presenting symptom)
• Since the incubation period is 4 to 6 weeks, few patients remember any
potential exposures

40
 Mononucleosis (Kissing Disease)
Objectiv • Throat examination:
e • Mildly inflamed posterior pharynx (less red than strep), swollen
tonsils
• About half have pus (purulent exudate) with some having profuse
exudates that is continuous over the posterior pharynx and tonsils
• Frenulum of tongue may be jaundiced
• Painful anterior and posterior cervical lymphadenopathy is common, in
some lymphadenopathy may extend to arm pit
• Patients have a low-grade fever and 90% have mildly elevated AST and
ALT levels (Jaundice develops in less than 5% of patients)
• All patients develop some degree of splenomegaly that may not be
evident upon physical examination
• CBC reveals lymphocytosis with the presence of >10% atypical
lymphocytes
• A positive Monospot test and elevated EBV antibody levels are
diagnostic
• Unfortunately, neither tests may be positive during the first 2 weeks of
the disease and may need to be repeated to confirm the diagnosis
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 Herpangina / Hand, Foot, and Mouth Disease (HFMD)
Herpangina Hand, Foot, and Mouth Disease (HFMD)
Definition Herpangina: acute febrile illness associated with HFMD: Mild, contagious viral infection common
small vesicular or ulcerative lesions on the in young children
posterior oropharyngeal structures (enanthem)
Causes • Both are caused by viruses in the enterovirus group, which includes coxsackieviruses and others
Subjective Herpangina Hand, Foot, and Mouth Disease (HFMD)
• Considered as different manifestations along the same disease spectrum
• Both diseases usually present with severe throat pain lasting all day, malaise, and difficulty
swallowing and symptoms last for 7 to 10 days
• Acidic or carbonated drinks make both worse
• Herpangina has a rapid onset and occurs • HFMD has a slightly slower onset of 12 to 36
most frequently in children hours and occurs in patients of all ages
• Herpangina presents with temperatures of • In HFMD, the fever is generally low grade
38.4°C to 40°C
42
 Herpangina/Hand, Foot, and Mouth Disease
(HFMD)
Objective Herpangina Hand, Foot, and Mouth Disease
(HFMD)
• Both have dermatological manifestations in more than 50% of patients
• Painful cervical lymphadenopathy is common in both disorders
• In herpangina, a maculopapular, • In HFMD, the vesicular lesions
vesicular rash appears on the with erythematous borders
Herpangina
trunk typically occur on the palms of
the hands and soles of the feet, as
well as the buttocks in some cases
• Throat examination:
• Both: varying degrees of erythema with red vesicles that ulcerate
and have a red border
• Throat examination: • Throat examination:
• Herpangina: lesions are • HFMD: they occur all over
limited to the posterior the oral cavity including
pharynx and tonsillar pillars tongue and gingivae and
throat
43
 Pharyngitis Due to Post-Nasal Drip
Definition • Patients with both allergic rhinitis and viral URIs can have sore throats
Pathophysiology • Mucus that accumulates in the back of the nose and throat drips downward from the
back of the nose
Epidemiology • Occurs in all ages, rarely is sore throat the primary complaint
Causes • Excess mucus that triggers post-nasal drip has many possible causes, including: colds,
flu, allergies, or sinusitis
Subjective • Mildly painful upon awakening gets better during the day (whereas in most other
causes of pharyngitis, the pain is constant throughout the day and night)
• Slow onset and lasts only as long as rhinitis (nasal symptoms) does
• Symptoms: Symptoms of URI or allergic rhinitis
Objective • Throat examination:
• Reveals drainage or discharge, often in two tracks, on the posterior pharynx. This
drainage is often of similar consistency and appearance as the nasal discharge
(clear to mucoid)
• There may be some mild inflammation on the soft palate or posterior pharynx
44
 Loss of Voice/Hoarseness
Definitio • Loss of voice or hoarseness sometimes accompanies sore throat or it
n can occur by itself
Causes • The most common cause of hoarseness is acute laryngitis:
• Respiratory viruses such as rhinovirus, adenovirus, and
coronavirus are the most frequent cause
• Allergies and voice strain due to overuse are other common causes
• Smokers as well as patients with GERD may also experience
hoarseness:
• Onset of the hoarseness is slow and is accompanied by other
symptoms of the causative disorder
Subjectiv • Loss of voice or hoarseness
e • Symptoms lasting longer than 2 weeks, especially in smokers, should
be referred to an ENT specialist to look for more serious causes such
as laryngeal carcinoma

45
 Viral Laryngotracheobronchitis (Croup)
Definition • Disease of infants and young children in which larynx, trachea, and
bronchi become inflamed due to common respiratory viruses
Epidemiology • Occurs mostly in the winter months
Causes • The most common viral etiologies are parainfluenza viruses
Subjective • Hallmark signs are abrupt onset of a nocturnal cough that sounds like a
seal barking along with inspiratory stridor and trouble breathing
• Severe difficulty breathing, continuous stridor at rest, retractions when
breathing, early cyanosis, and lethargy are all signs of severe disease
that may require immediate treatment and/or hospitalization
Treatment • Most cases are mild and require no treatment other than providing
humidified air for the child to breathe during attacks
• This can be accomplished by taking the child into the bathroom,
closing the door, and turning on the hot water in the shower to fill
the room with steam
• The warm moist air relieves the cough, stridor, and breathing
difficulties
• In severe cases, if the steam does not work well, then the child needs to Check out this video on croup:
be taken to a facility for definitive care 46
https://youtu.be/C1q6ATkMtm0
 Acute Epiglottitis
Definition • Acute inflammation in the supraglottic region of the oropharynx,
with inflammation of the epiglottis, vallecula, arytenoids, and
aryepiglottic folds
Epidemiolo • Incidence has drastically decreased in countries where routine
gy immunization of children against Haemophilus influenzae type b and
Streptococcus pneumoniae has been implemented
• The rate in adults has remained constant with the average
occurrence at age 45 with a gender ratio of 3:1 for males to females
• It is a life-threatening infectious disease, with a 7% mortality rate in
adults
Causes • Haemophilus influenzae type b and Streptococcus pneumoniae
are/were the two most common causes of the disease, although
many other bacterial (and even some viral and fungal) causes have
been documented

47
 Acute Epiglottitis
Subjectiv • It typically presents with an acute onset of sore throat, and
e difficult or painful swallowing
Objectiv • The classic sign is the sudden loss of voice as opposed to the
e slow onset of hoarseness and laryngitis seen in viral
conditions
• Patients generally present with a high fever and in later
stages may experience difficulty breathing and stridor

Treatme • This is a medical emergency and may require tracheostomy to

nt prevent asphyxia and death
• Patients (especially older males) presenting with a severe
sore throat and sudden loss of voice must be immediately
referred

48
 Summary THROAT
A. DIAGNOSTIC SCHEMATA FOR SORE THROAT
•Streptococcal Pharyngitis •Mononucleosis •Hand, Foot, and Mouth Disease (HFMD)
•Viral Pharyngitis •Herpangina •Post-nasal Drip due to Allergic Rhinitis/URI (PND)
B. DIFFERENTIAL DIAGNOSIS OF SORE THROAT
SUBJECTIVE Streptococcal Pharyngitis Viral Pharyngitis Mononucleosis Herpangina HFMD PND
Location May have referred ear pain
Onset Rapid onset of severe symptoms lasting 72 hours Usually slower onset and last Slow onset, lasting 5 to 7 Rapid onset lasts 7 to 10 12 to 36 hours onset, lasts Slow onset, lasts as long
5 to 10 days days may be preceded by days 7 to 10 days as nasal symptoms
fatigue/malaise
Quantity Severe with difficulty swallowing all day Wide range of symptoms from Mild to moderate lasting Severe pain lasting all day Severe pain lasting all day Mildly painful upon
PND to strep, but usually all day difficulty swallowing difficulty swallowing awakening gets better
milder during the day
Quality N/A N/A N/A N/A N/A N/A
Setting Occurs in school-age children beginning in All ages Adolescents/young adults Mostly children All ages All ages
elementary school and those in contact with that (kissing disease)
age group
Occurs primarily during school year in fall/winter
Nausea vomiting in children
Associated Absence of cough or other nasal symptoms Many also have cough and Marked fatigue/malaise Malaise Malaise, skin Symptoms of URI/ allergic
symptoms URI symptoms manifestations rhinitis
Modifying Acidic or carbonated drinks make it worse Certain forms can mimic strep Acidic or carbonated Acidic or carbonated
factors drinks make it worse drinks make it worse
OBJECTIVE Streptococcal Pharyngitis Viral Pharyngitis Mononucleosis Herpangina HFMD PND
° ° ° °
Fever 38.4 C to 40 C Usually low grade Low-grade fever 38.4 C to 40 C Usually low grade None
Throat Beefy red posterior pharynx with swollen tonsils Variable from mild to severe Mildly inflamed posterior Multiple vesicles and/or Similar lesions to Mildly inflamed posterior
examination with exudate (pus) on tonsils or posterior pharynx inflammation pharynx, swollen tonsils ulcerations with red herpangina only pharynx with clear to
About half have pus. A border on posterior distributed all over oral mucoid nasal mucous
few with sheets of pus pharynx and tonsils cavity and throat drainage
Frenulum of tongue may
be jaundiced
Other Painful anterior cervical lymphadenopathy Many have viral URI findings Elevated AST/ALT 50% have truncal rash 67% have painful blisters Findings of allergic rhinitis
on palms, soles, and or viral URI
buttocks
Fetid breath Positive Monospot test
Positive throat culture or rapid strep test Painful anterior/posterior
cervical lymphadenopathy
Lymphadenopathy may
extend to arm pit 49
Usual causative β-hemolytic Streptococcus pyogenes Same as URI Epstein-Barr virus Coxsackievirus, Coxsackievirus,
5.A NOSE

5.B EARS

5.C THROAT

5.D COUGH
50
 Cough Classification
• Bacterial Pneumonia
Productive Cough • Acute Bronchitis
• COPD (Acute/Chronic)

Subacute/Chronic • Asthma
• Tuberculosis (TB)
Nonproductive • Lung Cancer
(Dry Hacking) • GERD
• Medication (ACE Inhibitors)
Cough • Pertussis

• Upper Airway Cough Syndrome (UACS)

Acute/Subacute • Post-Infectious Cough Syndrome (PICS)
Mixed/Variable • Influenza/Viral Pneumonia
• Congestive Heart Failure (CHF)
Productivity Cough • Atypical Pneumonia
51
Auscultation Of Breath Sounds
Play below video for Lung sounds (respiratory
auscultation sounds)

FYI: Check out this video, it explains a complete respiratory exam

52
https://youtu.be/gRWSyqatWQQ
 ACUTE COUGH WITH PRODUCTIVE SPUTUM
Bacterial Pneumonia
Definitio • Community-acquired bacterial pneumonia (CAP) presents with a
n previous history of upper or lower respiratory infection that has
transformed into a purulent productive cough throughout the day
Causes • CAP: Streptococcus pneumoniae, Haemophilus influenzae, atypicals
• Inpatient: gram-negative rods, e.g., Klebsiella, Pseudomonas, or
MRSA
Subjectiv • Cough: frequent and purulent (mucous is opaque, dark yellow,
e brownish, or may be blood tinged)
• Onset: Gradual, 7 to 10 days after onset of viral URI or acute
bronchitis
• Symptoms: High grade Fever (>100°F (37.8°C)), tachypnea,
tachycardia, and elevated WBC and neutrophil counts
• Dyspnea and sometimes chest pain are present in all pneumonia
types
• Elderly may present as primarily a behavior change, fatigue,
malaise feverish, shortness of breath (not the typical symptoms)
53
 Bacterial Pneumonia
Objectiv • Auscultation and percussion of lungs: Crackles around
e area of consolidated infiltrates
• If large infiltrate, may not hear breath sounds over
central area and may have bronchophony,
egophony
• Chest X ray: Consolidated infiltrates (gold standard for
diagnosis)

• Atypical pneumonia:
• Symptoms tend to be milder; there is a lower incidence of productive
cough and less of a febrile response
• Atypical/ Viral pneumonia:
• Less neutrophil response than bacterial, infiltrates tend to be
interstitial rather than lobar in nature, auscultation can reveal crackles,
rhonchi… but have a much higher frequency of wheezing than
bacterial
• Elevated procalcitonin levels usually are absent in viral and atypical
infections , procalcitonin is usually high in bacterial
• In many cases determining the etiology is hard, antibiotics chosen will cover
both common typical and atypical bacteria 54
 ACUTE COUGH WITH PRODUCTIVE SPUTUM
Acute Bronchitis
Epidemiology • Over 90% of the cases of acute bronchitis in teens and adults are viral and
antibiotics offer no benefit
Causes • Pathogens generally same as common cold with more severe presentations:
rhinovirus, influenza, parainfluenza, respiratory syncytial virus, coronavirus,
and adenovirus
Subjective • Onset: Gradual, near the end of a URI (later stages of a viral URI)
• Low grade fever <100° F (37.8°C) (if any)
• Cough: Frequent cough, mucoid sputum (may be green tinged) worse in the
am and night
• Symptoms last from 1 to 3 weeks
Objective • Chest x-ray: normal
• Tachypnea and tachycardia are uncommon (suspect pneumonia if they
occur)
• Auscultation and percussion of lungs: Mostly clear, but may have rhonchi,
which clear/change after coughing, rarely expiratory wheezes
• Many patients with acute bronchitis develop bronchial hyperresponsiveness
and may experience expiratory wheezes: Inhaled β-adrenergic
bronchodilators such as albuterol are the treatment of choice 55
 Chronic obstructive pulmonary disease
(COPD)
Definitio • Will be discussed in details later as a separate lecture
n • Patients present with a productive cough that can be classified as
acute in acute exacerbation and chronic in stable disease
• COPD involves permanent changes to lung structure primarily due
to long-term smoking
Causes • Long-term smoking
Subjectiv • Onset: Very slowly after years and years of smoking (main cause),
e environmental or occupational hazard exposure
• Cough: frequency varies because coughing is to clear excessive
mucous from lungs, primarily mucoid sputum, increased in sputum
volume and/or purulence is noticed in exacerbations
• Stable patients are usually afebrile, but due to poor pulmonary
function have tachypnea and tachycardia

56
 Chronic obstructive pulmonary disease
(COPD)
Objecti • Chest X ray: Usually normal. May have markings
ve indicating emphysema
• Auscultation and percussion of lungs: may be
without findings in early stages, as the disease
progresses, auscultation reveals primarily
rhonchi (which change/clear after coughing) but
wheezing and occasional crackles may occur,
patients with emphysema and advanced disease
may have faint breath sounds
• In advanced stage: Use of ancillary muscles in
throat and neck to help breathing, enlarged
sternocleidomastoid muscles, cannot speak in
complete sentences, may have tachypnea even
on oxygen, markedly reduced pulmonary
function tests
57
SUBACUTE/CHRONIC COUGH WITH NO SPUTUM PRODUCTION
Asthma
Definition • Will be discussed in details later as a separate lecture
Pathophysi • Asthma is characterized by chronic inflammation of the small
ology airways of the lungs, which leads to bronchospasm and the
symptoms of asthma
Causes • Roughly 80% of asthmatics have involvement of IgE and up to
75% have a personal or family history of one or more of the
atopic triad (allergic rhinitis, atopic dermatitis, or asthma)
Subjective • Asthma attacks typically include a decreased peak expiratory
flow rate due to bronchoconstriction, cough, expiratory
wheezing, and difficulty breathing (dyspnea) that may be
manifested by a tightness in the chest
• In severe attacks, which may be called “status asthmaticus” if
patients do not respond quickly to standard treatments,
tachypnea and tachycardia can occur and patients may feel
like they are suffocating
58
 Asthma
Objecti • Asthma may present with an acute attack, but
ve frequently presents in a more subtle form as a
dry hacking cough
• Because the vital capacity of the lungs is lowest
between 2 and 6 in the morning, patients with
subclinical bronchospasm become hypoxic and
begin a series of coughs to increase oxygen
intake
• Repeated coughing episodes between 2 and 6
am can be an indicator of mild asthma and
should be investigated
• People may get coughing spells while running or
during exercise, causing them to stop exercising
or playing due to the coughing
• Cough preparations ineffective
59
 Tuberculosis (TB)
Definition • Potentially serious infectious disease that mainly
affects your lungs
Pathophys • Infection develops mostly in the lung, but can be
iology found in the pleura, lymphatic system, kidney,
central nervous system, and bone or joints
• Transmitted by aerosolized droplets released into
the air by coughing
• TB bacilli grow in alveolar lung tissue,
macrophages wall off TB bacillus forming a
granuloma, and no further growth or clinical
disease occurs, this is called latent TB
Setting • Living in close quarters with someone with active
TB, travel to potential endemic TB area
Causes • Mycobacterium tuberculosis
60
 Tuberculosis
Subjective • This primary infection is usually asymptomatic
• Patients whose immune systems are functioning have no symptoms and normal chest
x-rays
• Patients who eventually develop active TB do so because of a reactivation of a latent
primary infection when immunity fails to control it
• Symptoms:
• Dry cough, less than half the patients present with fever and/or night sweats
• Fatigue, malaise, and weight loss frequently accompany other symptoms
Objective • Auscultation: normal breath sound
• Active TB typically presents as a dry hacking cough
• Diagnostic tests:
• Positive PPD: tuberculin purified protein derivative administered intradermally, >15
mm induration (the lump, not the redness) is called a positive test
• Positive acid fast stain of sputum sample
• Positive interferon-γ release assay (very specific)

61
 Cancer
Causes • Patients with COPD or a productive smoker’s cough might note a change in cough
frequency or severity or notice blood in their sputum
• Patients generally have a significant history of smoking or exposure to
secondhand smoke
• Non COPD patients present with normal findings on auscultation
Subjective • Patients with lung cancer present with a subacute or chronic dry hacking cough
• Patients may present with fatigue, malaise, unexplained weight loss, night sweats
or some change in their ability to breathe normally
Objective • Definitive diagnosis of cancer type requires invasive procedures such as lung
biopsy to obtain a specimen from the tumor or lesion
Treatment • Patients suspected of having lung cancer need referral for chest x-ray or
computerized tomography of the lungs

62
 Gastroesophageal Reflux Disease (GERD)
Definition • Stomach acid frequently flows back into the tube
connecting your mouth and stomach (esophagus)
Pathophysio • Causes a dry hacking cough when stomach contents reflux
logy into the distal esophagus via an esophageal-
tracheobronchial reflex
Subjective • Associated with heartburn or sour taste in the mouth
• Cough occurs most frequently within an hour of lying
down horizontally (worse at night)
• Cough preparations ineffective
Objective • Chest x-rays and auscultation of the lungs are normal
Treatment • While proton pump inhibitor (PPI), antacids, and H2
blockers therapy can help in many patients, in others
normalizing the pH has no impact on the cough

63
 Angiotensin-Converting Enzyme
Inhibitors
Definition • Angiotensin-converting enzyme (ACE) inhibitors cause a dry hacking cough
Pathophysiology • Interfere with the normal breakdown of bradykinins in the lungs→ stimulation
of nitric oxide synthetase→ local accumulation of Nitric Oxide, an irritant to
lung tissue, causing a characteristic cough
Causes • ACE inhibitors
Subjective • Cough: Dry, hacking, very mild, not forceful, can be almost like clearing throat,
irritation, urge to cough
• Cough usually occurs within a week to 6 months after initiating ACE inhibitors
or increasing the dose
Objective • Radiological and physical examination findings are negative
Treatment • It typically stops within a week of discontinuation of ACE inhibitor therapy,
but may take up to a month

64
 Pertussis (Whooping Cough)
Definition • Pertussis is the primary non-viral cause of acute bronchitis in adults and
teenagers, representing less than 10% of all acute bronchitis infections
Epidemiology • Potentially fatal in unvaccinated infants, but much milder form in adults and
teens, without the classical “whoop” seen in infants
Causes • Caused by the bacteria Bordetella pertussis
Subjective • It typically presents as a dry hacking cough, >90% have episodic coughing spasm
(violent leaving patient breathless and might cause vomiting), >80% of cough
during the night (worse at night)
• Cough can last up to 8 weeks
Objective • Chest x-ray is negative, fever is either low grade or absent
• Auscultation: mostly clear but in some patients inspiratory stridor or expiratory
wheezes can be heard

65
ACUTE/SUBACUTE/CHRONIC COUGH WITH MIXED
OR VARIABLE PRODUCTIVITY
• Upper Airway Cough Syndrome (Post-Nasal Drip):
Definition • Any disease that causes post-nasal drip can cause a cough
Causes • During or after a viral URI or allergic rhinitis
Subjective • Cough: usually dry, potentially some productivity in the morning
• The cough is most notable in the first hour immediately after lying down for
sleep due to drainage from the sinus cavities and into the throat (PND)
Objective • Physical examination of the lungs is negative, No or low grade fever
Treatment • Antihistamines and decongestants can help with cough

66
 Post-Infectious Cough Syndrome (PICS)
Definition • Viral respiratory infections that involve the lower respiratory tract can result in a
lingering cough lasting 2 to 8 weeks with few physical findings consistent with
infection
Pathophysiology • The viral infection is thought to create enough irritation and inflammation to cause the
cough to continue long past the presence of an infectious process
• The continuing cough is the result of bronchial hypersensitivity and
hyperresponsiveness manifested as a cough
Causes • Viral respiratory infections
Subjective • Cough: Usually dry, potentially some productivity in the morning
• Cough preparations ineffective
Objective • Normal breath sounds, occasionally expiratory wheezes
Treatment • If a cough lasts more than 8 weeks, then further diagnostic workup is warranted,
looking for chronic causes including asthma, allergic rhinitis, TB, and cancer

67
 Influenza/Viral Pneumonia
Epidemiology • Viral pneumonias represent about 20% of community-acquired pneumonias in adults
and a much higher percentage in children
Causes • Influenza virus is the most common
• Other causes are respiratory syncytial virus, adenovirus, parainfluenza, and
coronavirus
• Other viruses cause milder symptoms, and the illness evolves more slowly with
many having symptoms of a viral URI as the initial presentation
Subjective • Cough: Initially dry, can change to mildly productive
• Cough preparations effective
• Influenza: abrupt onset, severe systemic symptoms such as high fever, malaise, aches
pains, and chills /Influenza detection tests are available
Objective • Auscultation: Clear to rhonchi, crackles, and expiratory wheezes (variable)
• Chest X ray: Normal to feathery interstitial infiltrates
• Leukocytosis with a neutrophilic response and elevated serum procalcitonin levels are
uncommon (Bacterial)
68
 Congestive Heart Failure (CHF)
Definition • Congestive heart failure can be a cause of cough
Pathophysi • Fluid accumulates as edema in the lower extremities during
ology the daytime
• Approximately 2 to 3 hours after laying down, the
edematous fluid redistributes itself in the vascular
compartment, overcoming the failing heart’s pumping
capability and causing fluid to leak into the lungs alveolae
• Patients wake up coughing, and/or short of breath several
hours after going to bed
• Sitting up or standing up causes the excess fluid to repool in
the periphery, reducing cardiac workload and causing the
symptoms to go away
• This is called paroxysmal nocturnal dyspnea or PND
• Patients realize over time that sleeping propped up with
several pillows or sleeping in a recliner prevents those
nocturnal events, this is called “Orthopnea”
69
 Congestive Heart Failure (CHF)
Subjective • Cough: can range from dry to productive depending on the severity of the heart failure
with frank pulmonary edema presenting with a productive cough
• Cough preparations ineffective
Objective • Physical examination of the lungs in the early stages is generally normal except for
cardiac enlargement upon percussion and peripheral edema due to excess fluid (pedal
edema)
• Once pulmonary edema occurs at any posture, crackles in both lungs or absent breath
sounds predominate physical findings along with a productive cough
• Chest X ray: Enlarged heart, fluid in base of both lungs

70
 Atypical Pneumonia
Definition • Atypical pneumonia or walking pneumonia was coined to describe pneumonias that
presented differently from typical bacterial pneumonia
• Atypical pneumonia also tends to have milder symptoms than typical pneumonia
Epidemiology • Atypical pathogens represent almost 25% of the causes of CAP in adults
Causes • Caused by atypical bacteria : Chlamydia pneumoniae, Mycoplasma pneumoniae,
Legionella
Subjective • Do not cause the classical symptoms or responses of bacterial pneumonia and
represent almost 25% of the causes of community-acquired pneumonia in adults
• Cough: Initially dry but can progress to productive
• Cough preparations effective
• Symptoms: develops over several days/weeks, mild symptoms that may worsen with
time (check each type in the coming slide)
Objective • Auscultation: Crackles, rhonchi with occasional expiratory wheezes

71
 Atypical Pneumonia
Mycoplasma pneumonia
• Is most common in school-aged children and
young adults
• The onset of illness is gradual and initial
symptoms may include headache, malaise, and
low-grade fever
• Patients generally feel worse than physical
findings would indicate
• The cough is usually nonproductive to mildly
productive and symptoms involving the upper
respiratory tract might be present
• The white blood count is normal in the vast
majority of patients, but in severe disease
there is a neutrophilic response typical of
bacterial pneumonias
• Chest x-ray abnormalities are typically
feathery rather than consolidated infiltrates
• Elevated cold agglutinin titers in 50-75 % of
cases
Chlamydophila pneumoniae
• Less frequent cause of
atypical pneumonia, but
parallels Mycoplasma in
terms of clinical
presentation
• Differs from Mycoplasma in
the presence of laryngitis
in most patients as a typical
symptom
Legionella infections
• Are the least common atypical pathogen
• Smokers, patients with chronic lung disease, or
immunosuppressed patients are at higher risk
• Clinical presentation most closely resembles
that of classical bacterial pneumonia with the
exception of minimal to mild sputum production
• Legionella infection should be suspected in
patients with pneumonia accompanied by a
high fever (>39°C), gastrointestinal symptoms,
especially diarrhea, a Gram stain of sputum
that reveals lots of neutrophils but no bacteria
• Elevated liver function tests are also a common
finding
• Radiologically, Legionella infections tend to be
more like bacterial pneumonia
• Urinary antigens can be diagnostic for the main
serotypes
72
 SUMMARY COUGH: Productive Cough

A. DIAGNOSTIC SCHEMATA FOR PRODUCTIVE COUGH

•Bacterial Pneumonia
•Acute Bronchitis
•Chronic Obstructive Pulmonary Disease (COPD)
B. DIFFERENTIAL DIAGNOSIS OF PRODUCTIVE COUGH
SUBJECTIVE Acute Bronchitis Bacterial Pneumonia COPD
Location N/A N/A N/A
Onset Gradual near the end of a URI Gradual, 7 to 10 days after onset of viral URI or acute Very slowly after years and years of smoking,
bronchitis environmental or occupational hazard exposure
Quantity Frequent coughing Frequent coughing Frequency varies because coughing is to clear excessive
mucous from lungs
Quality Mucoid sputum worse in the am and night Purulent (dark yellow/brown blood tinged) sputum Primarily mucoid sputum
throughout the day
Setting Usually associated with the later stages of viral URI Heavy chronic smoker

Associated symptoms May have remnants of a viral URI Elderly may present as primarily a behavior change, Shortness of breath
fatigue, malaise feverish, shortness of breath

Modifying factors Nothing seems to help Nothing seems to help Nothing seems to help
OBJECTIVE
Fever Low-grade fever <100° F (37.8°C) High-grade fever >100° F (37.8°C) Afebrile
Chest x-ray Normal Consolidated infiltrates Usually normal. May have markings indicating
emphysema
Auscultation and percussion of lungs Mostly clear, but may have rhonchi, which clear/change Crackles around area of consolidated infiltrates. If large Usually rhonchi, which change/clear after coughing.
after coughing, rarely expiratory wheezes infiltrate may not hear breath sounds over central area. Patients with emphysema may have faint breath
May have bronchophony, egophony sounds. Also in more advanced disease

Other findings May have URI findings Tachycardia, tachypnea, WBC >10,000/mL with >80% Use of ancillary muscles in throat and neck to help
PMNs (mature plus immature) breathing, well-developed sternocleidomastoid
muscles. Cannot speak in complete sentences. May
have tachypnea even on oxygen. Markedly reduced
pulmonary function tests
Usual causative agents 90% viral, 10% pertussis CAP: Streptococcus pneumoniae, Haemophilus Smoking
influenzae, atypicals. Inpatient: gram-negative rods,
e.g., Klebsiella, Pseudomonas, or MRSA
73
 SUMMARY COUGH: Subacute/Chronic Nonproductive (Dry) Cough
A. DIAGNOSTIC SCHEMATA
•Asthma Gastroesophageal Reflux Disease (GERD)
•Tuberculosis (TB) Medication (ACE Inhibitors)
•Lung Cancer Pertussis
B. DIFFERENTIAL DIAGNOSIS OF DRY HACKING SUBACUTE OR CHRONIC COUGH
SUBJECTIVE Asthma TB Cancer GERD Drugs Pertussis
Location N/A N/A N/A N/A N/A N/A
Onset After running for a short while. Worse at night in some stages N/A Starts within 1 hour after lying Within days to years of starting Sudden and dramatic initially.
Daily at 2 to 6 am down on medication May last for up to 8 weeks
Quantity Between 2 and 6 am coughs Varies Varies Varies Varies Worse at night
several times then stops
Quality Dry, hacking Usually dry, hacking Dry, hacking Dry, hacking Dry, hacking, very mild, not Dry, hacking cough >90% have
forceful. Can be almost like episodic coughing spasm
clearing throat, irritation, urge to
cough
Setting Same as onset Living in close quarters with Smoker, history of smoking Same as onset Same as onset Same as onset
someone with a chronic cough.
Travel to potential endemic TB
area
Associated symptoms History or symptoms of allergic Weight loss, night sweats, Weight loss, night sweats, History of GERD or frequent None >15% have trouble breathing
rhinitis and/or atopic dermatitis fatigue, malaise fatigue, malaise heartburn, that is worse at night after coughing spasm. 30% to
40% of patients have at least
one episode of vomiting due to
violent coughing spasms
Modifying factors Cough preparations ineffective Cough preparations ineffective Cough preparations ineffective Cough preparations ineffective. Cough preparations ineffective Cough preparations ineffective
Exercising may exacerbate Better with antacids, PPIs,
cough H2 blockers
Cough stops shortly after
ceasing to exercise
OBJECTIVE Asthma TB Cancer GERD Drugs Pertussis
Fever None Uncommon in early stages None None None None or low grade
Auscultation and percussion Normally clear but can have Normal breath sounds Normal breath sounds Normal breath sounds Normal breath sounds Mostly clear but can have
of lungs expiratory wheezes inspiratory stridor or expiratory
wheezes
Chest x-ray Normal Varies Varies Normal Normal Normal
Other Evidence of active atopic Positive PPD None None Stops several weeks after drug None
dermatitis and or allergic rhinitis discontinued

Peak flow (PEFR) <80% of Positive acid fast stain of sputum

predicted value sample
Positive interferon-γ release
assay
Usual causative agent IgE-mediated allergic reaction Mycobacterium tuberculosis N/A Acid reflux ACE Inhibitor Bordetella pertussis
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 SUMMARY COUGH: Acute/Subacute Mixed/Variable Productivity Cough
A. DIAGNOSTIC SCHEMATA
•Upper Airway Cough Syndrome (UACS) Influenza/Viral Pneumonia •Atypical Pneumonia
•Post-Infectious Cough Syndrome (PICS) Congestive Heart Failure (CHF)
B. DIFFERENTIAL DIAGNOSIS OF ACUTE/SUBACUTE/CHRONIC COUGH OF MIXED OR VARIABLE PRODUCTIVITY
SUBJECTIVE UACS PICS Influenza/Viral CHF Atypical Pneumonia
Location N/A N/A N/A N/A N/A
Onset During or after a viral URI or After a viral respiratory infection Sudden onset Starts about 2 to 4 hours after Develops over several
allergic rhinitis lying down days/weeks
Quantity Thought to be caused by post- Lasts 2 to 8 weeks postinfection Varies Excess fluid pooled in lower Mild symptoms that may worsen
nasal drip (PND) occurs extremities redistributes to with time
frequently during the first hour vascular system
after lying down to sleep
Quality Usually dry. Potentially, some Usually dry. Potentially some Initially dry, can change to mildly Dry or unknown in early stages. Initially dry but can progress to
productivity in the morning productivity in the morning productive Productive as pulmonary edema productive
progresses
Setting Same as onset Recent viral respiratory tract Exposure to influenza Same as onset Same as onset
infection
Associated symptoms History or symptoms of allergic Recent history of URI High fever, malaise, myalgia, PND, orthopnea, pedal edema Fever, malaise, myalgia,
rhinitis and/or viral URI arthralgia, sore throat, runny nose arthralgia, sore throat, possible
(20%) GI symptoms
Modifying factors Antihistamines and Cough preparations ineffective Cough preparations effective in Goes away in minutes after Cough preparations effective
decongestants can help with pneumonia phase patient sits or stands. Cough
cough preparations ineffective. Sleeping
propped up with extra pillows
prevents awakening
OBJECTIVE UACS PICS Influenza/Vira CHF Atypical Pneumonia
Fever None or low grade None High fever None Yes, but severity varies, generally
low grade
Auscultation and percussion of Normal breath sounds Normal breath sounds, Clear to rhonchi, crackles, and Crackles in both lung bases. May Crackles, rhonchi with occasional
lungs occasionally expiratory wheezes expiratory wheezes have dullness over crackles expiratory wheezes
Chest x-ray Normal Normal Normal to feathery interstitial Enlarged heart, fluid in base of Various infiltrates (feathery,
infiltrates both lungs consolidated, interstitial)
Other Signs of allergic rhinitis or viral None Positive POS tests for influenza A Edema, tachypnea, tachycardia Elevated cold agglutinin titers
URI or B in Mycoplasma (50% to 75%)
Usual causative agent Post-nasal drip Hyperresponsive/ hypersensitive Type A and B influenza viruses, Fluid in alveolae Atypical bacteria
airways RSV (Chlamydiohila, Mycoplasma, Leg
ionella)
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CASE 7.1
• SM, a regular customer at your store, comes in to pick up her
mother’s prescription. As she pays for the prescription, she asks: “Is
there anything better than Actifed for this cold I’ve got? I’m tired of
being stuffed up. It’s been six days!”
• Based on the information above, what are three likely causes for SM’s
symptoms? Explain your rationale.
• _________________________________
• List 10 questions you would ask, physical examinations you would conduct, or
lab tests you would order to identify the etiology of SM’s symptoms.
• _________________________________

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CASE 7.2
• Iloff Medkem, a first-year pharmacy student, has the “ 2014 Crud,” which
began 8 days ago with fever, rhinorrhea, facial fullness, myalgias, and
arthralgia. After 5 days he began to feel better. However, his rhinorrhea
returned 2 days ago as a mucoid discharge. Today he presents with pain
under both eyes and the discharge has markedly changed.
• List three questions you would ask to clarify his problem.
• _________________________________
• List three physical examinations you would perform to clarify the diagnosis.
• _________________________________
• What is the most likely diagnosis if the questions and examinations you listed above
are positive?
• _________________________________

77
CASE 7.3
• Howican Paddle presents to the pharmacy with a 3-day history of
right ear discomfort with decreased hearing. This morning he woke
up with a small yellow stain on his pillow.
• What are the two most likely causes of his symptoms? Explain your rationale.
• _________________________________
• List two questions you would ask to help identify the cause. Explain your
rationale.
• _________________________________
• For each of the diagnoses listed in question a above, list expected findings on
ear examination.
• _________________________________

78
CASE 7.4
• FF, a 33-year-old fourth-grade teacher asks what would be good for
this bad sore throat he has had for the last 48 hours.
• List 10 questions/physical examinations/lab tests you would want to ask,
conduct or order to confirm your assessment.
• _________________________________

79
CASE 8.1
• Roby Tussin, a 68-year-old male, presents to the pharmacy 4 months after
a bout of viral pneumonia. When you ask how he is feeling, he tells you
that while he occasionally still gets tired, he has not been able to get rid of
his cough, which is dry and hacking and worse at night.
• List three possible causes for his cough. Explain your rationale.
• ______________________________________________________
• ______________________________________________________
• List three questions you would ask Roby. Explain your rationale.
• ______________________________________________________
• ______________________________________________________
• List four diagnostic tests or physical examinations you would order or perform to
help make the diagnosis. Explain your rationale.
• ______________________________________________________
• ______________________________________________________

80
CASE 8.2
• You are introduced to TW, a famous 82-year-old golfer at a Tucson AZ golf function. He has been
visiting here for the last 3 months overseeing the construction of a golf course he designed. When
he finds out you are a pharmacist, he asks if there is anything stronger
than promethazine with codeine for coughing spells that have been bothering him for the last 4
weeks. It seems to be worse at night. He finished a 10-day course of amoxicillin 2 weeks ago for a
cough “that went to his chest.” He also complains about his recent 10-lb weight gain and the shot
of him on TV last night made him look “fat as a hog.” “Even my feet are getting fat! Why even my
favorite slippers are getting tight.” An excellent historian, TW tells you about his long-standing
hypertension, which is treated with carvedilol and doxazosin (also for his prostate), and coronary
artery disease that resulted in a tiny heart attack that led to a four-vessel CABG 15 years ago. He
also takes aspirin, tiotropium inhaler for his smoking-induced COPD, and atorvastatin. You notice
that his breathing appears to somewhat rapid.
• Given TW’s history and his current complaints, list three possible causes for his coughing attacks. Explain your
rationale.
• ______________________________________________________
• ______________________________________________________
• List six questions, examinations, or tests you would ask/order/perform to help clarify his diagnosis. Explain
your rationale.
• ______________________________________________________
• ______________________________________________________

81
Thank you…

82