By contrast, the symptoms of lung disease are relatively few. Cough is a particularly important sign of all diseases that affect any part of the bronchial tree. A cough productive of sputum is the most important manifestation of disease of the major airways, of which bronchitis is a common example. In severe bronchitis the mucous glands lining the bronchi enlarge greatly, and up to a cupful of sputum may be produced in a few hours; more commonly, 30 to 60 millilitres of sputum are produced in a 24-hour period, particularly in the first two hours after awakening in the morning. An irritative cough without sputum may be caused by extension of malignant disease to the bronchial tree from nearby organs. The presence of blood in the sputum (hemoptysis) is an important sign that should never be disregarded. Although it may result simply from an exacerbation of an existing infection, it may also indicate the presence of inflammation, capillary damage, or tumour. It is also a classic sign of tuberculosis of the lungs.
The second most important symptom of lung disease is dyspnea, or shortness of breath. This sensation, of complex origin, may arise acutely, as when a foreign body is inhaled into the trachea, or with the onset of a severe attack of asthma. More usually, it is insidious in onset and slowly progressive. What is noted is a slowly progressive difficulty in completing some task, such as walking up a flight of stairs, playing golf, or walking uphill. The shortness of breath may vary in severity, but in diseases such as emphysema (described below), in which there is irreversible lung damage, it is constantly present. It may become so severe as to immobilize the victim, and tasks such as dressing cannot be performed without difficulty. Severe fibrosis of the lung, resulting fromoccupational lung disease or arising from no identifiable antecedent condition, may also cause severe and unremitting dyspnea. Dyspnea is also an early symptom of congestion of the lung as a result of impaired function of the left ventricle of the heart. When this occurs, if the right ventricle that pumps blood through the lungs is functioning normally, the lung capillaries become engorged, and fluid may accumulate in small airways. It is commonly dyspnea that first causes a patient to seek medical advice, but absence of the symptom does not mean that serious lung disease is not present, since, for example, a small lung cancer that is not obstructing an airway willnot produce shortness of breath.
Chest pain may be an early symptom of lung disease, but it is most often associated with an attack of pneumonia, in which case it is due to an inflammation of the pleura that follows the onset of the pneumonic process. This pain is characteristically felt when a deep breath is taken, and it disappears when fluid accumulates in the pleural space, a condition known as a pleural effusion. Acute pleurisy with pain may signal a blockage in a pulmonary vessel, which leads to acute congestion of the affected part, sometimes with a pleurisy over it. Severe chest pain may by occasioned by the spread of malignant disease to involve the pleura, or by a tumour, such as a mesothelioma, arising from the pleura itself. Severe, intractable pain caused by such conditions may require surgery to cut the nerves supplying the affected segment to give relief. Fortunately, pain of this severity is rare.
To these major symptoms of lung disease—coughing, dyspnea, and chest pain—may be added several of less importance. A wheeziness in the chest may be heard. This is caused by airway obstruction, such as occurs in asthma. Some diseases of the lung are associated with the swelling of the fingertips (and, rarely, of the toes) called “clubbing.” Clubbing may be a feature of bronchiectasis (chronic inflammation and dilation of the major airways), diffuse fibrosis of the lung from any cause, and lung cancer. In the case of lung cancer, this unusual sign may disappear after surgical removal of the tumour. In some lung diseases, the first symptom may be a swelling of the lymph nodes that drain the affected area, particularly the small nodes above the collarbonein the neck; enlargement of the lymph nodes in these regions should always lead to a suspicion of intrathoracic disease. Not infrequently, the presenting symptom of a lung cancer is caused by spread of the tumour to other organs. Thus, a hip fracture from bone metastases, cerebral signs from intracranial metastases, or jaundice from liver involvement may all be the first evidence of a primary lung cancer, as may sensory changes in the legs, since a peripheral neuropathy may also be the presenting evidence of these tumours.
The generally debilitating effect of many lung diseases is well recognized. A person with primary lung tuberculosis or with lung cancer, for example, may be conscious only of a general feeling of malaise, unusual fatigue, or seemingly minor symptoms as the first indication of disease. Loss of appetite and loss of weight, a disinclination for physical activity, general psychological depression, and some symptoms apparently unrelated to the lung such as mild indigestion or headaches, maybe diverse indicators of lung disease. Not infrequently, the patient may feel as one does when convalescent after an attack of influenza. Because the symptoms of lung disease, especially in the early stage, are variable and nonspecific, physical and radiographic examination of the chest are an essential part of the evaluation of persons with these complaints.
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