Cardiovascular system

Cardiogenic acute pulmonary edema Chronic heart failure, myocardial ischemia

Respiratory system

Acute severe bronchial asthma

Acute exacerbation of COPD

Spontaneous pneumothorax

Pneumonia

Acute pulmonary embolism

Acute respiratory distress syndrome

Inhaled foreign body (especially in children)

Lobar collapse

Laryngeal edema (e.g. anaphylaxis) or obstruction

Chronic obstructive pulmonary disease (COPD)

Chronic bronchial asthma

Bronchial carcinoma

Interstitial lung disease (e.g. sarcoidosis, fibrosing

alveolitis, extrinsic allergic alveolitis, pneumoconiosis)

Chronic pulmonary thromboembolism

Lymphatic carcinomatosis

Large pleural effusion(s)

Severe anemia

Obesity

Deconditioning

Non-respiratory, Non-cardiac causes

Metabolic acidosis (e.g. diabetic ketoacidosis, lactic acidosis,

uremia, overdose of salicylates, ethylene glycol poisoning)

Psychogenic hyperventilation (anxiety or panic-related)

Box 3C.3: Acute severe breathlessness

Pulmonary edema

Massive pulmonary embolism

Acute severe asthma

Acute exacerbation of COPD

Severe pneumonia

Tension pneumothorax

Foreign body/mucous plug

Epiglottitis (children)

Metabolic acidosis

Psychogenic

CHEST PAIN

Chest pain discussed in detail under Chapter 4.

Respiratory causes

Upper sternal—tracheitis

Pleuritic-associated with breathing

Neurologic-invasion of nerves.

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the

chest when inhaling and exhaling. It is exacerbated by deep breathing, coughing, sneezing, or laughing. When pleuritic inflammation occurs near the diaphragm, pain can be referred to the neck or shoulder.

Pleuritic chest pain is caused by inflammation of the parietal pleura (dry pleurisy) and can be triggered

by a variety of causes.

Pulmonary embolism, myocardial infarction, pericarditis, aortic dissection, pneumonia, and

pneumothorax are the six serious conditions that cause pleuritic pain.

OTHER SYMPTOMS

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Noisy breathing (partial obstruction of airway):

Laryngeal level Stridor (inspiratory sound)

Oropharyngeal level Stertor

Tracheal level Rattling

Bronchial level Wheezing (inspiratory/expiratory)

Hoarseness of voice:

Inflammatory: Acute and chronic laryngitis

Smoke inhalation

Neoplastic—carcinoma/laryngeal papillomatosis

Recurrent Laryngeal nerve damage: Post-thyroidectomy carcinoma of lung/breast

Neurological: Myasthenia gravis, hypothyroidism

Rheumatoid arthritis—involvement of cricoarytenoid joint

Habitual dysphonias

Reinke’s dysphonia

Singer’s nodules/vocal cord polyps

Gastroesophageal reflux disease (GERD).

Hiccoughs

Respiratory causes include basal pneumonia and pleurisy.

Snoring

Feature of obstructive sleep apnea.

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D. DISCUSSION ON EXAMINATION

GENERAL EXAMINATION

Built and Nourishment

Body mass index (BMI), anthropometry has been discussed in detail in Chapter 2D of General

Examination.

Respiratory diseases associated with emaciation:

Respiratory diseases associated with HIV

Pulmonary tuberculosis

Malignancy.

Pickwikian syndrome (obesity hypoventilation syndrome):

Obesity

Hypoxia

Pulmonary HTN.

Vital Examination (with Respect to Respiratory system)

Pulse:

Rate—tachycardia (any pneumonia, febrile illness, hypoxia)

Irregular pulse seen in multifocal atrial tachycardia, atrial fibrillation

Bounding pulse—CO2

retention

Pulsus paradoxus—acute exacerbation of COPD/asthma.

Respiratory rate:

(for details on respiratory rate refer chapter on vitals examination).

Blood pressure:

Wide pulse pressure—in hypercapnia

Low blood pressure—seen with hypoxia, acute respiratory distress

Postural hypotension—Addison’s disease, paraneoplastic.

Jugular venous pressure:

Elevated: In cor pulmonale, tricuspid regurgitation

Nonpulsatile jugular venous pressure (JVP): Superior vena cava (SVC) obstruction.

Temperature:

Evening rise of temperature: Tuberculosis

High spiking fevers: Lung abscess, empyema, pneumonias.

Temperature fall by crisis: Pneumonias.

Pallor:

Tuberculosis

Malignancy

Any cause of massive hemoptysis.

Polycythemia:

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Chronic respiratory diseases are usually associated with polycythemia

So if patient with COPD has anemia look for other causes like GI bleed, CKD or coexistent

malignancy.

Icterus:

Hepatitis secondary to antitubercular (ATT) drugs

Atypical pneumonias (hemolytic jaundice)

As a part of multiple organ dysfunction syndrome (MODS)

Rarely metastasis to liver.

Edema:

Cor pulmonale

Bronchiectasis leading to hypoproteinemia (due to loss of protein in the sputum and nephrotic

syndrome secondary to amyloidosis)—100 mL of sputum can cause 3–4 g of protein loss.

Hypercapnia-induced dilation of the precapillary sphincters.

Reduced renal blood flow with relatively preserved glomerular filtration rate and elevated levels of

renin, aldosterone, arginine vasopressin and atrial natriuretic peptide.

Cyanosis, clubbing, and lymphadenopathy described in detail in the chapter 2D of General

Examination.

Lymphatic drainage of lung

Most of the lung (right upper lobe, Right middle lobe, Right

lower lobe, Left lower lobe)

Right tracheobronchial → right bronchomediastinal → right

supraclavicular lymph node

Left upper lobe Left tracheobronchial → left bronchomediastinal → left

supraclavicular lymph node

Lymphatic drainage of pleura (Fig. 3D.1)

Cervical pleura Axillary lymph nodes

Parietal pleura Anterior: Internal mammary nodes

Posterior: Extrapleural nodes

Diaphragmatic pleura Internal mammary nodes, cardiophrenic nodes

Para-aortic, intercostal and posterior mediastinal nodes

Mediastinal pleura Internal mammary nodes

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Fig. 3D.1: Parts of pleura with corresponding lymphatic drainage.

Oral cavity examination:

Halitosis seen in suppurative lung diseases

Tobacco staining of the teeth

Poor oral hygiene

Oral markers of malignancy—leukoplakia, erythroplakia, submucous fibrosis.

Cyanosis or polycythemia.

Oral candidiasis—due to inhaled steroids.

Posterior pharyngeal wall/tonsils—infection.

External markers of tuberculosis:

Matted lymph nodes

Erythema nodosum

Phlyctenular conjunctivitis

Choroid tubercle

Discharging sinuses

Scrofuloderma

Lupus vulgaris

Beaded vas deferens

Positive Mantoux test

Generalized tinea versicolor

Uveitis.

External markers of malignancy:

Cachexia

Grade IV clubbing (HPOA)

Hard lymph nodes

Acanthosis nigricans

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Horner’s syndrome

SVC obstruction features—non-pulsatile, dilated JVP, facial flushing and edema, conjunctival

suffusion, papilledema, dilated veins on the chest wall.

Features of respiratory failure:

Type 1 Type 2

Definition Hypoxemic respiratory failure (type 1) is characterized by an arterial

oxygen tension (PaO2

) lower than 60 mm Hg with a normal or low arterial

carbon dioxide tension (PaCO2

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Hypercapnic respiratory failure (type

2) is characterized by a PaCO2 higher

than 50 mm Hg

Sensorium Anxious agitated Drowsy to comatose

Peripheries Cold Warm

Pulse Feeble Bounding

Blood

pressure

Low Wide pulse pressure

Cyanosis + –

Asterixis – +

Respiratory

rate

Tachypneic Normal to low

Papilledema – +

Cause ARDS

Pneumonia

Acute severe asthma

Tension pneumothorax

COPD

Obesity

Respiratory paralysis

Type 3 (perioperative): Functional residual capacity falls below closing volume as a result of atelectasis in postoperative

patients. This is generally a subset of type 1 failure but is sometimes considered separately because it is common

Type 4 (shock): Secondary to cardiovascular instability

Features of Cor Pulmonale

Right ventricular dilatation:

Parasternal heave

Epigastric pulsation.

Right ventricular failure:

Raised JVP

Pedal edema

Tender hepatomegaly

Ascites

Sustained abdominojugular reflux is first sign of RVF.

EXAMINATION OF RESPIRATORY SYSTEM

Examination of Upper Respiratory Tract

Demarcation of upper and lower respiratory tract:

Externally: Demarcated by cricoid cartilage

Internally: Demarcated by glottis.

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