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SIGNS OF RESPIRATORY DISEASE / General Examination 27 Further Reading Atkinson S and Fox SB (2004) Vascular endothelial growth factor (VEGF)-A and platelet-derived growth factor (PDGF) play a central role in the pathogenesis of digital clubbing. Pathology 203(2): 721–728. Augarten A, Goldman R, Laufer J, et al. (2002) Reversal of digital clubbing after lung transplantation in cystic fibrosis patients: a clue to the pathogenesis of clubbing. Pediatric Pulmonology 34: 378–380. Brouwers AA, Vermeij-Keers C, van Zoelen EJ, and Gooren LJ (2004) Clubbed fingers: the claws we lost? Medical Hypotheses 62: 321–324. Dickinson CJ (1993) The aetiology of clubbing and hypertrophic osteoarthropathy. European Journal of Clinical Investigation 23: 330–338. Hippocrates (1849) The Book of Prognostics. In: Adams F (translator) The Genuine Works of Hippocrates. London: Sydenham Society. John B, Subhash H, and Thomas K (2004) Journal of the New Zealand Medical Association, 117: 1192. Martinez-Lavin M (1997) Hypertrophic osteoarthropathy. Current Opinion in Rheumatology 9(1): 83–86. Martinez-Lavin M, Matucci-Cerinic M, Jajic I, and Pineda C (1993) Hypertrophic osteoarthropathy: consensus on its definition, classification, assessment and diagnostic criteria. Journal of Rheumatology 20(8): 1386–1387. Menard H (2004) Hypertrophic osteoarthropathy. Pineda C, Fonseca C, and Martinez-Lavin M (1990) The spectrum of soft tissue and skeletal abnormalities of hypertrophic osteoarthropathy. Journal of Rheumatology 17: 626–632. General Examination T E King Jr, San Francisco General Hospital, San Francisco, CA, USA A C Zamora, Hospital Universitario ‘Dr Jose E Gonzalez’, Monterrey Nuevo Leon, Mexico & 2006 Elsevier Ltd. All rights reserved. Abstract This article describes the initial evaluation of a patient with new onset respiratory problem. A thorough medical history and physical examination are the keys in making a specific diagnosis or narrowing the differential diagnosis of most respiratory disorders. The common signs and symptoms of respiratory problems include dyspnea, cough, hemoptysis, wheezing, chest pain, and snoring. Introduction Patients with respiratory problems commonly present for medical attention because of the development of dyspnea, cough, hemoptysis, wheezing, chest pain, or snoring. Occasionally, patients are asymptomatic and abnormalities are detected on routine health screening examination or through the evaluation of another unrelated medical condition. This article describes the initial evaluation of a patient with new onset respiratory problem. We will focus on the interpretation of common presenting symptoms and physical findings. A thorough medical history and physical examination are the keys in making a specific diagnosis or narrowing the differential diagnosis. Medical History The past medical history is important in defining and characterizing the patient’s illness. It is important to determine whether or not there are previous or concurrent nonrespiratory illnesses that could be a factor in causing or worsening the present clinical problem. Particular attention needs to be placed on the identification of occupational and environmental exposures, smoking history, medication history, and family history. It is critical that the clinician obtain and review any prior chest-imaging studies. Often this process uncovers risk factors for specific respiratory disorders, identifies the recurrence of a dormant condition, or uncovers a previously undiagnosed condition. The family history is occasionally helpful since familial associations or genetic transmission of lung diseases have been identified (e.g., asthma, COPD, cystic fibrosis, a-1 antiprotease deficiency, sarcoidosis). Life style, habits, and travel history are important areas to explore. For example, a history of travel to an endemic area for a particular disease (e.g., tuberculosis) might identify this as the cause of the patient’s illness. Finally, the family history might identify illnesses related to common exposures. A strict chronological listing of the patient’s entire lifelong employment must be sought, including specific duties and known exposures to dusts, gases, and chemicals. The degree of exposure, duration, latency of exposure, and the use of protective devices should be elicited. Review of the environment (home and work, including that of spouse, children, and friends), especially relating to pets, air conditioners, humidifiers, hot tubs, evaporative cooling systems (e.g., swamp coolers), etc., is valuable as well. Symptoms may diminish or disappear after the patient leaves the exposure for several days; similarly, symptoms reappear on returning to the exposure. Obtaining the occupational and environmental history can be quite difficult. Consequently, questionnaires are commonly given to patients that allow them to review their employment record, military service, hobbies, pets, or other potential exposures. The history of tobacco use is important since some diseases occur largely among current or former smokers (e.g., chronic obstructive pulmonary disease 28 SIGNS OF RESPIRATORY DISEASE / General Examination (COPD)) or among never or former smokers (sarcoidosis and hypersensitivity pneumonitis). Active smoking can lead to complications such as pulmonary hemorrhage in patients with Goodpasture’s syndrome. A detailed medication history is needed to exclude the possibility of drug-induced disease, including over-the-counter medications, oily nose drops, and supplements. Importantly, lung disease may occur weeks to years after the drug has been discontinued. Gender is important in lymphangioleiomyomatosis which occurs exclusively in premenopausal women. Also, interstitial lung disease (ILD) in the connective tissue diseases is more common in women; the exception is ILD in rheumatoid arthritis which is more common in men. Age is helpful given that the majority of patients with asthma, sarcoidosis, and connective tissue disease present between the ages of 20–40 years. Conversely, most patients with idiopathic pulmonary fibrosis are over age 60. symptoms, the relationship of symptoms to activity, and any factors that may improve or exacerbate symptoms. In most cases, the primary problem is heart, lung, or neuromuscular abnormalities, which can be identified largely by the history and physical examination. The quality of breathing discomfort often provides tips to the underlying diagnosis; the absence of cigarette smoking is strongly against a diagnosis of COPD. The occupational history may lead to a diagnosis of asbestosis or hypersensitivity pneumonitis. The presence of reproducible events such as exposure to fumes or cold air is common with airways hyperreactivity. When developing a differential diagnosis, it is useful to distinguish respiratory systems dyspnea from cardiovascular dyspnea. It is not uncommon for a patient to have more than one problem contributing to the breathing discomfort. Diagnostic testing commonly follows to identify the specific nature of the disorder. Dyspnea is classified into the following categories: Respiratory Symptoms 1. Acute dyspnea has a short list of causes, most of which are readily identified: asthma, pulmonary infection, pulmonary edema, pneumothorax, pulmonary embolus, metabolic acidosis, or acute respiratory distress syndrome (ARDS). 2. Orthopnea (dyspnea on recumbency) and nocturnal dyspnea suggest asthma, gastroesophageal reflux disease (GERD), left ventricular dysfunction, or obstructive sleep apnea. 3. Platypnea (dyspnea that worsens in the upright position) is a rare complaint associated with arteriovenous malformations at the lung bases or with hepatopulmonary syndrome, resulting in increased shunting and hypoxemia in the upright position (orthodeoxia). 4. Episodic dyspnea suggests congestive heart failure, asthma, acute or chronic bronchitis, or recurrent pulmonary emboli. 5. Chronic dyspnea is invariably progressive. Symptoms often first appear during exertion; patients learn to limit their activity to accommodate their diminished pulmonary reserve until dyspnea occurs with minimal activity or at rest. The most common causes of chronic dyspnea are asthma, chronic obstructive lung disease, ILD, and cardiomyopathy, but deconditioning is often a major contributing factor in patients with chronic lung disease. The most common presenting symptoms are progressive breathlessness with exertion, cough (with or without hemoptysis), wheezing, chest pain, or snoring. These are discussed in detail in other articles so we will only provide a general overview. Dyspnea Dyspnea is the term applied to sensations experienced by individuals who complain of uncomfortable respiratory sensations (see Signs of Respiratory Disease: Breathing Patterns). Dyspnea has been defined in several ways, for example, ‘difficult, labored, uncomfortable breathing’, an ‘awareness of respiratory distress’, ‘the sensation of feeling breathless or experiencing air hunger’, and ‘an uncomfortable sensation of breathing’. The sensation of dyspnea derives from interactions among multiple physiological and behavioral responses. It is the result of an imbalance between ventilatory demand and capacity due to increased work of breathing. Often, the patient has attributed the insidious onset of breathlessness to aging, deconditioning, obesity, or a recent upper respiratory tract illness. Some patients deny the presence of dyspnea even when questioned because they perform a limited amount of activity and so do not ‘experience’ any significant discomfort. Occasionally a spouse or friend brings the problem to their attention. It is important to determine the duration and extent of dyspnea, cough, and sputum production (if any). The dyspnea history should focus on onset and timing of symptoms, the patient’s position at onset of The initial evaluation following the history and physical examination should include a complete blood count (to exclude anemia as a contributing factor to respiratory discomfort), renal function test, chest radiograph, standard spirometry, and noninvasive oximetry during ambulation at a normal pace SIGNS OF RESPIRATORY DISEASE / General Examination 29 over 200 meters. The chest radiography may provide evidence of hyperinflation and bullous disease suggestive of obstructive lung disease, or change in interstitial markings consistent with inflammation or interstitial fluid. Abnormalities of heart size may indicate valvular heart disease or other cardiac dysfunction. Standard spirometry can distinguish patients with restrictive pulmonary disease from those with obstructive airway disease. Lung-volume measurements and diffusing capacity are generally reserved for patients in whom ILD is being considered, in those who have significant declines in oxygen saturation with exercise, or in those for whom there is a suspicion of ventilatory muscle weakness. Echocardiography is reserved for patients in whom chest radiography reveals the heart to be enlarged, or in whom the diagnosis of chronic thromboembolic disease or pulmonary hypertension is being considered. Computed tomography (CT) of the chest is valuable in two circumstances – when patient has crackles on physical examination or reduced lung volumes on pulmonary function test even if the radiography is normal, and for those who have oxygen desaturation with exercise and a low diffusing capacity (occult emphysema). Cardiopulmonary exercise testing is recommended if the etiology of a patient’s dyspnea remains unclear after the initial evaluation described above. This test allows to determine if the patient’s dyspnea is more likely due to cardiovascular or respiratory system abnormalities, or if it is due to deconditioning. Cough Cough by definition is an explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign material. Cough is often divided into three categories: acute (defined as lasting o3 weeks), subacute (lasting 3–8 weeks), and chronic (lasting 48 weeks). Coughing may be initiated either voluntarily or reflexively. As a defensive reflex, it has both afferent and efferent pathways. The afferent limb includes receptors within the sensory distribution of the trigeminal, glossopharyngeal, superior laryngeal, and vagus nerves. The efferent limb includes the recurrent laryngeal nerve and the spinal nerves. The cough starts with a deep inspiration followed by glottic closure, relaxation of the diaphragm, and muscle contraction against a closed glottis. The resulting markedly positive intrathoracic pressure causes narrowing of the trachea. Once the glottis opens, the large pressure differential between the airways and the atmosphere coupled with tracheal narrowing produces rapid flow rates through the trachea. The shearing forces that develop, aid in the elimination of mucus and foreign materials. The duration of the cough at the time of presentation helps to determine the likely cause. Acute cough is most often associated with upper respiratory tract infections such as common cold, acute bacterial sinusitis, pertussis, exacerbations of COPD, allergic rhinitis, and rhinitis due to environmental irritants. Acute cough can be the presenting manifestation of pneumonia, left ventricular failure, or asthma especially in elderly patients, because classic signs and symptoms may be minimal or not present. Subacute cough often follows an upper respiratory tract infection and lasts for 3–8 weeks, the most common conditions are postinfectious cough, bacterial sinusitis, and asthma. Postinfectious cough may result from postnasal drip or clearing of the throat due to rhinitis, tracheobronchitis, or both, with or without transient bronchial hyperresponsiveness. When cough is subacute and is not associated with an obvious respiratory infection, then the patient should be evaluated in the same way as patients with chronic cough (see below). The main causes (B95% of cases) of chronic cough include postnasal drip syndrome from conditions of the nose and sinuses, asthma, gastroesophageal reflux disease, chronic bronchitis due to cigarette smoking or other irritants, bronchiectasis, or the use of drugs (especially an angiotensin-converting enzyme (ACE) inhibitor). Other causes of chronic cough include bronchogenic carcinoma, carcinomatosis, sarcoidosis, left ventricular failure, and aspiration due to pharyngeal dysfunction. The patient’s clinical history is often very helpful in arriving at the cause of the cough (if there are symptoms suggestive of a respiratory infection, if there is a seasonal cause of wheezing or postnasal drip, if the patient has heartburn or sensation of regurgitation, if there is sputum or dry cough, etc.) Focus should be on the smoking history, environmental exposures, and medication use (e.g., ACE inhibitors or b blockers). Figure 1 provides an algorithm for diagnosing chronic cough in immunocompetent adults from a Consensus Panel Report of the American College of Chest Physicians. Physical examination is necessary to find a nonpulmonary cause of cough such as heart failure or AIDS. Auscultation of the chest is useful to find stridor (upper airway disease), rhonchi, or expiratory wheezing (lower airway disease), inspiratory crackles (ILD, pneumonia, or pulmonary edema). In a patient without asthma, sputum studies with greater than 3% eosinophils on staining suggest the possibility of eosinophilic bronchitis. Sometimes other tests are needed, for example, bronchoprovocation with methacholine to demonstrate hyperreactivity and confirm asthma; high resolution computed tomography 30 SIGNS OF RESPIRATORY DISEASE / General Examination Cough gone Chronic cough Stop ACEI Hx PE ACEI Cough persists Chest radiograph Normal Abnormal Avoid irritant Cough gone Order according to likely clinical possibility Abnormality may not be related to cough Sputum cytology, HRCT scan, modified BaE, bronchoscopy, cardiac studies Cough persists Treat accordingly Evaluate for three most common conditions singly in the following order, or in combination: 1. PNDS Cough gone 2. Asthma Cough persists Cough gone 3. GERD Consider postinfectious cough Cough persists Evaluate for uncommon conditions Sputum tests, HRCT scan, modified BaE, bronchoscopy, cardiac studies Cough gone Cough persists Reconsider adequacy of treatment regimens before considering habit or psychogenic cough Figure 1 Guidelines for evaluating chronic cough in immunocompetent adults. ACEI, angiotensin-converting enzyme inhibitor; BaE, barium esophagography; GERD, gastroesophageal reflux disease; HRCT, high-resolution computed tomography; HX, history; PE, physical examination; PNDS, postnasal drip syndrome. Reproduced from Irwin RS, Boulet LP, Cloutier MM, et al. (1998) A consensus panel report of the American College of Chest Physicians. Managing cough as a defense mechanism and as a symptom. Chest 114(2 supplement Managing): 133S–181S, with permission. (HRCT) to confirm the presence of ILD, COPD, or bronchiectasis; and 24 h monitoring of esophageal pH to help identify silent gastroesophageal reflux disease. Hemoptysis The word ‘hemoptysis’ comes from the Greek ‘haima’ for ‘blood’ and ‘ptysis’ for ‘a spitting’ together meaning, ‘a spitting of blood’. The source SIGNS OF RESPIRATORY DISEASE / General Examination 31 of the blood originates below the vocal cords. It is classified as massive when more than 200–600 ml in 24 h, or when the patient is hemodynamically significant or it threatens ventilation. The history should include questions regarding smoking habits, past respiratory infections (e.g., pneumonia or tuberculosis), bronchiectasis, history of deep venous thrombosis, bleeding disorders, anticoagulant therapy, and recent weight loss (Table 1). Physical examination should include careful inspection of the upper airway. Certain findings may be helpful in suggesting a diagnosis: a saddle nose deformity with rhinitis and septal perforation are signs of Wegener’s granulomatosis; oral or genital aphthous ulcerations, uveitis, or cutaneous nodules may be the clinical presentations in patients with Behc¸et’s disease; clubbing may be a sign of lung carcinoma or bronchiectasis. In the examination of the lungs, a pleural friction rub may suggest pulmonary embolism. Cardiac examination may demonstrate findings of cor pulmonale or mitral stenosis. Chest imaging studies may help to identify lung parenchymal pathologies. HRCT can demonstrate lesions that may not be visible in chest radiograph, such as bronchiectasis or a small bronchial carcinoma. When performed with contrast material, CT may detect pulmonary embolism, thoracic aneurysm, or arteriovenous malformation. Fiberoptic bronchoscopy is commonly performed, both for anatomic localization of the bleeding site and to exclude neoplasm. Flexible bronchoscopy can be performed at bedside, does not require general anesthesia, and is usually quicker than the rigid bronchoscopy. It also allows easy access to the upper lobes. The disadvantages are a limited suctioning capability and an inability to localize bleeding when the hemorrhage rate is rapid. The diagnosis yield increases when patients undergo bronchoscopy within 48 h of a bleeding episode. In general, bronchoscopy should be performed in patients who smoke, in those who are older than 40 years, and those who have bleeding that persists (even intermittently) for more than 2 weeks. Some authors have found bronchogenic carcinoma in as many as 15–20% of bronchoscopies in patients with normal chest radiography. Except for life-threatening situations, CT should be performed before bronchoscopy. Rigid bronchoscopy is less frequently used but has been found to be safe and well tolerated under local anesthesia and conscious sedation, when performed by experienced hands. It offers better suctioning capability, continuous airway control, and a larger lumen for introducing packing materials and clearing clots and debris from the airways of patients with active bleeding. Its disadvantages include a reduced Table 1 Common causes of hemoptysis Cardiac Mitral stenosis Tricuspid endocarditis Drugs/toxins Anticoagulants Aspirin Crack cocaine Hematologic Coagulopathy Platelet dysfunction Thrombocytopenia Infection Fungal Lung abscess Mycetoma Necrotizing pneumonia Tuberculosis Iatrogenic Bronchoscopic Lung biopsy Swan-Ganz catheter use Neoplastic Bronchial adenoma Lung cancer Metastasic disease Pulmonary Bronchitis Bronchiectasis Pulmonary embolism Cryptogenic Foreign body Cryptogenic hemoptysis Systemic Goodpasture’s syndrome Idiopathic pulmonary hemosiderosis Systemic lupus Systemic vasculitides Traumatic Aortic aneurysm Chest trauma Fat embolism Ruptured bronchus Vascular Aortic aneurysm Arteriovenous malformation Pulmonary hypertension range of visibility of upper lobe and the need for general anesthesia. Chest Pain The evaluation of acute chest pain should begin with a clinical history that focuses on the characteristics of the pain, the time of onset, and the duration of symptoms, and an examination that emphasizes vital 32 SIGNS OF RESPIRATORY DISEASE / General Examination signs and cardiovascular status. An electrocardiogram should be obtained within 5 min after presentation, followed by a chest X-ray. The goal of the initial evaluation of the patient is to rule out coronary artery disease (CHD) and conditions that are life-threatening. Common causes of chest pain include muscle or skeletal chest pain, costochondritis, gastroesophageal reflux, and stable angina pectoris. Unstable angina was an uncommon cause in a recent large prospective study. Nonetheless, cardiac pain must be ruled out quickly. Quality of the pain. The patient with ischemia often denies feeling chest ‘pain’. The sensation is commonly described as squeezing, tightness, pressure, constriction, strangling, burning, heartburn, fullness in the chest, to band-like sensation, knot in the center of the chest, lump in the throat, ache, heavy weight on chest (elephant sitting on chest), like a bra too tight, and toothache (when there is radiation to the lower jaw). Some patients cannot qualify the nature of the discomfort but will place fist in the center of the chest (the ‘Levine sign’). Patients with a history of CHD tend to have the same quality of chest pain with recurrent ischemic episodes. Location of the pain. Unlike the muscular or pleuritic pain that can be located, ischemia is more diffuse and thus difficult to locate. Radiation. The radiation of the pain to right arm (2.9 likelihood ratio) or even toward both arms (7.1 likelihood ratio) is a predictor of acute myocardial infarction. Pain associated with acute cholecystitis radiates to the right shoulder. The pain of aortic dissection radiates toward the back and that of pericarditis toward one or both trapezes. Onset of the pain. The pain due to pneumothorax, aortic dissection, or acute pulmonary embolism is sudden; ischemic pain is gradual and increases with time, and pain of the musculoskeletal type has a very vague beginning. Provocation. If the chest pain increases when eating, we suspect a gastrointestinal cause or myocardial ischemia. Myocardial ischemia also increases by exercise, cold, and emotional stress. The pain that increases with the change of position suggests a musculoskeletal source. Pleuritic type of pain increases with deep breathing and when lying down. Other useful findings. Vital signs can be helpful, for example, a marked difference in blood pressure between the two arms suggests the presence of aortic dissection. Hyperestesia combined with a skin rash indicates herpes zoster. Chest auscultation for pleural or pericardial rub, signifies heart murmur, crackles, wheezes or signs of consolidation are useful in suggesting possible cause of the chest pain, for example, pericarditis, valvular heart disease, ILD, asthma, or pneumonia respectively. Also, careful examination of the abdomen is important, with attention to the right superior quadrant and epigastrium. Wheezing A wheeze is a continuous musical sound that lasts longer than 250 msec. Wheezing occurs during inspiration or expiration and originates from airways of any size; conversely, stridor is an inspiratory wheezing that is loudest over the central airways. The whistling sound (wheezing) occurs when a patient attempts to exhale through bronchial passages that are constricted or excreting excess mucus due to irritation, infection, or allergy. The more common symptoms are tightening in the chest and dyspnea. In evaluating patients with wheezing, it is important to be aware that ‘‘All that wheezes is not asthma; all that wheezes is obstruction.’’ Using the history, physical examination, lung function studies, and knowledge of the spectrum of differential diagnostic possibilities, especially those that have been shown to be the most common is how we can make the diagnosis (see Table 2). Snoring Snoring is an inspiratory sound produced by vibration of the soft tissues of the upper airway during sleep. Snoring is a common symptom in the general population. However, snoring may indicate a more serious medical problem, such as obstructive sleep apnea (OSA) or the upper airway resistance syndrome (UARS). Some patients appear asymptomatic unless the clinician makes a systematic effort to elicit symptoms. Consequently, it is important to recognize whether clinical features suggest an underlying sleeprelated breathing disorder and if some form of objective testing is indicated. The physiology, clinical significance, and evaluation of snoring is discussed elsewhere in this text. Physical Examination Examination of the patient with pulmonary disease includes inspection, palpation, percussion, and auscultation of the chest. Inspection. This includes the respiratory rate and rhythm, breathing pattern, as well as the depth and symmetry of lung expansion. Respiratory rate normal values are 12–14 breaths per min. Tachypnea is an increased rate of breathing. During normal breathing, the primary muscle of respiration is the diaphragm, but when the patient uses the intercostals and sternocleidomastoid muscles (accessory muscles), it indicates labored breathing. The chest normally expands SIGNS OF RESPIRATORY DISEASE / General Examination 33 Table 2 Causes of wheezing based on anatomic site of obstruction Extrathoracic upper airway obstruction Intrathoracic upper airway obstruction Lower airway obstruction Postnasal drip syndrome Vocal cord dysfunction Hypertrophied tonsils Epiglottitis Laryngeal edema Laryngostenosis Postextubation granuloma Retropharyngeal abscess Neoplasms Anaphylaxis Malignancy Obesity Klebsiella rhinoscleroma Mobile supraglottic soft tissue Relapsing polychondritis Laryngocele Abnormal arytenoid movement Vocal cord hematoma Bilateral vocal cord paralysis Cricoarytenoid arthritis Wegener’s granulomatosis Tracheal stenosis Foreign body aspiration Benign airway tumors Malignancies Intrathoracic goiter Tracheobronchomegaly Acquired tracheomalacia Herpetic tracheobronchitis Right sided aortic arch Asthma COPD Pulmonary edema Aspiration Pulmonary embolism Bronchiolitis Cystic fibrosis Carcinoid syndrome Bronchiectasis Lymphangitic carcinomatosis Parasitic infections Reproduced with permission from Irwin RS, Diagnosis of wheezing illnesses other than asthma in adults. In: UpToDate, Rose (ed.) UpToDate, Wellesley, MA, 2005. Copyright & 2005 UpToDate, Inc. For more information visit http://www.uptodate.com. Table 3 Extrapulmonary physical findings associated with lung diseases Physical findings Associated conditions Fever Infections, eosinophilic pneumonia, drug reactions, cryptogenic organizing pneumonia, hypersensitivity pneumonitis, sarcoidosis, lymphoma, lymphangitic carcinoma Skin changes Erythema nodosum Maculopapular rash Heliotrope rash Telangiectasia Raynaud phenomenon Cutaneous vasculitis Subcutaneous nodules Calcinosis Café-au-lait spots Eye changes Uveitis Scleritis Keratoconjunctivitis sicca Albinism Salivary gland enlargement Peripheral lymphadenopathy Myositis; muscle weakness Arthritis Sarcoidosis, connective tissue disease, Behc¸et syndrome, histoplasmosis, coccioioidomycosis Drug-induced diasease, amyloidosis, lipoidosis connective tissue disease, Gaucher disease Dermatomyositis Scleroderma Connective tissue disease (scleroderma) Systemic vasculitides, connective tissue disease Von Recklinghausen disease, rheumatoid arthritis Dermatomyositis, scleroderma Neurofibromatosis Sarcoidosis, Behc¸et syndrome, ankylosing spondilitis Systemic vasculitis, systemic lupus erythematosus, scleroderma, sarcoidosis Lymphocytic interstitial pneumonia, Sjögren syndrome Hermansky–Pudlak syndrome Sarcoidosis, Lymphocytic interstitial pneumonia, Sjögren syndrome Sarcoidosis, lymphangitic carcinomatosis, Lymphocytic interstitial pneumonia, Sjögren syndrome Connective tissue disease, sarcoidosis, drugs Connective tissue disease, vasculitis, sarcoidosis, Goodpasture syndrome Reproduced from Schwarz MI, King TE Jr, and Raghu G (2003) Approach to the evaluation and diagnosis of interstitial lung disease. In: Schwarz MI and King TE (eds.) Interstitial Lung Diseases, 4th edn., p. 8. Hamilton, ON: BC Decker, with permission from BC Decker. 34 SIGNS OF RESPIRATORY DISEASE / General Examination simultaneously. Asymmetric expansion of the chest is usually due to an asymmetric process affecting the lungs, and suggests unilateral pleural or parenchyma problem. Visible abnormalities of the thoracic cage include kyphoscoliosis which can alter compliance of the thorax and cause dyspnea. Palpation. The trachea at the suprasternal notch, detects shift in the mediastinum. The symmetry of lung expansion can be assessed, confirming the findings observed by inspection. Vibration produced by spoken sounds is transmitted to the chest wall and is assessed by the presence or absence and symmetry of tactile fremitus, especially on the posterior chest wall. Transmission of vibration is decreased or absent if pleural liquid is interposed between the lung and chest wall; in contrast, transmitted vibration may increase over an area of underlying pulmonary consolidation. Percussion. Assess the resonance or dullness of the tissue underlying. The normal sound of underlying aircontaining lung is resonant. Dull areas correspond to lung consolidation or pleural effusion and hyperresonant areas suggest emphysema or pneumothorax. Auscultation. We listen for both the quality and intensity of the breath sounds and the presence of abnormal or adventitious sounds. Normal lung sounds heard over the periphery of the lung are called vesicular breath sounds, in which inspiration is louder and longer that expiration. Normal sounds heard over the suprasternal notch are called tracheal or bronchial lung sounds and have a hollow quality that tends to be louder on expiration. The breath sounds are diminished in intensity or absent if there is an endobronchial obstruction, or when there is fluid in the pleural space. When sound transmission is improved and has a more pronounced expiratory phase, a consolidated lung is present. Listening through the consolidated lung, the spoken sound (bronchophony) or the whispered sound (pectoriloquia) is part of the routine evaluation as is the presence of egophony, which is the sound of a spoken E that becomes more like an A. Adventitious sounds can be continuous or discontinuous. Continuous ones are divided into wheezes and rhonchi. Wheezes that are more prominent during expiration than inspiration, reflect the oscillation of airway walls that occurs when there is airflow limitation, as may be produced by bronchospasm, airway edema or collapse, or intraluminal obstruction by neoplasm or secretions. Rhonchi originate in the large airways when excessive secretions and abnormal airway collapsibility cause repetitive rupture of fluid films and frequently clear after cough. Discontinuous sounds are called crackles which are typically inspiratory, are produced by the sound created when alveoli and small airways open and close with respiration. Fine crackles are heard in ILD or filling alveoli liquid as pulmonary edema. Coarse crackles result from air bubbling through fluid and are heard in pneumonia and late pulmonary edema. Appearance Normal Clubbed (a) Nail-fold angles C D Normal B A B Clubbed A C D (b) Phalangeal depth ratio Normal DPD IPD Clubbed DPD IPD (c) Schamroth sign Normal Clubbed (d) Figure 2 Appearance on inspection for clubbing: (a) normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. (b) The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 1691 and 1831, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 1911 and 2031, respectively. (c) Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. (d) Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to the increase in tissue at the nail bed causes obliteration of this space (arrowhead). Reproduced from Myers KA and Farquhar DR (2001) The rational clinical examination. Does this patient have clubbing? Journal of the American Medical Association 286: 341–347, with permission. Copyright & (2001) American Medical Association. All rights reserved. SIGNS OF RESPIRATORY DISEASE / Lung Sounds 35 Extrapulmonary Signs of Pulmonary Disease Table 3 lists the extrapulmonary physical findings associated with lung diseases. Digital clubbing There are structural changes at the base of the nails that include softening of the nail bed and loss of the normal 1501 angle between the nail and the cuticle (Figure 2). The distal part of the finger is enlarged in comparison with the proximal part. It may be a normal variant but more commonly is a sign of underlying pulmonary disease such as lung cancer, ILD, and chronic infections in the thorax such as bronchiectasias, lung abscess, and empyema. It is not commonly seen in COPD; if present, a complicating lung carcinoma may be present. Cor pulmonale In the mid or late stages of pulmonary diseases, findings of pulmonary hypertension (e.g., augmented P2, right-sided lift, and S3 gallop) and cor pulmonale may become evident. These can be primary manifestations of a connective tissue disorder (e.g., progressive systemic sclerosis) though. See also: Chronic Obstructive Pulmonary Disease: Smoking Cessation. Signs of Respiratory Disease: Breathing Patterns; Clubbing and Hypertrophic Osteoarthropathy. Sleep Apnea: Overview. Symptoms of Respiratory Disease: Cough and Other Symptoms; Dyspnea; Chest Pain. Further Reading American Thoracic Society (1999) Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Journal of Respiratory and Critical Care Medicine 159: 321–340. Braman SS and Corrao WM (1987) Cough: differential diagnosis and treatment. Clinics in Chest Medicine 8: 177–188. Cahill BC and Ingbar DH (1994) Massive hemoptysis. Assessment and management. Clinics in Chest Medicine 15: 147–167. Fitzgerald RS and Lahiri S (1986) Reflex response to chemoreceptor stimulation. In: Cherniack NS and Widdicombe JG (eds.) Handbook of Physiology, Section 3: The Respiratory System, Vol. 2. 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Lung Sounds D C J Howell, Centre for Respiratory Research, University College London, London, UK & 2006 Elsevier Ltd. All rights reserved. Abstract Sound has a number of vital characteristics including frequency, intensity, duration, and quality. These components determine the plethora of lung sounds that can be heard by the human ear. Historically, lung sounds were detected by placing the ear on the chest wall of the patient. However, with the discovery of the stethoscope, this practice was abandoned. Although much can be elucidated about underlying chest pathology by listening to a patient breathing while standing at the end of the bed, auscultation has added much to the clinical examination of patients with respiratory disease. Lung sounds can broadly be divided into breath sounds and voice sounds, and can be normal and abnormal. Abnormal lung sounds can be either abnormally transmitted by breath or voice, or may be adventitial (accidental). In this article, the range of various normal and abnormal sounds that the lung produces will be discussed and their pertinence to respiratory disease highlighted. The Perception of Sound, the Stethoscope, and Auscultation Prior to discussing lung sounds in detail, it is prudent to elaborate on the nature of sound itself. Sounds consist of audible vibrations, which are created by alternating regions of compression and rarefaction of air. Sound has a number of important characteristics including frequency, intensity, duration, and quality. The frequency of sound reflects a measurement of the number of vibrations per unit time, in cycles per second, and is expressed in hertz (Hz). The large range of normal and abnormal lung sounds will be elaborated upon below but as examples, a sound producing a large amount of vibrations per unit time will be interpreted on clinical examination as a highpitched wheeze. Conversely, sounds with low vibrations per unit time are heard as low-pitched wheezes.