Interpretation of Symptoms and Signs of Respiratory diseases
H.A.M. Nazmul Ahasan Professor of Medicine
PMC
Philosophy of a Physician
• ‘A man who has no philosophy is a bad philosopher’
• Medicine is the most scientific art and the most huministic science
• Doctors have close relationship with people even more than priests and lawyers
• Charaka (300-500 BC) outlined 6 qualities and 4 principles of a physician
– Having knowledge
– Critical approach
– Insight into allied sciences
– Sharp memory
– Promptness
– Perseverance
• Cordial towards the sick
• Sympathy towards the sick
• Interest in cases according to one’s
capabilities
• No attachment with the patient after his
recovery
Significance of Hippocratic Oath
• serve s as a lasting model for
– Professional integrity
– Conduct
– Philosophy
(460 – 370 BC)
Abu al-Hasan Ali ibn-e Raban Tabari (807-861 AD)
in the book "the Paradise of Wisdom" (Ferdous al Hekmat) :
• personal characters of the physician,
• obligation towards patients,
• obligation towards the community,
• obligations towards his colleagues, and
• obligations towards his assistants
The art & science of Diagnosis
• A detective work controlled by a system of logical analysis
• Every diagnosis is Based in 3 foundations: history, physical signs
and investigations
• Not lucky guesses
• Inspection is active search for evidence not just hurried glance
• Physical examination must be precise, standardized &
interpreted with appropriate criteria in order to achieve
uniformity and consistency
No Lung, Air flows Through out body
Lungs: expands, pulls air during inhalation, exhale air during expiration
Lung is stationary: Air Sac flows air unidirectionally
Contents • Introduction
• Cardinal symptoms
• Cardinal Signs
– Inspection
– Palpation
– Auscultation
• Clinical pearls from some diseases
• Take home message
Introduction
• High index of suspicion on the basis of clinical information is
necessary to diagnose a disease even in very modern and
sophisticated investigation technologies
• There is no alternative of meticulous history taking and
physical examination to reach a diagnosis of any diseases
including respiratory diseases.
• This is equally important to medical students and clinicians at
any stage
Cardinal Symptoms
• Cough
• Sputum
• Hemoptysis
• Chest pain
• Breathlessness
Symptoms: Cough • Duration:
• Diurnal Variation: Br Asthma, COPD
• Dry: Influenza, Pneumonia
• Productive: Lung Abscess, Bronchiectasis
• Paroxysmal Cough: Chr. Bronchitis, Bronchial Asthma
• Bovine Cough: Rec. Laryngeal Nerve palsy
• Painful Cough: Pleurisy, Pneumonia
• Cough with Stridor:Retrosternal goitre Diphtheria, Whooping
cough
Prolonged Persistent Cough(>2months)
X-ray Negative causes of prolong cough
• Chr Bronchitis
• Cough variant asthma
• GERD
• Sarcoidosis in early state
Common causes
• Chr Bronchitis
• Cough variant asthma
• Pulmonary Tuberculosis
• Bronchiectasis
• Bronchial Carcinoma
Less common
• GERD
• Sarcoidosis in early state
Sputum • Amount
– Profuse, Purulent, days to weeks: Lung Abscess
– Copious, long duration, recurrent, months to years:
bronchiectasis
• Colour:
• Odor :Foetid – lung abscess by Anaerobic organism
Sputum Types Characteristics
Example
1 Serous Watery, Frothy, Clear Acute Pulmonary Oedema
2 Mucoid Thick, white Chr. Bronchitis, Chr. Bronchial Asthma
3 Purulent/ Mucopurulent
Yellow, green Lung Abscess, Bronchiectasis, Empyema thoracis with Bronchopleural fistula
4 Rusty Altered blood Pneumonia
5 Hemoptysis Blood staining of sputum Pul. TB, Bronchiectasis, Lung Abscess, Br. Carcinoma, Pul infarction, Mitral Stenosis
6 Coloured Gray Black
Excessive dust inhalation Coal miner’s pneumoconiosis
Hemoptysis Vs Hematemesis Characteristics Haemoptysis Haematemesis
Definition Coughing out of Blood Vomiting out of Blood
Duration Days together episodic
Colour Bright red Altered, Coffee ground
frothy Yes No
Food material Absent May be present
Melaena Absent Present
Premonitory symptoms
None Present
Reaction Alkaline Acidic
Other symptoms Resp /CVS GIT/ Hepato-billiary
Chest Pain
Types Characteristics Example
Pleuritic chest pain Usually unilateral, worse on deep inspiration, aggravated by cough, sneezing
Pneumonia, Pulmonary TB, Pulmonary infarction, Bronchial Carcinoma, pleurisy
Sudden severe chest pain Associated breathlessness Acute MI, Desecting Aneurysm, Pneumothorax,
Central chest pain Acute MI, Angina Pectoris, Pericarditis, Desecting Aneurysm, Pneumothorax, Acute Tracheaitis Reflux esophagitis, Hiatus Hernia, Hyeterical
Unilateral chest pain Pneumonia, Pleurisy, Pul. Infarction, Pneumothorax, Br. Carcinoma, MSK Pain, Herpes Zoster
Breathlessness
Definition: Difficulty in breathing reaches the level of consciousness
• Respiratory:
– Bronchial Asthma
– Pneumothorax
– Massive pleural effusion
• CVS:
– Acute pulmonary oedema,
– Massive pulmonary
embolism
• Others:
– Uremia,
– DKA
– Myasthenia
– GBS,
– Foreign Body in airway,
– Diphtheria
Acute Breathlessness 1. Severe acute asthma
2. Acute LVF
3. Tension pneumothorax
4. Massive pulmonary embolism
5. Conversion Disorder
Causes of PND
1. LVF
2. Chr Bronchial Asthma
3. COPD
Central Cyanosis
Respiratory
– Tension Pneumothorax
– COPD
– Severe Acute Asthma
– Severe Pneumonia
– Massive pleural effusion
– Interstitial lung Disease
– Pulmonary infarction
Cardiac
• Acute LVF
Clubbing
Respiratory diseases
• Suppurative Lung Diseases – Lung Abscess – Bronchiectasis – Empyemqa Thoracis
• Bronchial Carcinoma • Interstitial Lung Diseses
Cardiovascular diseases
• Congenital Cyanotic Heart Diseases
• Infective Endocardidtis Miscellaneous Inflammatory Bowel diseases Coeliac Disease
Other findings on General examination
• Neck: Lymphadenopathy: Bronchial Carcinoma
Sup. Venacaval obstruction: Br Carcinoma, lymphoma
• Anaemia: Bronchial Carcinoma
• Gynaecomastia: Bronchial Carcinoma
• Eyes: Hornors Syndrome (Partial Ptosis)
• Skin: Erythema Nodosum-Primary Pulmonary TB,
` sarcoidosis
• Skin Nodules: Br. Carcinoma
• Oedema: Cor pulmonale
Examination of the Chest
Resp Rate: Increased: Ecercise, Excitement, fever, Pneumonia,
Acidosis
Type of respiration:
Abdominal
Abdominothoracic
Thoracic
Rhythm
Regular
Irregular: Chyne stokes Breathing
Inspection
• Shape: Bilaterally Symmetrical (Ratio 5:7)
• Deformities:
– Increased Anterior : Posterior
Diameter
– Barrel Shaped Chest
– Kyphoscoliosis
– Pectus carinatum(Pegion chest)
– Pectus excavatum
Inspection of Chest
• Indrawing of – Suprasternal notch – Supraclavicular fossa – Intercostal space
• Intercostal Space fullness :
o Amoebic liver Abscess, Pl effusion,
• Scar mark of thoracotomy
• Swelling
COPD Bronchial Asthma
Chest movement
Unilateral restricted movement
– Pleural Effusion
– Pneumothorax
– Consolidation
– Collapse
– Fibrosis
Palpation
• Movement: Bilaterally Symmetrical
• Expansion: reduced in emhysema
• Position of trachea
• Position of Apex beat
• Vocal vremitus: Increased: Consolidation, Cavitation
Decreased: Pleural effusion Pneumothorax
Pull: Fibrosis, Collapse
Push: Pneumothorax, Pl effusion
Position of the trachea
Push
• Tension
Pneumothorax
• Massive Pleural
effusion
Pull
• Collapse
• Fibrosis
No Push No Pull
• Pneumonia
• Bronchial Asthma
• COPD
• ILD
• Pulmonary
Tuberculosis
Percussion note
• Normal
• Hyper resonant: Unilateral: Emphysema
Bilateral: Pneumothorax
• Dull- Impaired: Consolidation
• Woody dull, Stony Dull: Pleural effusion
Auscultation
• Breath sounds:
Vesicular,
Vesicular with prolong in expiration
in Chr Bronchitis, COPD
Bronchial: consolidation
• Added Sounds: Rhonchi
Crepitations
Pleural rub
Stridor
• Vocal Resonance: Normal
Increased
Decreased
Reduced breath sound
• Pl effusion
• Pneumothorax
• Emyema thoracis
• Neoplasm
• Pulmonary collapse
Bronchial Breath sounds
• Common:
Pneumonic consolidation
Large cavity-Lung Abscess
Uncommon: At the top of pl effusion
Localized Pulmonary fibrosis with patent bronchi
Pulmonary collapse with patent bronchi
Crepitations
Bilateral Creps:
– Left Ventricular Failure – Bilateral Bronchiectasis – Interstitial Lung Disease – Bronchopneumonia – Extensive Bilateral
Tuberculosis
Unilateral Creps:
– Pneumonia – Lung Abscess – Pulmorary
Tuberculosis(post tussive Apical creps)
Unilateral chest disease
• Pneumonia • Pleural effusion • Pneumothorax • Collapse • Fibrosis • Mass lesion • Bronchiectasis: Unilateral • Pulmonary Tuberculosis: Unilateral
Bilateral Chest disease
• Bronchial Asthma • COPD • Interstitial Lung Disease • Pulmonary oedema • Bronchiectasis: Bilateral • Pulmonary Tuberculosis: BIilateral
Pleural effusion and Pneumothorax
Pleural effusion Pneumothorax
Symptoms: Chest pain Breathlessness Symptoms of underlying disease
Present , dull aching Present Present
More and acute Present Present
Physical Examination
Trachea Shifted towards opposite side
Shifted towards opposite side
Percussion Woody dull Hyper resonant
Breathsound Absent on affected side Absent on affected side
Vocal fremitus Decreased Decreased
Vocal resonance Decreased decreased
Pneumonia
• Symptoms: Fever, Cough, chest pain • Signs: febrile, herpes labialis • Chest:
– Chest movement reduced in one side – Percussion note dull – Diminished Breath sound in affected area – Bronchial Breath sound in affected area – Crepitations in affected area – Vocal fremitus & resonance increased
Bronchial Asthma
• Prolong history of chough,wheeze & Breathlessness
• Patients of all age • Onset: Childhood/ young age • History of allergy • Family history positive • Sign: Rhonchi and Wheeze
COPD • Cough, wheeze breathlessness • In aged patients • History of smoking • Often PND • Pink puffer or blue bloater • associated cyanosis, respiratory failure • Prominent accessory muscles of respiration
COPD
Collapse Vs Fibrosis
Fibrosis Collapse
Course of illness long Acute
Chest movement Reduced unilaterally Reduced unilaterally
Flattening of the side Present Absent
Trachea Same side Same side
Auscultation Crepitation if bronchi is patent
Bronchial breath sound over the bronchus Absent over the collapsed area
ILD • Progressive breathlessness
• Age more than 40 years
• Clubbing
• Cyanosis
• Fine crackles on both base of the lungs
Bronchiectasis
• Prolong course of diseases
• Recurrent productive cough with copious purulent sputum,
hemoptysis, fever, toxic undernourished,
• Clubbing
• Bilateral coarse crackles
• May have receive anti TB drug regimen
Lung Abscess
• Fever, cough, productive purulent sputum • Acute onset • Febrile toxic patient • May have hemptysis • Clubbing • Bronchial breathsound • Crepitations
Bronchial Asthma vs Cardiac Asthma Severe Acute Asthma Acute LVF (?Cardiac Asthma)
History Known pt of Bronchial Asthma for years
Known case of IHD, Valvular Heart disease, HTN
Symptoms Breathlessness, wheeze, cough, mucoid sputum, fever
Breathlessness, palpitation, chest pain, pink frothy sputum
Signs Cyanosis
May be present May be present
Oedema Absent Present
Pulse Pulsus paradoxus Pulsus alternans
supraclavicular, suprasternal recession, Accesory muscles of respiration
Prominent absent
cont. Severe Acute Asthma Acute LVF
Rhonchi Over whelming few
Crepitations absent Bilateral basal
Apex beat Normal May be changed- LVH, Valvular Heart disease
Auscultation Normal Evidences of heart valves
X-ray Chest PA Normal Evidences of Valvular heart diseases
ECG Normal MI, LVH, Arrhythmias
Treatment Morphine
Contraindicated
given
Frusemide No help Helpful
Aminophylline often given Often harmful
Bronchial Asthma vs Cardiac Asthma
Chr. Bronchitis Emphysema Bronchial Asthma
Age of onset > 40 years Smoker, late Often in childhood
Family history of Asthma
Uncommon Uncommon Common
Personal History of Allergy
Uncommon
Uncommon
Common
Smoking Smoker Smoker Non-Smoker
Early Symptoms Persistent morning cough & sputum
Breathlessness Paroxysms of wheeze
Infective episodes
common Occasional Variable
Exercise tolerance
Often reduced poor Often normal in remission
Central cyanosis Common in late stage Blue & Bloated
Absent Pink puffer
Absent except severe attack
Wheeze, Rhonchi Present Often inaudiable Present during attack
Prognosis poor very poor good
Clinical signs of respiratory diseases: Summery
Disease Movement of the chest
Mediastinal displacement
Percussion note
Breath sounds Added sounds
Pneumonic consolidation
Reduced Nil Dull Bronchial Crepitations
Pulmonary collapse
Reduced Towards affected side
Dull Reduced or Absent Vesicular
Nil
Localized fibrosis
Reduced Towards affected side
Dull
Vesicular Crepitations
Pleural effusion
Reduced Away from affected side
Stony Dull Reduced or Absent
Nil
Pneumo- thorax
Reduced Away from affected side
Hyper Resonant
absent Nil
Take Home Message
• Diagnosis is a detective work controlled by a system of logical
analysis based on 3 foundations: history, physical signs and
investigations
• Symptoms & Signs hardly change over years
• Classical presentations are discussed here
• There may be atypical presentation
• Few routine investigations like CBC, ESR and X-ray Chest may affirm
the clinical diagnosis
Acknowledgements
• Scientific committee, BSM
• Dr. Chandra Shekhar Bala FCPS (Medicine) Jr. Consultant, NINS & H
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