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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