3. Symptoms and Signs
Cough
• A protective reflex act
• Forceful expiration against a closed glottis that helps in clearing
airways including foreign body
• Contraction of respiratory muscles against closed glottis with
resultant increase in intrathoracic pressure followed by opening of
the glottis with forced expiration at very high flow rate in upper
airways.
4. Cough – Types
• Dry Cough
• Pleural, ILD, Mediastinal Lesions
• Productive Cough
• Suppurative Lung Disease, Chronic Bronchitis
• Short Cough
• URI
• Brassy Cough
• With metallic sound produced by compression of the trachea by intra thoracic SOL
• Bovine Cough
• Cough with loss of its explosive nature. Tumours pressing on Recurrent LN
6. Cough
Normal chest X-ray Abnormal chest X-ray
Acute cough
(<3 weeks)
Viral respiratory tract infection
Bacterial infection (acute
bronchitis)
Inhaled foreign body
Inhalation of irritant dusts/fumes
Pneumonia
Inhaled foreign body
Acute extrinsic allergic alveolitis
Sub acute Cough
( 3 to 8 weeks)
GERD
Tourette’s Syndrome
Intentional Cough
Tuberculosis
CAP
Bronchiectasis
Post viral Tussive Syndrome
Chronic cough
(>8 weeks)
GERD
Asthma
Post viral bronchial hyper-reactivity
Rhinitis/sinusitis
Cigarette smoking
Drugs, especially ACE inhibitors
Irritant dusts/fumes
Lung tumour
Tuberculosis
Interstitial lung disease
Bronchiectasis
7. Cough with expectoration
Quantity Quality Odour
1. Quantity - Normally 10 - 20 ml
2. Colour and appearance.
Green colour: Commonly Pseudomonas infections.
• Sometimes normal individuals expectorate greenish sputum in the morning .It is due to the breakdown of leucocytes in
the night and subsequent release of verdoperoxidase / Myeloperoxidase gives the greenish colour to the sputum.
Rusty coloured:
• In pneumonia, typically Streptococcal pneumonia, during the stage of red hepatisation rusty colour because of the
destruction of the RBCs.
Anchovy sauce:
• Hepato-pulmonary amoebiasis
Red currant jelly:
• Klebsiella pneumonia
Pink and frothy:
• Pulmonary oedema
8. Cough with expectoration
3. Consistency.
• Serous
Clear, Watery and Frothy
• Mucoid
Clear, Greyish white or black, Frothy
• Mucopurulent
Yellowish or greenish brown
4. Effect on changing position (Postural variation)
• suppurative lung diseases like bronchiectasis, lung abscess
5. Associated chest pain while coughing
6. Foul smelling in anaerobic infections
• Peptostreptococci, Fusobacterium, Bacteroids. short chain fatty acids producing butyrate or butyric acid.
Seasonal and diurnal variation should be enquired
9. Hemoptysis
Coughing out blood
• It may be a large quantity - aspergillosis or streaking of sputum - Carcinoma
bronchus initial stage
Types
• Frank – Expectoration of blood only-Bronchogenic Ca
• Hemoptysis in Suppurative lung disease - foul smelling
• Spurious – Present secondary to Upper respiratory tract infection, above the
level of larynx
• Pseudo – Due to pigment , Prodigiosin produced by Serratia marcescens
• Endemic – Paragonimus westermani
11. Hemoptysis
• Massive haemoptysis - 600 ml or more in 24 hours as one episode or
at different bouts.
• Moderate haemoptysis – 50 to 200 ml in 24 hours
• Minimal haemoptysis – Streaking of sputum with blood or 50 ml or
less in 24 hours.
Most important cause of death in haemoptysis is due to aspiration and
asphyxia than due to blood loss.
12. Breathlessness or Dyspnoea
Unpleasant awareness of one’s own breathing
Grading Scales
• MRC classification
• mMRC dyspnoea scale
• NYHA Scale
• Sherwood Jones grading
• Visual analogue scale
• BORG scale
• BODE scale
• American Thoracic Society scale
15. Clinically useful classification
1) Dyspnoea of sudden onset ( Within Minutes )
Pneumo thorax, asthma, pulmonary embolism, pulmonary oedema,
foreign body in major airways, inhalation of noxious gases
2) Acute Dyspnoea ( Hours to days)
Pneumonia, Asthma, AE COPD
3). Sub acute dyspnoea (weeks or months)
Congestive cardiac failure, anaemia, obesity, pleural effusion, ascitis,
pregnancy, interstial lung disease
4).Dyspnoea progressing over months or years
Chronic bronchitis, emphysema, pneumoconiosis, pulmonary fibrosis
(common in India due to pulmonary tuberculosis)
17. Dyspnoea - Position
Orthopnoea - The patient is more comfortable sitting up and may become breathless on lying flat.
• Usually occurs in cardiac failure due to increase in left atrial pressure.
• Paroxysmal Nocturnal Dyspnoea As the term indicates occurs at night (early morning),
• Pulmonary oedema (previously known as cardiac asthma),asthma.
• It can also be a feature of respiratory muscle weakness, large pleural effusion, massive ascites, morbid obesity
or any severe lung disease
Platypnoea - Shortness of breath in upright position
• AV malformation in lung
• chronic liver disease ( hepatopulmonary syndrome )
• hereditary condition – atrial myxoma
• Right-to-left shunting through a patent foramen ovale, atrial septal defect or a large intrapulmonary shunt.
Trepoponea - Breathlessness while lying on the side
• due to unilateral lung disease (patient prefers the healthy lung down),
• dilated cardiomyopathy (patient prefers right side down) or
• tumours compressing central airways and major blood vessels.
18. Dyspnoea - Evaluation
• How fast did it happen?
• Do you have chest pain?
• Does the pain change with respiration (pleuritic) ?
• Does your SOB gets better or worse with walking?
• Does your breathing pattern improve when you sit up?
• Do you have a history of asthma or emphysema (COPD)?
• Have you had clots in your legs?
• Have you been hit in the chest?
• Are you sleepy during the day?
19. Chest pain - History
• Site
• Radiation
• Mode of onset
• Duration
• Severity
• Aggravating/Relieving factors including the effects of breathing and
movement
20. Chest pain - Pleurisy
• Sharp
• Stabbing
• Intensified by inspiration or coughing
• Irritation of the parietal pleura of the upper six ribs causes localised pain.
• Irritation of the parietal pleura overlying the central diaphragm
innervated by the phrenic nerve is referred to the neck or shoulder tip
• The lower six intercostal nerves innervate the parietal pleura of the lower
ribs and the outer diaphragm, and pain from these sites may be referred
to the upper abdomen
21. CHEST wall PAIN
• Sudden and localised after vigorous coughing or direct trauma is
characteristic of rib fractures or intercostal muscle injury.
• Pre vesicular herpes zoster and intercostal nerve root compression can
cause chest pain in a thoracic dermatomal distribution
• Chest wall pain due to direct invasion by lung cancer, mesothelioma or rib
metastasis is typically dull, aching or gnawing, unrelated to respiration,
progressively worsens and disrupts sleep.
• Pancoast’s tumour of the lung apex may involve the first rib and the
brachial plexus, causing referred pain down the medial side of the
ipsilateral arm.
• Massive pulmonary thromboembolism acutely increasing right ventricular
pressure may produce central chest pain similar to myocardial ischaemia
22. Mediastinal Pain
• Central, retrosternal and unrelated to respiration or cough. Irritant
dusts or infection of the tracheobronchial tree produce a raw, burning
retrosternal pain worse on coughing.
• A dull, aching retrosternal pain that disturbs sleep is a feature of
cancer invading mediastinal lymph nodes or an enlarging thymoma
24. Wheeze
• What dose the patient mean by wheezing?
• Some patients may complain of funny noises produced in the chest while breathing as in the case
of asthmatics or patients with chronic bronchitis, vocal cord dysfunction, mainly on expiration.
• You should be able to differentiate between wheeze and stridor.
• Wheezing may be intermittent as in asthma or persistent as in chronic bronchitis.
• Wheezing may be diffuse as in asthma and chronic bronchitis or localized as in
bronchogenic carcinoma/ Foreign body.
• Stridor - This is a serious condition results from partial obstruction, narrowing of
larynx, trachea or major bronchi usually inspiratory and may be audible without
stethoscope.
25. Constitutional Symptoms
Fever
• Normal temperature is 36.60 to 37.20C. Usually above 370C is taken as
pyrexia. All individual have a circadian rhythm with evening temperature of
0.50 to 10C more than in the morning. A slight rise in temperature during
ovulation can occur.
Types of fever
• 1. Continuous – Temperature is present throughout the day but never
touches the baseline in 24 hours and the fluctuation is not more than l0C
• 2. Remittent – Temperature never touches the baseline in 24 hours and the
fluctuation is more than 20C.
• 3. Intermittent- Temperature touches the baseline at least once in 24 hours
26. Constitutional Symptoms
Loss of Appetite
• Patient may not be eating as well as before and disinclination to take the food.
Loss of Weight
• Patient or the relatives note the loss of weight. In India two commonest causes
for loss of weight are pulmonary tuberculosis or carcinoma bronchus.
Significant weight loss
• 5% in 30 days
• 7.5% in 60 days
• 10% in 180 days
(Different authors give different percentage)
27. Other Symptoms
Hoarseness of voice
• Patient notices change in voice. Common causes are pharyngitis, laryngitis,
Tuberculous laryngitis, carcinoma larynx, recurrent laryngeal nerve palsy, and inhaled
corticosteroids producing myopathy adductor muscles of the vocal cord, Ortner’s
syndrome
Dysphagia
• Compression of oesophagus secondary enlarged mediastinal node compression due
to various pathology.
Sleep disturbances
• Enquire patient’s sleep pattern (it was not given much importance previously)
• History of sneezing and rhinitis (seasonal variation),allergy (food, pollen etc,)
recurrent headaches probably due to sinusitis (Kartagener’s syndrome) and recurrent
upper respiratory tract infections (aspiration pneumonias).
28. Past History
Previous history of any illness might give us a clue regarding the present
disease.
In respiratory medicine the must to know - past history are
Asthma,
Allergic disorders,
Diabetes mellitus,
Hypertension,
Pulmonary tuberculosis,
Epilepsy (aspiration pneumonia),
Childhood history of measles, whooping cough.
29. Family history
• Asthma,
• Allergy,
• Diabetes Mellitus,
• Hypertension,
• Pulmonary Tuberculosis,
• Epilepsy
30. Occupational History
• Duration of exposure: several years are needed for pneumoconiosis
to develop.
• Adherence to safety measures as wearing special masks during work
to prevent inhalation of the dust.
– Silicosis which may be complicated by pulmonary T.B.
– Asbestosis which may be complicated by mesothelioma
31. Personal history
• Sleep,
• Bowel and Bladder habits,
• Smoking
(smoking index is number of cigarettes smoked per day X number of years)
• Alcoholism,
• Substance abuse,
• Dietary habits,
• Socioeconomic status can be enquired into and
can be made out from the dress , cleanliness & occupation.
32. Treatment history
This may be asked with the past history but patients with respiratory
disorder volunteer even the specific names of the drug like –
• An asthmatic may say he is on salbutamol, or aerosol therapy or
• A person who had tuberculosis may give the name of the drugs he had taken
or say while taking the drugs urine was orange coloured (rifampicin).
• History of surgery, anaesthesia (aspiration pneumonia) should be taken.
• History of hypertension is important because ACE inhibitors produce dry
cough
33. Menstrual history
• Female patients.
• One of the commonest causes of sterility in India is genito-urinary
tract tuberculosis.
• All types of menstrual irregularities can be encountered in genitor-
urinary tuberculosis.
• In endometriosis (ectopic endometrium) the patient may have
haemoptysis or pneumothorax during menstruation
- Catamanial
35. General Examination
• Pallor
• Icterus
• Cyanosis
• Clubbing
• Edema
• Lymphadenopathy
• Temperature
• Pulse
• Respiratory Rate
• BP
• JVP
36. Pallor (Anemia)
The pallor of anemia is best seen in the mucous membranes of the
conjunctivae, lips and tongue and in the nail beds
Anaemia may occur when there is
a. Haemoptysis
b. Excessive sputum production and protein loss
c. Loss of appetite leading to malnutrition
37. Cyanosis
This is a blue discoloration of the skin and mucous membranes caused
by increased concentration of reduced hemoglobin (5g/dl)
Central cyanosis may result from the reduced arterial oxygen saturation
caused by cardiac or pulmonary disease.
• Intra cardiac or extra cardiac shunting
• Impaired pulmonary function
a. Alveolar hypoventilation
b. Ventilation—Perfusion mismatch
c. Impaired oxygen diffusion.
38. Clubbing
Bulbous enlargement of the distal portion of the digit due to
increased subungual soft tissue.
Schamroth’s Sign
Fluctuation Test
39. Clubbing - Grading
• Grade I Positive nail bed fluctuation/Obliteration of the angle
between the nail and the nail bed
• Grade II Parrot Beak appearance
• Grade III Drumstick appearance
• Grade IV Hypertrophic osteoarthropathy.
40. Clubbing - Causes
Respiratory
a. Bronchogenic carcinoma
(rare in adenocarcinoma)
b. Metastatic lung cancer
c. Suppurative lung disease
1. Bronchiectasis
2. Cystic fibrosis
3. Lung abscess
4. Empyema
d. Interstitial lung disease
e.Longstanding pulmonary tuberculosis
f.Chronic bronchitis
g.Mesothelioma
h.Neurogenic diaphragmatic tumour
i.Pulmonary AV malformation
j.Sarcoidosis.
42. Clubbing - Hypertrophic Osteoarthropathy
• It is a painful swelling of the wrist, elbow, knee, ankle, with
radiographic evidence of sub-periosteal new bone formation. It can
be familial or idiopathic.
common disorders that can produce it are:
• a. Bronchogenic carcinoma
• b. Cystic fibrosis
• c. Neurofibroma
• d. A-V malformation.
43. Clubbing - Theories
• Neurogenic – Vagal stimulation causes vaso dilatation and clubbing
• Humoral – GH,PTH,Estrogen,PG,Bradykinin causes vaso dilatation and
clubbing
• Ferritin – Decreased Ferritin in systemic circulation causes dilatation
of AV anastomosis and Hypertrophy of Terminal Phalanx
• Hypoxia – Persistant Hypoxia causes opening of deep A-V fistula of
Terminal Phalanx
• PDGF/VGF – released secondary to infection also causes
vasodilatation and clubbing
44. Neck
Scalene lymph node enlargement
1. Large and fixed in secondary involvement from a primary lung malignancy
2. Hard and craggy, matted, with or without sinus formation in healed and
calcified tuberculous lymphadenopathy.
Troisiers sign
45. Blood Pressure
Pulsus Paradoxus
Systolic blood pressure normally falls during quiet inspiration in normal
individuals.
Pulsus paradoxus is defined as a fall of systolic
blood pressure of >10 mmHg during the inspiratory phase.
• severe acute asthma or exacerbations of
chronic obstructive pulmonary disease.
46. Examination of the Neck Veins - JVP
Jugular Venous Pulse
• COPD/cor pulmonale
• Bilateral non-pulsatile
• SVC obstruction
• Massive right sided pleural effusion
47. JVP
"A" wave: Atrial contraction (ABSENT in atrial fibrillation)
"C" wave: Ventricular contraction (tricuspid bulges). YOU WON'T SEE THIS
"X" descent: Atrial relaxation
"V" wave: Atrial venous filling (occurs at same of time of ventricular
contraction)
"Y" descent: Ventricular filling (tricuspid opens)
48. Abnormal Jugular Venous Waveforms
Elevated "a" wave
• Resistance to right atrial emptying, may occur at or
beyond the tricuspid valve. Examples include:
• Pulmonary Hypertension
• Rheumatic tricuspid stenosis
• Right atrial mass or thrombus
Cannon "a" wave
• Large positive venous pulse during "a" wave. It occurs
when an atrium contracts against a closed tricuspid valve
during AV dissociation. Examples include:
• Premature atrial/junctional/ventricular beats
• Complete atrio-ventricular (AV) block
• Ventricular tachycardia
Absent "a" wave
• No atrial contraction, common to atrial fibrillation
Elevated "v" wave
• Tricuspid regurgitation is the most common cause (Lancisi
sign).
• The ventricle contracts and if the tricuspid valve
does not close well, a jet of blood shoots into the
right atrium.
• Tricuspid regurgitation, if significant, will be
accompanied by a pulsatile liver (feel over the lower
costal margin).
• You will also hear the murmur of tricuspid
regurgitation—a pansystolic murmur that increases
on inspiration.
Other signs:
• Kussmaul's sign: neck veins rise in inspiration rather than
fall—often a sign of pericardial tamponade or right heart
failure (acute right ventricular myocardial infarction)
• Friedrich's sign: exaggerated "x" wave or diastolic
collapse of the neck veins from constrictive pericarditis
