Clinical Examination

Respiratory System

Some important terminologies used by people are:

1. बलगम = Phlegm
2. जुकाम = Catarrh
3. फु फ्फु स = Pleurisy
4. घरघराहट = Wheeze

Respiratory Breathlessness
problems
Wheeze
Cough
Sputum/Haemoptysis
Chest Pain
Fever
Weight loss
Sleepiness
Clinical Examination
 Clinical Examination

Determined by
the MRC
Breathlessness
scale

Stimulation of
intrapulmonary
Aggravating
factors
Breathlessness afferent nerves

Is breathing
normal on some
days
Normal in Asthma
Questions to be Can be caused
Daily in COPD
asked due to multiple
mechanisms

mechanical
loading of
respiratory
How did it muscles
begin
Instantaneous
Pneumothorax
Breathing at Pulmonary embolism
rest Acute allergy
Hypoxia due to
Over hours
Asthma V/P mismatch
Acute Pulmonary edema
Acute infections

In order to rule out dyspnoea due to cardiovascular causes, the exertional dyspnoea is to be observed.
 Clinical Examination

if during If after
excercise excercise
COPD Asthma

Is the
wheeze
worse
during or
after
excercise
Bronchiectasis Asthma

Sputum which Do you wake

is yellow or with wheeze at
green in night
colour

Wheez
e
Do you smoke?

Do you have
hay fever or
any other
allergies

COPD Is it worse on
waking in the
morning

COPD
 Clinical Examination

Duration of cough

Wheeze
May signal
cough-
variant
asthma

Whether present
everyday
Associated
clinical
features
Altered
voice
Considered Heartburn
laryngeal
causes

Coug
h
Intrusive or
Smoking patient coughs
deliberately

Whether it
produces sputum

How much
Any triggers

What colour

Cough is most commonly a symptom of acute viral upper respiratory tract infections, which are usually self-limiting
over days to weeks.
Cough that fails to settle over weeks may be the presenting feature of bronchial carcinoma. A history of smoking
raises further suspicion of malignancy, although chronic cough is a non-specific symptoms in smokers.

Sputum: In acute or chronic airways infection, accumulation of neutrophils, mucus and proteinaceous
secretions in the airways results in cough with expectoration of sputum.
 Colour:
 Clinical Examination

1. Clear (mucoid): COPD/ Bronchiectasis/ Rhinitis

2. Frothy white: Heart failure
3. Yellow (mucopurulent): Acute lower respiratory tract infection/ Asthma
4. Green (purulent): current infection
5. Red (rusty): Pneumococcal pneumonia
6. Pink (serous): Acute pulmonary edema
 Volume: Establish volume produced over 24 hours: small amounts into a tissue, or enough to fill a
spoon, eggcups or cups. Compare the current volume with the patient’s baseline or minimal volume
 Consistency: An increase in stickiness may indicate exacerbation in bronchiectasis.
 Clinical Examination

Blood in mouth Blood from nose

Was the
blood
definitely
coughed up
from chest?

Short history of
blood streaks +
purulent sputum
Pulmonary Acute Bronchitis
arteriovenous

Hemoptysis
malformation

Pulmonary
vasculitis

Large Blood
volumes present
sudden or
for a while

Sudden episode +
pleuritic pain +
breathlessness
Pulmonary embolism
Cavitatory
disease

Recurrent
episode
Malignancy
Lung cancer

Bronchiectasis
 Clinical Examination

Onset
Rapid
Gradual

Exacerbating
Character or relieving
factors

Site and Establishment Associated

severity of symptoms

Chest pain

Subdiaph Where
ragmatic can it Chest
organ arise wall
from

Parietal
Pleura
Oesophag
us worse on
inspirat
ion
stabbing
nature
site
away
Mediasti from
Pericard nal midline
ium structur
es
Tracheob
ronchial
tree

Large pulmonary embolus can cause angina-like chest pain due to increased right ventricular work together with
reduced coronary oxygen delivery caused by hypotension and hypoxemia, resulting in right ventricular ischaemia.
Pain can never originate in lungs parenchyma or visceral pleura as they only have an autonomic nerve supply.

Fever/Rigors/Night sweats: These are non-specific symptoms but point towards an infection or lung cancer or
lymphoma or vasculitis. Rigors are generalised, uncontrollable episodes of vigorous body shaking lasting a
few minutes. They indicate Bacterial sepsis, lobar pneumonia and acute pyelonephritis.
 Clinical Examination

Night sweats are more closely associated with chronic infection and malignancy or lymphoma rather than
acute infection.

Weight loss: This is a common feature of several important respiratory diseases like lung cancer, chronic
infective diseases, and diseases causing chronic breathlessness. Small amount of weight loss also occurs in
acute infection with consequent loss of appetite, particularly during hospitalisation.

Sleepiness: Can help in determining the sleep apnoea

 Clinical Examination

Inspection: (1).Normal shape, (2).scars over the thorax, (3).lumps, (4).lesions and (5).respiratory movements
of the chest wall are to be looked at. Obstruction causes prolonged expiration relative to inspiration and
sometimes pursed lip breathing. Chest deformities may be congenital, as in pectus excavatum or acquired as
in pectus carinatum. Asymmetry of the chest- secondary to scoliosis, shrinkage of scarred lung following
tuberculous infection or prior to surgical resection of lung and/or ribs.
The heart rate normally at rest is 12-15 breaths per minute. Anxious patients may breathe at 15-20 breaths per
minute, but a rate above 20 breaths per minute is abnormal for an adult.
Cheyne-stokes breathing- seen in heart failure
Dusky red lesions of erythema nodosum- indicates sarcoidosis

Clubbing- seen commonly in chronic suppurative lung disease like bronchiectasis, lung cancer and pulmonary
fibrosis
Hypertrophic Pulmonary Osteoarthropathy- Lung carcinoma
Fine tremors of the outstretched hands is common in respiratory patients and usually due to direct effect of
high dose beta-agonist bronchodilators.

Dusky generalised swelling of the head, neck, and face with subconjunctival oedema- Superior Vena Cava
Obstruction

Jugular Venous Pressure is raised- Pulmonary hypertension, Tension pneumothorax

 Clinical Examination

Tracheal deviation- tension pneumothorax

Cricosternal distance increased- hyperinflation

Palpation: Apex beat displaced laterally by dilatation of ventricles or leftward displacement of the
mediastinum. Hyperinflation in obstructive lung disease causes the lingula of the left upper lobe to come
between the heart and the chest wall, making the apex beat impalpable and heart sounds inaudible.
Lower sternum lifted by cardiac cycle- Pulmonary hypertension
Paradoxical inward movement of the lower ribs (Hoover’s sign)- COPD
Palpation done for lymph nodes, swellings, and tenderness.

Percussion: Hollow ringing sound accompanied by a palpable resonance- air-filled lung

Anterior chest percussion is symmetrical except for the area immediately lateral to the lower left sternal edge,
where the right ventricle cause dullness.
Cardiac dullness is lost in hyperinflated patients
Resonance on percussion + Unilateral absent breath sounds- Pneumothorax

Auscultation: In larynx and trachea, the flow rate is fast and causes the sound to be turbulent where as in distal
airways the flow rate of air is slow and is virtually silent. Thus most sound heard while auscultating arises in
large central airways.
Dullness on percussion +reduced breath sounds + vocal resonance = lobar collapse
Breath sounds absent = pneumothorax or pleural effusion
Added breath sounds:
o Wheeze: musical, continuous and more common in expiration.
Usually multiple wheezing sounds are heard together (polyphonic wheeze)- asthma, bronchitis, COPD
o Crackles: non-musical, continuous. Crackles after several deep breaths is considered pathological.
It is graded “fine,” and “course.”
Fine crackles during inspiration- Interstitial Pulmonary Fibrosis
Coarse crackles- bronchopneumonia, bronchiectasis
o Pleural rub: rasping sound; it indicates pleural inflammation usually due to infection
o Vocal resonance: the spoken sound is muffled and deadened- healthy lung
Loud spoken sound and clear- fibrotic lung scarring
Spoken sound absent or greatly diminished- pneumothorax and pleural effusion
 Clinical Examination

Circulatory System
 Clinical Examination

Intermittent pain

Chest pain

Acute chest pain

Orthopnoea

Heart failure Dyspnoea on lying flat

Frothy white or Blood-

Dyspnoea Pulmonary embolism
stained sputum

Arrythmia
Chest Problems

Felt occasionally after

excercise

More common in bed at

night and Slim people
notice it while lying on side

Palpitation Ectopic beats

Supraventricular
tachycardia
Presyncope

Ventricular tachycardia associated with

Syncope

Postural hypotension

Neurocardiogenic syncope

Syncope

Arrythmia (Bradyarrythmia)

Oedema Aortic stenosis

Mechanical obstruction of
cardiac output
Hypertrophic
cardiomyopathy
 Clinical Examination

Site and
severity

Exaggerating
factors Onset

Ches
t
Time
duration
of pain
pain Character

Associated
symptoms Radiation
 Clinical Examination

Intermittent chest pain is a dull type of pain that is described as a diffuse band like sensation over the chest, it may
radiate down one or both arms and into throat, jaw or teeth. The episodes of pain are precipitated by exertion and may
occur more readily when walking in cold or windy weather. This pain is also relieved by medication such as
sublingual glyceryl nitrate spray.

Acute chest pain is a severe kind of prolonged pain. It can be sharp, sstabbing, radiating in nature. It is exacerbated by
inspiration or lying down and relieved by sitting forwards. It can be caused by inflammation of the pericardium
secondary to viral infection, connective tissue disease or myocardial infarction.
 Clinical Examination

Duration
of onset
Associated Background
symptoms symptoms of
like ankle exertional
swelling, dyspnoea and
cough, usual
wheeze or excercise
sputum intolerance

Dyspnoe
Effect
a Associated
symptoms
of of chest
posture discomfort

Degree of
limitation Relationship
between
s caused symptoms and
by exertion
symptoms

Patient feels comfortable sitting upright- Pulmonary oedema and Acute heart failure
Patient feels comfortable lying down- Massive pulmonary embolism
Exertional dyspnoea is symptomatic hallmark of chronic heart failure
 Clinical Examination

Is
heartbeat
rapid

Nature of
palpitation

Irregular Forceful
Speed of
onset and
offset

History of
underlying
disease
Timing of
symptoms

Duration Frequency
Palpitation

Presyncop
e

Precipitants for
symptoms or
relieving
factors
Associted
symptoms

Chest Syncope
pain

Ectopic beats are benign cause of palpitation at rest. The premature ectopic beat produces a small stroke volume and
an impalpable impulse due to incomplete left ventricular filling. The subsequent compensatory pause leads to
ventricular overfilling and a forceful contraction with the next beat.
 Clinical Examination

Nausea
Light-
Tinnitus
headedness

Palpitation Sweating

Visual
Chest pain
disturbance

Circumstanc
es of event
and
preceding
symptoms
Appearance of patient while
unconscious

Current status
Syncope Duration of loss of
consciousness

Injuries sustained

Time to full recovery

The main differential diagnosis of syncope is seizure, while light-headedness and presyncope must be distinguished
from dizziness or vertigo due to non-cardiovascular causes.
Postural hypotension, a fall of more than 20 mmHg in systolic blood pressure on standing, may lead to syncope or
presyncope. It can be caused by hypovolaemia, drugs or autonomic neuropathy and is common in the elderly.
 Clinical Examination

Presyncope

Exact nature of Frequency of

Precipitants Any medications
symptoms episodes

postural change

prolonged
standing

Intense emotion

exertion

Deep vein
thrombosi
s

Unilatera
l

Oedema
Abdominal Heart
distensio failure
n

Other
Orthopnoe symptoms Bilateral
a to be
enquired

Chronic
venous
disease

Dyspnoea Fluid
overload Drugs
 Clinical Examination

Past history: Inquire about

1. Chronic diseases
2. Rheumatic fever
3. Any skin infection, dental work
4. Systemic diseases like marfan syndrome

o Drug History
o Family history: Inquire about first degree relatives for premature coronary artery disease, sudden death at a
young age, thrombophilia, familial hypercholesterolaemia
o Social History: Inquire about Smoking (peripheral and coronary artery disease), Alcohol (atrial fibrillation),
recreational drugs (arrythmias, chest pain, aneurysmal peripheral arterial disease, myocardial infarction)

Inspection: Inspect for tobacco staining, skin crease pallor, peripheral cyanosis, finger clubbing and splinter
haemorrhages (found in infective endocarditis and vasculitic disorders). Examine the extensor surface of
hands for tendon xanthoma (hypercholesterolaemia) and look for Janeway lesion and osler’s nodules
(endocarditis).
Eyelids are inspected for xanthelasmata, iris for corneal arcus (hyperlipidemia).
Central cyanosis to be observed (heart failure)

Palpation: The hands are palpated to determine the temperature and to check for the capillary filling time
(normally less than 2 seconds).
Blood pressure measurement is to be taken from both arms. A difference of more than 10 mm Hg indicates the
presence of aortic or subclavian artery disease
Pulse is to be palpated for:
1. Rate
2. Rhythm- can be regular or irregular. Irregular pulse can be divided into regularly irregular (seen in normal
deep respiration) or irregularly irregular (atrial fibrillation)
3. Volume- It can be normal, decreased (severe heart failure, hypovolaemia, cardiac tamponade, mitral
stenosis, coarctation) or increased (hypertension, fever, aortic regurgitation, anaemia, thyrotoxicosis,
pregnancy, exercise)
 Clinical Examination

4. Character
5. Sychronicity
6. Radio-femoral delay

Jugular venous pressure is to be observed. It has two waves: a wave and v wave. It is elevated in case of fluid
overload conditions, particularly heart failure. Other conditions of JVP elevation include pulmonary
embolism, pericardial effusion, pericardial constriction. It is absent in atrial fibrillation (a-wave absent). Giant
a -wave is seen in tricuspid stenosis, giant v-wave is seen in tricuspid regurgitation; canon waves are seen in
complete heart block.