Clinical Examination and

Applied Medicine
Clinical Examination and
Applied Medicine
Pulmonology Series

Volume I

Mushtaq Haroon

MOMENTUM PRESS, LLC, NEW YORK

Clinical Examination and Applied Medicine: Pulmonology Series, V
­ olume I

Copyright © Momentum Press, LLC, 2020.

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
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First published in 2020 by

Momentum Press, LLC
222 East 46th Street, New York, NY 10017
www.momentumpress.net

ISBN-13: 978-1-94708-301-1 (paperback)

ISBN-13: 978-1-94708-302-8 (e-book)

Momentum Press Health Education C

­ ollection

Cover and interior design by Exeter Premedia Services Private Ltd.,

Chennai, India

First edition: 2020

10 9 8 7 6 5 4 3 2 1

Printed in the United States of America.

This book is dedicated to my loving wife, Romana.
My daughters Sundus, Saima, and Anum.
 Abstract
This book is the second in the series of books, which deals simultaneously
with examination techniques pathophysiological principles, ­differential
diagnosis, and clinical interpretation, along with applied medicine about
common pulmonary diseases. A medical student or a postgraduate doctor
studying for higher exam will learn to take a good history, e­ xamine the
patient, and find relevant applied medical knowledge, which is needed
for assessment of the patient. It should also serve as an invaluable collec-
tion of facts to get through undergraduate or postgraduate examination
including viva and bedside short and long case evaluation.
This book attempts to answer pertinent questions such as how? and
why? about clinical examination while providing relevant information
needed for a thorough bedside assessment. The book intends to fill this
gap and inspires the reader to gain confidence to make a correct diagnosis
exclude relevant differential diagnosis, localize the disease and determine
its cause.
The Volume II of this book includes a section on common ­pulmonary
investigations, blood gases, pulmonary functions, and radiology. A wealth
of diagrams and figures along with brief clinical note has been included
to arouse understanding and learning. As a further stimulus for ­learning,
a picture test with MCQ and a short applied medical note has also been
added. The book is not a replacement for standard textbook on the s­ ubject,
but it is hoped that it would serve as an invaluable source of revision.

Keywords
History taking; respiratory examination; pulmonary clinical examination;
bedside assessment; pulmonary diseases; chest diseases; lung diseases;
­pulmonology images; COPD; asthma; X-ray chest; pulmonary func-
tions; ABG; pulmonary investigations; pulmonary infections; chest dis-
eases; interstitial lung disease; tuberculosis; pulmonary embolism; pleural
­diseases; lung tumor; obstructive airway disease; restrictive airway disease
 Contents
Preface xiii
Acknowledgments xv
Part I
Introduction and History Taking
Introduction1
History-Taking3
Past History 5
Family History 6
Personal History 7
Socioeconomic Status 7
Occupational History 7
History of Allergy and Immunization 8
Travel History 8
Treatment History 8
Concluding Remarks 9
Common Respiratory Symptoms 11

Part II
General Examination
Anemia21
Clinical Features 22
Jaundice23
Cyanosis25
Clubbing26
Peripheral Edema 29
Skin Complexion and Face 30
Hands32
Neck33
Oral Examination 34
Anatomy37
Respiratory Examination 38
Inspection38
x Contents

Posture of the Patients 39

Accessory Muscles 40
Palpation46
Examination46
Clinical Interpretations 47
Posterior Examination 48
Anterior Examination 49
Apical Movement 49
Clinical Interpretations 50
Percussion52
Types of Percussion 53
Methods of Percussion 54
Note54
Areas to be Percussed 54
Auscultation56
Prerequisites of Auscultation 57
Whispering Pectoriloquy 60
D’espine Sign 61
Note62
Types of Crepitations 64
Summary Examination 66
Acute Bronchitis 70
ARDS (Acute Respiratory Distress Syndrome) 71
Aspergillosis74
Atelectasis or Collapse 75
Bronchial Asthma 77
Bronchiectasis84
Bronchial Carcinoid 88
Bronchiolitis89
Bronchogenic Carcinoma 89
Chronic Bronchitis 94
Churg–Strauss Disease (Allergic Angiitis) 95
COPD (Chronic Obstructive Airway Disease) 95
Cystic Fibrosis 101
Diffuse Alveolar Hemorrhage (DAH) 103
 Contents xi

Emphysema104
Empyema106
Extrinsic Allergic Alveolitis (Farmer’s Lung or Hypersensitivity
Pneumonitis)106
Goodpasture Syndrome (GPS) 108
Granulomatosis with Polyangitis 109
Idiopathic Pulmonary Hemosiderosis 111
Influenza112
Loeffler’s Syndrome 113
Lung Abscess 113
McLeod Syndrome 116
MERS (Middle East Respiratory Syndrome) 116
Metastatic Lung Disease 117
Miliary TB 118
Obesity Hypoventilation Syndrome (OHS) 120
Occupational Lung Diseases 122
Asbestosis122
Coal Worker’s Pneumoconiosis 123
Silicosis123
Pleural Effusion 123
Pneumonia129
Clues for Etiology of Pneumonia 135
Empirical Treatment for CAP 138
Pneumothorax145
Pulmonary Alveolar Proteinosis 148
Pulmonary ArterioVenous Malformation (PAVM) 149
Pulmonary Edema 150
Pulmonary Embolism 151
Pulmonary Fibrosis 156
Pulmonary Hamartoma 162
Pulmonary Hypertension 162
Pulmonary Nodules 165
Pulmonary Renal Syndrome 167
Respiratory Failure 167
Rheumatoid Arthritis (RA) 169
xii Contents

Sarcoidosis172
SARS (Severe Acute Respiratory Syndrome) 173
Sleep Apnea 174
Superior Vena Caval Syndrome 176
Tropical Pulmonary Eosinophilia 176
Tuberculosis177
Pulmonary Calcification 182
Yellow Nail Syndrome 183

List of Contributors 185

About the Author 187
Index189
 Preface
The pulmonology series of clinical examination and applied medicine is
the second in the series of books dealing with examination techniques,
pathophysiological principles, and clinical interpretation, besides provid-
ing pertinent details of applied medicine in common diseases. A ­medical
student or a postgraduate doctor studying for higher exam will find rel-
evant applied medical knowledge that is needed for assessment of the
patient. It should hopefully serve as an invaluable collection of facts to get
through undergraduate or postgraduate examination.
History-taking and clinical examination form the foundation of diag-
nosis and pave the way for the correct management. Clinical examination
is an essential prerequisite for a medical student entering the clinical side
of his or her undergraduate career. It can haunt him or her at all stages of
the undergraduate and postgraduate life. It forms the basis of his or her
clinical practice during the professional career.
Pathophysiological principles of examination, where relevant, are
explained for a thorough understanding. Once the pathophysiological
basis of signs and symptoms is understood, it can be applied to a variety
of clinical situations in different patients. The process then becomes one
of deduction, application of principle, and logical outcome that is the
foundation and cornerstone of knowledge. This book attempts to answer
pertinent questions such as how and why about clinical examination and
bedside medicine besides providing interpretation of physical signs. It is
not enough to know that there is a lesion, but it is important to localize
it and find a possible cause. The investigations and treatment plan then
depends on proper differential diagnosis. The book intends to fill this gap
and provide solutions, inspiring the reader to gain confidence not only in
the performance of the examination, but to address most bedside queries
and problems.
This new edition includes a wealth of radiological material, figures,
and photos to arouse understanding and learning. As a further s­timulus
for learning, picture test and MCQs with important facts have been
added in Volume II.
xiv Preface

The book is not a replacement for standard textbook on the subject,

but it is hoped that it would help transferring relevant clinical knowledge
and provide the arsenal to solve bedside problems of patients efficiently
and get through undergraduate and postgraduate examination.
Dr. M. Haroon
MBBS (Pb); MCPS (Pak); MRCP (UK)
FRCP (London)
 Acknowledgments
I am ever grateful to the Almighty, Allah Subhana wa Taala for granting
me the knowledge and strength to reproduce what I have learned through
my teachers, colleagues, and students of Allama Iqbal Medical College,
Lahore King Edward Medical University, Lahore; and Quaid-e-Azam
Medical College, Bahawalpur. I am blessed to be working in Pakistan
kidney and liver institute, Lahore, where I have conducive environment
of learning and cooperation.The task would never have been possible
without the blessings from the Lord Almighty.
 Part I

Introduction and
History Taking
Introduction
Patient care begins with the development of a personal relationship
between the patient and the physician with trust and confidence. In
many cases, confidence and reassurance to the patient may be all that is
required. When no treatment is available or possible, the patient should
be given a feeling that the doctor is trying his or her best. A subjective
assessment of the quality of life, or assessment of what each patient values
the most has to be made. This requires a detailed and intimate knowledge
of the patient, through unhurried conversation, in a comfortable atmo-
sphere. Improvement in the quality of life is the main goal, especially in
incurable diseases.
As the cost of medical care continues to rise, making it neces-
sary to not only tailor the investigations but prescribe what is essential
and required. Prevention is always better than cure. Measures such as
vaccination, immunization, reduction in accidents and occupational
­
­hazards, improved environmental control, and screening of newborns for
­common diseases have been found to be economical. The equation of
cost versus benefit and necessity should always be kept in mind. Confir-
matory tests instead of screening seem logical where the clinical diagnosis
is almost certain.
History-taking is an art, as well as science that requires a thorough
knowledge of medicine along with patience and good command on
the language of the patient. The history is the written record of all the
facts about the patient’s present and past illnesses. It is best to use the
patients’ words, and not suggest answers. Quite often, the main problem
of the patient may not be clinically significant, but some other problem
on which the patient may be paying very little attention, may be more
2 Clinical Examination and Applied Medicine

significant for the doctor to reach a correct diagnosis. To write a good

history, patience, attention, concentration, and encouragement of the
patient are required.
Physical findings are subject to change. Just because the examination
is normal on one occasion does not guarantee that this will be the case
on subsequent examinations. Likewise, abnormal findings may disappear
in the course of illness. Therefore, repeat the physical examination as
­frequently as the clinical situation warrants.
Diagnosis requires a logical approach, an analytic mind that is able to
recollect, interpret and organize data. It is most important to keep the
objective of history-taking in mind.

Objective of History-Taking
1. To make a clinical diagnosis, plan relevant investigations and then formulate a
management plan.
2. To determine the cause or etiology of the disease.
3. To effectively rule out relevant differential diagnosis.
4. To pick any complications in relation to the disease.
5. To look for other illnesses that the patient may not be aware of or that may be silent
for the time being.
6. To know your patient’s socio-psychological and economic condition.

A good history should be concise to the point and able to fulfill these
objectives without irrelevant detail. It is not a translation of the patient’s
complaints from one language to another. History is not writing of an ele-
gant essay of the patient’s complaints. Each question that is asked should
be directed toward a diagnosis or help to exclude relevant differential
diagnosis. It is best to use the patient’s words in history taking, rather than
using medical terms. Asking the most appropriate questions in relation
to the patient’s complaint will save time and be most fruitful. This art is
best learned at the bedside after interviewing a large number of patients.
A general introduction should include:

Introductory Remarks
Name Date of birth
Sex Occupation
Religion Date of admission
Address Mode of admission
 Introduction and History Taking 3

History-Taking
After introductory remarks, the presenting complaints which brought
the patient to the hospital, are listed in chronological order, that is, the
most prolonged complaint first and most recent last. It is also possible to
write the presenting complaints in order of importance, with the most
significant complaint first and the least significant one last. Mention any
known disease like hypertension, diabetes, and so on if they are thought
to contribute to presenting complaints.

Presenting Complaints
1. Cough with sputum 4 days

2. Fever 4 days

3. Chest pain 1 day

Presenting Complaints
1. Known case of interstitial lung disease since 10 years

2. Worsening shortness of breath since 1 weeks

3. Cough with sputum since 5 days

4. Blood in the sputum since 1 day

In the preceding example, interstitial lung disease did not primarily

bring the patient to the hospital, but it is considered likely to contributing
to the presenting problem. Therefore, it is mentioned in the presenting
complaints or alternately can be mentioned as opening remarks in the
history of presenting illness.
After the presenting complaint, the details of these complaints are
given. This is termed the history of presenting illness. It is described in the
same order as the presenting complaints, and one at a time. The ­opening
remark usually begins by mentioning when the patient was ­perfectly
healthy. At the end of the description of each complaint, a ­reasonable
conclusion about the underlying cause of the complaint should be
­
­possible. If not, there are deficiencies in the history-taking or back-
ground medical knowledge. The detailed description of the c­omplaint
should include:
4 Clinical Examination and Applied Medicine

Details of History of Presenting Illness

  1. When and how it started?
  2. How did it progress?
  3. What are its special characteristics?
  4. Are there any associated features?
  5. How has it affected the patient?
  6. Which medications have been used?
  7. Which investigations have been performed?
  8. What was the presumed diagnosis, if any?
  9. What was the effect or side-effect of treatment?
10. Ask related questions to confirm the diagnosis.
11. Ask questions to exclude differential diagnosis.

Each presenting complaint is pursued with relevant questions until all

the details have been gathered. It is important to note how the complaint
started, progressed, and evolved. What are the precipitating and relieving
factors, and whether there is any relation to any particular event like pos-
ture or breathing? Also, ask how the complaint has altered the patient’s
lifestyle. At times, a lot of cross-questioning may be required until a fair
conclusion about the diagnosis is reached. A patient with shortness of
breath may be interviewed as follows:

Patient with Shortness of Breath

  1. When did you first notice shortness of breath?
  2. How did it start, or what were you doing at the time?
  3. How did it progress over time?
  4. What relieves it?
  5. What precipitates it?
  6. Does the shortness of breath get worse on lying down?
  7. Does the shortness of breath wake you up in the middle of the night from sleep?
  8. Is it accompanied by chest pain? (Determine the character and details.)
  9. Are you a known asthmatic, or do you take inhalers or a nebulizer?
10. Do you have an underlying heart problem?
11. Is the shortness of breath related to smoke, pollution, or inhalation?
12. Do you smoke? (Obtain complete history with calculation of pack years.)
13. What treatment have you used or were given for the shortness of breath?
14. Is there any history of similar problem in the past?
15. Is there any history of cough and sputum or blood in sputum?
16. What investigations have you had previously for this problem?
 Introduction and History Taking 5

During history-taking, the doctor is thinking about asthma, Chronic

obstructive pulmonary disease (COPD), chest infection and pneumonia,
pleuritic problems, occupational lung disease, allergic problems, pul-
monary embolism, and other illnesses while keeping in mind the other
­systems that can affect the respiratory system.
The intention of these questions is to reach a diagnosis, exclude rele-
vant differential diagnosis, and determine any associated complication or
find the cause of the underlying disorder, if possible.
It is up to the doctor to decide which part of the patient’s history is
relevant and which is not. A good doctor should be a good and patient lis-
tener, and at the same time, should politely prevent the patient form side
tracking and wasting time in irrelevant details. A vigilant physician will
pick up minute detail in the history, which, although not important to the
patient, may clinch the diagnosis. In some patients, however, the diagnosis
is only possible after proper examination or even after investigations. At
the end of the history of presenting illness, it is necessary to inquire about
any other complaints the patient may have in any of the major systems.

Direct Questioning in History

RT Cough, sputum, dyspnea, hemoptysis, wheezing, etc.
CVS Chest pain, palpitations, dyspnea, syncope, orthopnea, and paroxysmal
­nocturnal dyspnea, history of heart disease or hypertension, etc.
GIT Abdominal pain, dyspepsia, nausea, heartburn, diarrhea, and constipation.
CNS History of headache, decreased level of consciousness, seizures, dizziness,
­sensory or motor problems, etc.
MKL Joint pains, morning stiffness, limitation of movement, restricted activities, etc.
ENDO Changes in growth, weight, and metabolism. Ask about problems related to
thyroid, parathyroid, pancreas, and adrenal glands.
GUT Polyuria, dysuria, frequency, oliguria, and change in color and smell of urine.
History of passage of blood, stones, gravel, or any kidney problems should
be inquired.
CNS = central nervous system, CVS = cardiovascular system, RT = respiratory system,
GIT = gastrointestinal system, MSKL = musculoskeletal system, ENDO = endocrine
system, GUT = genitourinary tract

Past History

This includes a detail of the patient’s past medical and surgical record. It
is not sufficient to say that nothing abnormal is detected. List important
6 Clinical Examination and Applied Medicine

positive and negative findings in chronological order. Ask about past ill-
nesses and hospitalizations for any reason. Ask about past operations,
if any. A past illness may be the source of the present problem.

Details of Past Illness

How long have you had the illness? How well is your disease controlled?
What treatment are you taking for it? Is it associated with any complications?
Do you take your treatment regularly?

Direct questions about common diseases like asthma, COPD, diabe-

tes, hypertension, heart disease, renal disease, peptic ulcer, asthma, joint
disease, bowel problems, etc. may be mentioned here or at the end of the
presenting complaint.

Family History

Ask about the family members and any significant history of disease in
the immediate (first-degree relatives) or distant family. Does any rela-
tive have an identical or similar illness? Does any relative suffer from an
unusual disease, or has died from a rare condition? If a disease happens to
run in the family, it does not mean that all the sufferers may have the same
manifestations. In others, it may involve a different system, for example,
in sarcoidosis, although the lung is commonly involved, any other organ
may be involved. Ask about marriages within the family, as consanguin-
eous marriage may be the source of rare autosomal recessive syndromes.
What is the ethnic origin of the family? Various ethnic groups have higher
incidence of certain inherited disorders.
Various diseases tend to run in families and have different modes of
inheritance (there may be chromosomal abnormalities, Mendelian disor-
ders and multifactorial disorders).

Some Pulmonary Genetic Disorders

1. Alpha-1 antitrypsin deficiency
2. Cystic fibrosis
3. Kartagener syndrome
4. Interstitial fibrosis
 Introduction and History Taking 7

Ask about the history of contact with sick patients, especially with
flu-like symptoms, tuberculosis, HIV patients. History of contact with
animals and birds is important because of the outbreaks of SARS, bird flu,
and MERS CoV in endemic areas.
Ask about the health of parents, if alive, and if dead, the cause of
death. Always ask about the probable cause of death and circumstances
leading to death. Ask about the health of wife and children, if applicable.

Personal History

Ask about personal habits like tobacco use or smoking, addictions (espe-
cially alcohol and others), and hobbies. Ask about recent travel (especially
to areas where AIDS or TB is common or endemic) and sex life, if thought
necessary for the diagnosis. It is necessary at this stage to take the patient
into confidence and tell him or her that his or her personal life will always
remain a secret. It may be necessary to inquire about the beliefs and faith
and about psychological problems, as psychotherapy may be required as
a form of treatment. Ask about the living conditions, as some diseases are
prone to occur in poor hygienic and overcrowded conditions.

Socioeconomic Status

Ask about the means of earning, and whether the patient is well to do
or can hardly make both ends meet. A patient may have more than one
source of income. Also, ask about support from the family, as the patient
may have or is likely to develop a disabling illness. It may be important to
avoid choosing expensive medications whenever possible, as the patient
may not be able to afford them.

Occupational History

Ask about the present and past occupations that the patient may have
had, as it may be related to the disease. Many a times, the disease may
be related to the patient’s work or workplace. Examples of some occupa-
tional diseases are as follows:
8 Clinical Examination and Applied Medicine

Occupational Lung Diseases

  1. Occupational asthma

  2. Farmer’s lung

  3. Silicosis

  4. Asbestosis

  5. Coal worker’s pneumoconiosis

  6. Bird fancier’s lung disease

  7. Bagassosis

  8. Obstructive airway disease (associated with grain, wood, cotton dust)

  9. Lung cancer (asbestosis and arsenic).

10. Cheese worker, malt worker, chemical worker, etc.

11. People exposed to cobalt, tin, barium, graphite, metal dust, stone, wood, cereals,
textile, agriculture, etc.

History of Allergy and Immunization

Ask the patient if there is any history of allergies to any material, includ-
ing drugs. If yes, what kind of reaction was noted with the offending
agent? Also, ask about pervious or any regular course of immunization
that the patient has received.

Travel History

Ask about any history of travel in the recent past. This may be useful,
especially if the patient has visited a TB endemic area and has low-grade
fever with cough and constitutional symptoms and night sweats. In
Legionella infection, history of travel is important, as it is transmitted via
contaminated air conditioning systems.

Treatment History

It is mandatory to take a detailed history of the past medical and surgical

treatment. This includes not only the treatment of the present problem,
but any significant and especially related problems in the past.
 Introduction and History Taking 9

Some Related Questions

What diseases have you suffered in the past or that are still ongoing?
Which medication were you prescribed, in what dose, for how long, with what benefit
and when did you stop?
Were there any complications of the treatment?
If the patient is on inhalers, then ask to demonstrate its use for assessment.

In a patient with COPD, for example, it is important to note the

following:

1. How much the patient smokes, the number of cigarettes per day,
duration and the type of smoking habit. Calculate the pack years
(1 packet per day for 1 year = 1 pack year).
2. How motivated is the patient in giving up smoking?
3. When did the patient stop smoking?
4. What has been the frequency of exacerbations?
5. Does the patient have wheezing and is he or she using any inhalers?
6. How much is the shortness of breath (how much activity can he or
she do without getting shortness of breath)?
7. What is the vaccination status?
8. Is there a history of passive smoke contact? If so, how much?

Without this information, adjustment of therapy may not be ideally

possible. It is important to take the history of the risk factors associated
with a particular disease like COPD or lung cancer.

Concluding Remarks
A good history should give a correct diagnosis of the patient’s problem
in most cases. Not only that, it should pick up complications associated
with that disease, assess the severity, chronicity, and determine how has
it affected the individual in terms of functional loss, if any. It should also
probe into other related or unrelated problems in different systems so that
a complete picture of the patient’s problems may be viewed. The aim is
to offer the best possible treatment, prevention or cure, if possible. This
10 Clinical Examination and Applied Medicine

can only be achieved through honest work, deliberation, patience, and

knowledge of the subject with a willingness and attitude to learn from
experience, and specially form mistakes.
In most cases, the diagnosis is reachable through a good history alone.
One is able to determine, to a reasonable extent, the type of illness, for
example, whether it is an inflammatory, neoplastic, infectious, occupa-
tional-associated, traumatic, genetic, or congenital disease. Examination
helps to confirm the diagnosis, but at times, it may give the only clues
to diagnosis. Still, in other cases, a diagnosis may not be reachable with
a good history and thorough examination, where a battery of investiga-
tions is required. A typical example is PUO (pyrexia of unknown ori-
gin). Rarely, the diagnosis is not made even after thorough investigations
and becomes obvious only after some time has passed, and is then made
retrospectively.
After the history, the patient is thoroughly examined with the diseased
system being examined first. Throughout the examination, a systematic
approach is adopted so that small details are not left out. One should
learn to examine with the intention to pick up physical signs, to deter-
mine the site of lesion, type of disease, and try to determine the cause. It is
not enough to determine that the patient has pulmonary hypertension,
but it is imperative to determine the cause like pulmonary arterial hyper-
tension, secondary to left heart disease, secondary to respiratory disease,
thromboembolic disease, veno-occlusive disease, etc. It is obvious that the
management in each case may be different. This book should help you
achieve these goals.

Objective of Examination
1. To confirm the diagnosis made during history-taking.
2. To demonstrate signs of disease and exclude differential diagnosis.
3. To look for other signs that may be related or unrelated to the present disease.
4. To determine the site, type, and cause of illness.
5. To determine the effects or complications of disease on different systems.
6. To formulate a logical investigation plan to confirm or refute the diagnosis.

The art of history-taking is best learned at the bedside of the patient.

There are no shortcuts, and practice makes one perfect. It is best to take
 Introduction and History Taking 11

a history, and then read up the different diseases, which make up the
­differential diagnosis form a textbook of medicine. One can then learn
from the mistakes made in history-taking and omissions made in the
examination and plan of investigations.

Common Respiratory Symptoms

The section deals with an introduction to common respiratory symp-
toms, signs and differential diagnosis of some of the common respiratory
diseases.

Common Respiratory Symptoms

Cough Dyspnea Sputum
Hemoptysis Chest pain Wheezing
Stridor Fever Weight loss

Cough is a powerful involuntary reflex or sudden voluntary expiration

that serves in clearing the airways. It is the commonest respiratory symp-
tom and may be related to irritation and disease from the throat to the
alveoli with some extra-pulmonary causes as well. When present for less
than three weeks, it is said to be acute, and when between three to eight
weeks, it is subacute and when over eight weeks it may be called chronic.

Causes of Acute Cough

  1. Common cold and influenza
  2. COPD exacerbation
  3. Asthma
  4. Pertussis
  5. Allergic rhinitis
  6. Acute bronchitis
  7. Drug-induced
  8. Pneumonia
  9. Heart failure
10. Aspiration pneumonia
11. Pulmonary embolism
12. Lung cancer
13. Foreign body inhalation
12 Clinical Examination and Applied Medicine

Causes of Persistent Cough

1. Pharyngeal and laryngeal infections and tumor.
2. Tracheal and bronchial involvement with infection, irritants, tumor, and
­foreign  body.
3. Lung infection, fibrosis, and tumors.
4. Pleural effusion may also produce cough.
5. Mediastinum involvement via pressure and secondary infection of trachea and
bronchi.
6. Heart disease with pulmonary edema.
7. Extra-pulmonary, for example, sub-diaphragmatic lesions, external ear disease, and
psychological causes.
8. Drugs, for example, angiotensin converting enzyme inhibitors.

Chronic cough is said to be present if it persists for longer than eight

weeks. It may be associated with smoking or due to pulmonary disorders
such as asthma, extra-pulmonary disorders like gastroesophageal reflux
disease, or may be a chronic idiopathic cough (a diagnosis of ­exclusion).
One should do a chest X-ray and spirometry after excluding drugs
like Angiotensin-converting enzyme (ACE) inhibitors as a cause. Also,
remember that postnasal drip syndrome is also an important cause.

Related Questions for Cough

  1. What is the duration and severity of cough?
  2. Is there any seasonal or diurnal variation?
  3. Is it productive or non-productive and dry? (What color is the sputum, and is it
blood stained?)
  4. Is the cough related to changes in posture?
  5. It is associated with chest pain?
  6. Is there accompanying fever?
  7. Is it related to dyspnea with orthopnea and paroxysmal nocturnal dyspnea (PND)
and chest pain?
  8. Is there associated wheezing, or is there history of allergy or asthma?
  9. What is the history of smoking?
10. Is there history of exposure to any irritant?
11. Is there associated weight loss or hoarseness?
12. Is there history of drug intake (ACE inhibitors)?
13. Ask about history of rhinitis, flu, COPD, asthma, heart failure, retrosternal burning,
HIV status (if applicable), contact with sick patients (TB, SARS, MERS CoV, etc.).
14. Are there any precipitating or relieving factors?
 Introduction and History Taking 13

The common causes of acute cough include upper respiratory tract

infections, exacerbation of COPD, asthma, postnasal drip, aspiration,
and pneumonia and associated with heart failure or drugs. Chronic cough
may be commonly related to smoking, chronic bronchitis, tuberculosis
(in endemic areas) gastroesophageal reflux, postnasal drip, and tumors.
Further investigations are based on the initial clinical impression from
a detailed history and examination along with basic labs like blood counts,
X-ray chest, oxygen saturation, and culture and microscopy reports.
Dyspnea is the subjective awareness and difficulty in breathing or feel-
ing of shortness of breath, which may be objectively seen as an increase in
rate and depth of respiration.

Inquiries in Relation to Dyspnea

  1. Onset, severity, and progression?
  2. Duration, timing, and frequency?
  3. Precipitating and relieving factors?
  4. Associated features (pregnancy, headache, jaundice, diarrhea, anorexia, etc.)?
  5. Note the patient’s previous level of dyspnea, and how has the present illness
affected it?
  6. Inquire about shortness of breath on lying that is relieved on sitting (orthopnea)
and dyspnea that awakens the patient at night (PND).
  7. The exact amount of functional disability caused by dyspnea?
  8. History of smoking?
  9. History of recent drug intake?
10. History of cardiac, respiratory, renal, metabolic, neurological, or hematological
disease?
11. History of anxiety and conditioning to exercise?

Causes of Sudden Onset of Dyspnea

1. Left ventricular failure (LVF) (myocardial infarction (MI), hypertension, etc.)
2. Pneumothorax
3. Pulmonary embolism
Foreign body and toxic inhalation
4. Acute laryngeal edema
5. Anaphylactic shock
6. Chest trauma
7. Adult respiratory distress syndrome
8. Hysterical
14 Clinical Examination and Applied Medicine

Causes of Subacute Onset of Dyspnea

1. Acute asthma
2. Severe pneumonia
3. Adult respiratory distress syndrome
4. Metabolic acidosis
5. Pericardial disease

Causes of Chronic Dyspnea

  1. COPD (emphysema, chronic bronchitis)
  2. Chronic asthma
  3. Severe chronic anemia
  4. Chronic heart disease (congestive cardiac failure (CCF), cardiomyopathy, valvular
heart disease)
  5. Pulmonary fibrosis and interstitial lung disease
  6. Thyrotoxicosis
  7. Pulmonary tumors
  8. Large pleural effusion
  9. Chronic kidney disease (with anemia and acidosis)
10. Gross chest wall disorders (kyphoscoliosis)
11. Pulmonary vascular disease and pulmonary hypertension
12. Severe anxiety must be excluded
13. Neuromuscular diseases
14. Psychological

Sign/Symptom Likely Cause of Diagnosis

  1. Chest pain Ischemic heart disease (IHD) or pulmonary embolism
  2. Wheeze Asthma (sometimes pulmonary edema).
  3. Fever Pneumonia (chest infection)
  4. Acidotic breathing Renal failure
  5. Severe pallor Anemia
  6. Blue bloater/pink puffer COPD
  7. Fine basal crepitations Pulmonary edema of pulmonary fibrosis
  8. Palpitations Arrhythmias
  9. Dullness on percussion Pneumonia or pleural effusion
10. Raised JVP Fluid overload
11. Edema CCF or cor pulmonale (renal or liver disease)
12. Weight loss Malignancy, Tuberculosis (TB) or HIV
 Introduction and History Taking 15

13. Stridor External obstruction, foreign body, local edema

14. Leg pain and swelling Pulmonary embolism
15. Pulsus paradoxus Severe asthma or constrictive pericarditis
16. Pulsus alternans Heart failure

Sputum production under normal circumstances is barely noticeable.

It is only when excessive amount is formed due to inflammation or irri-
tation that it is expectorated. It is important to ask about the quality and
quantity of phlegm. Malodorous or foul-smelling sputum is found when
anaerobic infection is present, for example, lung abscess, bronchiectasis,
and empyema with bronchopleural fistula. Greenish sputum may be seen
due to degeneration of leukocytes or by pseudomonas aeruginosa infec-
tion. Blackish sputum signifies excessive exposure to dust, smog, coal, or
aspergillosis. In pulmonary edema, sputum may be pink due to a tinge
of blood. It is common for the smokers to deny any significant phlegm
production because they consider it normal. In bronchiectasis, there is a
history of copious sputum, which may be related to postural changes as
well. Bronchial casts may be expectorated in asthma, and Charcot ­Leyden
crystals (clumped eosinophils) may be seen under the microscope in
­allergic asthma.
Hemoptysis is coughed-up blood and an alarming symptom for the
patient. It is called massive when the amount is in excess of 600ml in
one day and may be life threatening. The commonest causes include
TB, bronchitis, bronchogenic carcinoma, and bronchiectasis. In up to
30 ­percent cases, the cause cannot be identified.

Hemoptysis vs Hematemesis
1. It is usually bright red. Dark red or coffee ground.
2. Mixed with frothy sputum. Mixed with gastric contents.
3. pH is alkaline. Acidic pH.
4. Accompanied with coughing. Accompanied with nausea and vomiting.
5. History of pulmonary disease. History of gastrointestinal disease.

It is important to remember that blood-streaked sputum may be a

­feature of any upper respiratory infection like acute bronchitis or may
represent a more serious underlying problem like TB, malignancy,
­pulmonary embolism, bronchiectasis, etc.
16 Clinical Examination and Applied Medicine

Common Causes of Hemoptysis

Common Lung Causes
Source may be from mouth, nose, or larynx.
Tuberculosis Bronchogenic carcinoma
Bronchiectasis Chronic bronchitis
Uncommon Lung Causes
Pneumonia (e.g., Klebsiella) Lung abscess
Fungal chest infection Pulmonary embolism
Goodpasture syndrome Granulomatosis with polyangiitis
Idiopathic pulmonary hemosiderosis Associated with vasculitis or Systemic
lupus erythematosus (SLE)
Pulmonary arteriovenous (AV) malfor- Drugs (anticoagulants and anti-platelets,
mations cocaine)
Cardiovascular Causes
Mitral stenosis LVF
Aortic aneurysm AV malformation
Bleeding Disorders and Others
Hemophilia, etc. Thrombocytopenia
Henoch Schonlein purpura Iatrogenic Scurvy
(aspirin and anticoagulants) Cryptogenic (in 30 percent cases, no cause
is found)
Pulmonary endometriosis Lung trauma and contusion

Its duration, severity, frequency, and any associated symptoms are

relevant in the history. Try to determine the amount of hemoptysis in
24  hours. Determine whether blood is coming from the mouth and
throat, or is actually coughed up with the sputum. A common cause is
bad oro-dental hygiene and throat infection. Hematemesis is ­vomited-out
blood that may be coffee-ground and accompanied with nausea. Patient
in this case may give a history of peptic ulcer disease or taking anti-­
inflammatory medication. The commonest causes of hemoptysis include
upper respiratory tract infection, severe necrotizing pneumonia, bronchi-
ectasis, bronchogenic carcinoma, and tuberculosis. Among these causes,
TB, bronchiectasis, and lung malignancy may cause massive hemopty-
sis. Pulmonary edema may be associated with pink frothy sputum, and
cardiac disease may be associated with back pressure and leakage from
pulmonary vessels.
 Introduction and History Taking 17

Detailed History in a case of Hemoptysis

  1. Fever (infections)
  2. Chest pain (associated pleuritis or pulmonary embolism)
  3. Leg swelling and pain (Deep vein thrombosis (DVT) and pulmonary embolism)
  4. Having underlying cancer or recent immobilization (pulmonary embolism)
  5. Dyspnea (indicates the severity of underlying disease)
  6. Cough and purulent sputum (chest infection)
  7. Putrid smell in lung abscess
  8. Amount of sputum (large in bronchiectasis)
  9. Low-grade fever, weight loss and night sweats (TB)
10. Smoking, weight loss, and clubbing (malignancy)
11. History of bleeding disorders or taking anti-platelets or anticoagulants
12. History of bruising or bleeding disorders
13. History of heart disease
14. History of hematuria and renal involvement (Goodpasture syndrome or Wegener
granulomatosis)
15. History of chronic nasal discharge and renal involvement (granulomatosis with
polyangiitis)
16. History of HIV status
17. History of chronic liver disease
18. Back pain may be indicative of aortic aneurysm
19. Multisystem involvement in connective tissue diseases
20. Kaposi sarcoma in AIDS

Chest pain due to pleural inflammation is a localized and sharp pain

made worse on deep breathing. It is due to disease process involving the
parietal pleura, as the visceral pleura is insensitive to pain. On auscul-
tation, there may be an associated pleural rub best heard at the site of
maximum pain.

Causes of Pleuritic Chest Pain

1. Post-pneumonic pleuritis
2. Post viral pleuritis
3. Costochondritis
4. Pulmonary embolism
5. Tuberculosis
6. Pulmonary infarction
18 Clinical Examination and Applied Medicine

  7. Pleuro-pericarditis
  8. Connective tissue diseases
  9. Malignancy
10. Lung abscess

Rhonchi or wheezes are musical or squeaky sounds in the chest that the
patient is aware of during an attack of asthma or other causes of broncho-
spasm. Wheezes and rhonchi are synonymous terms which are produced
due to vibration produced when air passes through narrowed bronchi.
The pitch of the rhonchi is inversely related to the size of the bron-
chus. Rhonchi are better heard during expiration when the bronchi are
­narrower, but may be both expiratory and inspiratory. They are usually
associated with prolonged duration of expiration. Localized rhonchi are
due to local obstruction of the bronchus due to any cause in the lumen,
in the wall, or outside the bronchus. Reflex bronchospam can occur in
early pulmonary edema when low-pitched rhonchi may be heard. This
has been termed cardiac asthma.
In the history, determine the duration, seasonal variation, n
­ octurnal
variation, and association with allergy. Ask about precipitating and
reliving factors, effect with cold, drugs and association with infection.
Find out if the patient awakens late at night with tightness in the chest,
­dyspnea, and wheeze. PND can occur in bronchial asthma where it is due
to bronchospasm precipitated in the middle of the night. In LVF, it is due
to back pressure and pulmonary edema occurring with reabsorption of
fluid during recumbent position.

Causes of Rhonchi
  1. Asthma
  2. Cardiac asthma
  3. Pulmonary embolism
  4. COPD
  5. Allergy and anaphylaxis
  6. Acute bronchitis
  7. Toxic inhalation
  8. Drugs (beta-blockers)
  9. Local obstruction (foreign body, tumors, fibrosis, mucous plug)
10. Carcinoid syndrome
 Introduction and History Taking 19

11. Polyarteritis nodosa

12. Churg Strauss syndrome

Stridor is an inspiratory sound usually due to obstruction of the

upper airway. It is mostly acute, but chronic stridor may occur with
tracheomalacia.

Causes of Stridor
1. Foreign body
2. Angioedema and allergic reactions
3. Severe upper airway infection (laryngospasm)
4. Vocal cord dysfunction
5. Croup and epiglottitis in children
6. After extubation (local edema)
7. Laryngeal tumors
8. Inhalation injury
9. External compression of the upper airway

In the history, look for foreign body and local cause of obstruction of
the upper airway. Take history of upper respiratory infection and allergy
or angioedema. History of inhalation and recent endotracheal tube place-
ment is important. Note the vital signs, including oxygen saturation,
cyanosis, respiratory distress, level of consciousness, and use of accessory
muscles of respiration. ENT evaluation including laryngoscopy may be
necessary with vocal cord paralysis. X-ray of the neck, CT scan, and flow
volume loop may help in the diagnosis of non-acute cases.
Fever in relation to pulmonary disease usually indicates an underlying
infective process. Rarely, it may be associated with underlying malignancy
or connective tissue disorder. Chronic low grade fever in TB endemic
areas is always dealt with suspicion.
Weight loss is an important symptom and signifies severe disease like
TB, malignancy, or AIDS. Always document the weight, and ask the
amount of weight loss and its duration. Also, whether it is associated with
severe anorexia or whether it is intentional or associated with depression.
 Index
abdomino-thoracic inspiration, 40
ABPA. See allergic bronchopulmonary
aspergillosis
acanthosis nigricans, 31
accessory muscles
apex beat, 45
chest shapes, 42–43
chest symmetry, 43–44
expansion of chest, 44
of expiration, 40
of inspiration, 40
inter-costal spaces, 45
movement of alae nasi, 40
position of trachea, 44
pulsations, 45
supra-clavicular fossae, 45
type and rate of respiration, 40
working of, 40
ACE inhibitors. See angiotensin-
converting enzyme inhibitors
acidotic breathing, 41
acute bronchitis, 70–71
acute cough, 11, 13
acute exacerbations in chronic
obstructive pulmonary disease
(AECOPD), 97–98
acute respiratory distress syndrome
(ARDS), 71–74
management outline, 73–74
risk factors and causes of, 72–73
severity of, 72
AHI. See apnea-hypopnea index
allergic angiitis, 95–100
allergic bronchopulmonary
aspergillosis (ABPA), 74
allergies, patient’s history of, 8
anemia
clinical features, 22–23
etiology, 22
examination, 21
features of iron deficiency, 23
history, 21
laboratory features, 23
anesthetist’s nightmare, 171
angiotensin-converting enzyme (ACE)
inhibitors, 12
anterior chest percussion, 54
antiglomerular basement membrane
(GBM), 108
apical movement of chest, 49
apical percussion, 55
apnea-hypopnea index (AHI),
175–176
ARDS. See Acute Respiratory Distress
Syndrome
arousal index (AI), 176
asbestosis, 122–123
Asian flu, 112
aspergillosis, 74
aspiration pneumonia, 139–140
asterixis, 32
asthma, 5
bronchial, 77–83
causes of acute exacerbation of,
80–81
causes of occupational, 80
classification with severity and
control, 78–79
complications, 81
differential diagnosis with, 80
history of, 78
indications of ventilation,
81–82
management outline, 82–83
risk for near-fatal attack of, 79
signs of Imminent respiratory
arrest, 81
atelectasis, 75–76
auscultation, 56–66
prerequisites of, 57–58
character of breath sounds,
58–61
crepitations, 64–66
duration of respiration, 58
intensity of breath sounds, 58
rhonchi, 61–63
190 Index
barrel-shaped chest, 42
Biot’s breathing, 41
bird flu, 112
BOOP. See bronchiolitis obliterans
with organizing pneumonia
breathing patterns, 40–45
chest shapes, 42–43
breath sounds
bronchial, 59–60
character of, 58–61
intensity of, 58
types of, 58–59
vesicular, 59
bronchial asthma, 77–83
severity of, 79
bronchial breath sounds, 59–60
causes of, 59
character of, 60
types of, 60
bronchial carcinoid, management
outline, 88–89
bronchiectasis, 84–88
causes and predisposition of, 85
common organisms causing
infection in, 86
complications, 86–87
investigations, 87
management outline, 88
signs and symptoms, 86
types of, 85
bronchiolitis, 89
bronchiolitis obliterans, 171
bronchiolitis obliterans with
organizing pneumonia
(BOOP), 89
bronchogenic carcinomas, 89–94
classification of, 91
common cutaneous associations, 93
contraindications to surgical
resection, 94
diagnosis, 93
management outline, 93
metastasis, 93
other syndromes and local spread,
92
paraneoplastic syndromes with, 92
bronchopulmonary segments, 38
broncho-vesicular breathing, 60
bruising of skin, 31
bulging chest, causes of, 43–44
Caplan’s syndrome, 171
central sleep apnea (CSA), 175
chest
expansion of, 44, 48, 49
movement of, 48–50
palpations of, 46–52
parameters of inspection of, 39
reference lines on, 38
shapes, 42–43
swelling on, 51
symmetry, 43–44
tenderness of, 51
chest pain, 17–18
Cheyne–Stokes respiration, 41
choroid tubercles, 31
chronic bronchitis, 94–95
chronic cough, 12
chronic obstructive airway disease
(COPD)
acute exacerbations in, 97–98
clinical characteristics of, 96
complications of, 97
diagnosis of, 96
etiology of, 96–97
gold guidelines of, 99
history of, 95–96
investigations, 98–99
management outline, 100
severity of, 99
chronic obstructive pulmonary disease
(COPD), 5, 9, 47
chronic sinusitis, 32
Churg–Strauss Disease, 95–100
clavicular percussion, 55
clubbing, 26–29
causes of, 28–29
clinical stages of, 27–28
demonstration of, 27
etiology of, 28–29
hands, 32
neck, 33
other types of, 29
pulmonary causes of, 32
skin complexion and face, 30–33
coal worker’s pneumoconiosis, 123
 Index 191

coarse crepitations, 65 diagnosis, 2

coin sign, 66 diffuse alveolar hemorrhage (DAH),
common respiratory symptoms, 103–104
11–19 clinical features, 103–104
chest pain, 17–18 treatment, 104
cough, 11–13 dilated veins, 45
dyspnea, 13–15 dull percussion, 52
fever, 19 dyspnea, 13–15
hemoptysis, 15–17 causes of chronic, 14
rhonchi, 18–19 causes of subacute onset of, 14
sputum, 15 causes of sudden onset of, 13
stridor, 19 diagnosis of, 14–15
weight loss, 19 inquiries in relation to, 13
COP. See cryptogenic organizing
pneumonia edema, 31
COPD. See chronic obstructive edema of chest, 51
airway disease; chronic egophony, 59
obstructive pulmonary disease emphysema, 104–105
cough, 11–13 clinical findings, 105
acute, causes of, 11 diagnosis of, 104–105
persistent, causes of, 12 empyema, 106
crepitations, 64–66 erythema nodosum, 31
coarse, 65 exophthalmos, 31
coin sign, 66 extrinsic allergic alveolitis, 106–107
due to fibrosis, 64–65 causes of, 106–107
due to fluids, 64 clinical diagnosis, 107
fine, 64–65 management outline, 107
forced expiratory time, 66
medium, 65 family history, 6–7
pleural rub, 66 farmer’s lung, 106–107
pleuropericardial rub, 66 fine crepitations, 64
stridor, 65–66 flail chest, 45
types of, 64–66 forced expiratory time, 66
vocal resonance, 66 frozen chest, 48
Crico-aratanoiditis, 171 funnel-shaped chest, 43
cryptogenic organizing pneumonia
(COP), 89 GBM. See antiglomerular basement
CSA. See central sleep apnea membrane
cyanosis, 26 goodpasture syndrome (GPS),
cystic fibrosis, 101–102 108–109
abnormality in, 101 clinical features and diagnosis, 108
presentation, 101 management outline, 108–109
treatment, 102 patients at higher risk, 108
granulomatosis with polyangitis,
Da Costa’s syndrome, 51 109–111
DAH. See diffuse alveolar hemorrhage ANCA-associated vasculitides, 111
dental sepsis, 31 clinical features, 109
D’espine sign, 61 diagnosis, 110–111
192 Index
management outline, 111
gums and teeth examination, 34–35
hands, 32
Harrison’s sulcus, 45
hematemesis, hemoptysis vs, 15
hemolytic, vs. obstructive jaundice, 24
hemoptysis, 15–17
causes of, 16
detailed history in case of, 17
vs. hematemesis, 15
history-taking, 1–2, 3–9
objective of, 2
Hong Kong flu, 112
Horner’s syndrome, 31
hypercarbia, 168–169
features of, 169
HYPERPNOEA, 41
hyper-resonant note, 52
hypersensitivity pneumonitis,
106–107
hypertrophic osteoarthopathy, 29
hysterical overbreathing, 41
idiopathic pulmonary hemosiderosis,
111
immunization, patient’s history of, 8
impaired percussion, 52
influenza, 112–113
clinical features and diagnosis, 112
management outline, 113
intensity of breath sounds, 58
interstitial fibrosis, 170–171
interstitial pneumonitis, 171
jaundice, 23–24
hemolytic vs. obstructive,
24diseases affecting lung and
liver, 24
Kartagener’s syndrome, 32
Koilonychia, 23
Kussmaul breathing, 41
laryngitis, 171
lateral percussion, 55
legionella pneumophila, 140–141
LIPS. See Lung Injury Prediction
Score
lips examination, 34
Little’s sign, 45
liver, diseases affecting, 24
Loeffler’s syndrome, 113
lung abscess, 113–115
clinical findings in, 114
management outline, 115
non-infectious cause of, 114
typical locations, 114–115
Lung Injury Prediction Score (LIPS),
72–73
lungs
bronchopulmonary segments, 38
diseases affecting, 24
surface anatomy, 37–38
lymph nodes, 52
macrocytic anemia, 22
management outline
asthma, 82–83
bronchial carcinoid, 88–89
bronchiectasis, 88
bronchogenic carcinomas, 93
COPD, 100
empyema, 106
extrinsic allergic alveolitis, 107
goodpasture syndrome, 108–109
granulomatosis with polyangitis,
111
influenza, 113
lung abscess, 115
Middle East Respiratory Syndrome,
116–117
obesity hypoventilation syndrome,
121–122
obstructive sleep apnea, 176
pneumonia, 138
pneumothorax, 147–148
pulmonary arteriovenous
malformation, 149
pulmonary edema, 151
pulmonary embolism, 155–156
pulmonary fibrosis, 162
pulmonary hypertension, 165
rheumatoid arthritis, 172
sarcoidosis, 173
 Index 193

tuberculosis, 181 movement of chest, 48–50

medium crepitations, 65 position of trachea, 46–48
MERS. See Middle East Respiratory rhonchi/pleural rub, 51
Syndrome superficial crepitations, 51
metastatic lung disease, 117–118 tenderness, 51
workup of, 118 vocal fremitus, 50–51
Middle East Respiratory Syndrome papilledema, 31
(MERS), 116–117 past history, 5–6
miliary TB, 118–120 patient’s history, 5
clinical features, 119–120 of allergies and immunization, 8
lab findings, 120 family history, 6–7
movement of chest, apical, 49 occupational history, 7
mycoplasma pneumonia, 141–142 past history, 5–6
personal history, 7
neck, 33 socioeconomic status, 7
non-resolving pneumonia, 139 travel history, 8
normal percussion, 52 treatment history, 8–9
normal pleural fluid, 124 PAVM. See pulmonary arteriovenous
malformation
obesity hypoventilation syndrome percussion, 52–56
(OHS), 120–122 anterior chest, 54
clinical features, 121 areas to be percussed, 54–56
management outline, 121–122 clavicular, 55
workup, 121 lateral, 55
obstructive jaundice, hemolytic vs., 24 methods of, 54
obstructive sleep apnea posterior, 55
associations of, 175 rules of, 53
diagnosis of, 175 supraclavicular/apical, 55
management outline, 176 techniques, 53
severity of, 174 tidal, 55–56
occupational history, 7 types of, 53
occupational lung diseases, 8, 122 peripheral edema, 29–30
OHS. See obesity hypoventilation personal history, 7
syndrome petechiae, 37
oral examination physical findings, 2
gums and teeth, 34–35 pigeon-shaped chest, 42–43
lips, 34 pigmentation, 45
throat, 36 pink puffers, 104. See also emphysema
white patch in, 36–37 pleural effusion, 123–129, 169–170
tongue, 35–36 causes of, 124
clinical findings, 125–126
pallor, 30 diagnosis from duration of,
palpations, 46–52 128–129
apex beat, 50 diagnosis of, 126–129
of breast, 51–52 examination of fluid, 127–128
edema, 51 pleural rub, 51, 66
fluctuation, 51 pleuropericardial rub, 66
lymph nodes, 52 PMF. See progressive massive fibrosis
194 Index
pneumocystis jiroveci, 143
pneumonia, 129–145
aspiration, 139–140
atypical, 137
clinical findings, 131
clues for etiology of, 135–136
diagnosis of, 137
empirical treatment for CAP,
138–139
features of severe, 134–135
legionella pneumophila, 140–141
management outline, 138
mycoplasma, 141–142
other, 143–145
pneumocystis jiroveci, 143
slowly or non-resolving, 139
types of, 131–132
typical work of a case of suspected,
136–137
x-ray findings in, 137
pneumothorax, 145–148
clinical findings, 145–146
etiology, 147
management outline, 147–148
types of, 146–147
polycythemia, 31
posterior percussion, 55
posture of patients, 39
progressive massive fibrosis (PMF),
123
pulmonary alveolar proteinosis, 148
pulmonary arteriovenous
malformation (PAVM), 149
clinical features, 149
diagnosis, 149
management outline, 149
pulmonary calcification, 182–183
pulmonary edema, 150–151
causes of acute, 150
clinical features of cardiogenic, 150
management outline, 151
pulmonary embolism, 151–156
diagnostic aids, 153–155
HOPPE score, 152–153
management outline, 155–156
poor prognostic indicators of, 152
risk factors, 152
rule-out criteria (PERC) for, 153
signs of, 151–152
Wells’ criteria for diagnosis, 152
pulmonary fibrosis, 156–162
causes of ILD, 161
classification of ILD, 158
clinical findings, 157–158
diagnosis aids for ILD, 159–160
diagnosis of ILD, 158–159
history of, 156
management outline, 162
presentation, 158
pulmonary genetic disorders, 6
pulmonary harmartoma, 162
pulmonary hypertension, 162–165
classification of, 163–164
clinical features of, 163
management outline, 165
signs and symptoms, 163
workup for, 164–165
pulmonary infection, 171
pulmonary nodules, 165–167, 171
causes of, 165–166
pulmonary renal syndrome, 167
pulsations, 45
quality of life, 1
RA. See rheumatoid arthritis
rash, 31
RDI. See respiratory disturbance index
reciprocal movement, 45
reference lines on chest, 38
respiration, duration of, 58
respiratory disturbance index (RDI),
176
respiratory examination, 38–39
accessory muscles, 40
breathing patterns, 40–45
respiratory failure, 167–169
acute vs chronic, 169
causes of ventilatory defect and
hypercarbia, 168
features of hypercarbia, 169
features of hypoxia, 168
with hypoxia and normal CO2, 168
with low PO2 and high PCO2, 168
retracted chest, causes of, 44
rheumatoid arthritis (RA), 169–172
 Index 195
characteristics of rheumatoid
effusion, 170
management outline, 172
rhonchi, 18–19, 51, 61–63
causes of generalized, 63
causes of localized, 63
types of, 62
sarcoidosis, 172–173
clinical features, 172
diagnosis, 173
lab work, 173
management outline, 173
SARS. See severe acute respiratory
syndrome
scars, 45
severe acute respiratory syndrome
(SARS), 173–174
shape, chest, 42–43
barrel, 42
funnel, 43
pigeon, 42–43
silicosis, 123
skin complexion and face, 30–33
sleep apnea, 174–176. See also
obstructive sleep apnea
slowly/non-resolving pneumonia,
139
socioeconomic status, 7
splinting of trachea, 48
sputum, 15
stony dullness, 52
stridor, 19, 41, 65–66
superficial crepitations, 51
superior venacaval syndrome,
176
supra-clavicular fossae, 45
supraclavicular percussion, 55
surface anatomy of lungs, 37–38
swine flu, 112
Swyer–James–McLeod syndrome,
116
symmetry, chest, 43–44
bulging chest, causes of, 43–44
retracted chest, causes of, 44
TACHYPNOEA, 41
tap marks, 45
teeth examination, 34–35
tenderness of chest, 51
thoraco-abdominal inspiration, 40
throat examination
white patch in, 36–37
thyroid acropachy, 29
tidal percussion, 55–56
tongue examination, 35–36
trachea
position of, 46–48
shift of, 47
splinting of, 48
technique of palpating, 47
tracheal tug, 48
travel history, 8
treatment history, 8–9
tropical pulmonary eosinophilia,
176–177
differential diagnosis, 177
tuberculosis, 177–182
clinical features, 178
clinical findings, 180
complications, 181
diagnosis of pulmonary, 178–179
epidemiological facts, 178
forms of pulmonary, 179–180
management outline, 181
risk of developing, 181
second-line anti-tuberculosis drugs,
181–182
tympanitic note, 52
vesicular breath sounds, 59
vocal fremitus, 50–51
vocal resonance, 66
Wegener granulomatosis. See
granulomatosis with
polyangitis
wheezes, 18–19
whispering pectoriloquy, 60
yellow nail syndrome, 183