In respiratory system, history taking (the questionnaire part) is the most important part of clinical approach. It is often more helpful than clinical examination. Without proper history taking, clinical examination will be fruit less. As for example, uncomplicated pulmonary tuberculosis may not have any physical finding. Similarly a lung pathology surrounded by normal lung parenchyma like lung abscess, lung mass, etc. may not have any sign. Physical examination findings and investigation results should be interpreted on the basis of history. Clinical examination may suggest pleural effusion or high-resolution computed tomography (HRCT) findings may suggest ILD but that means nothing. Proper history taking will help you in reaching a final complete diagnosis.
History taking, the questionnaire part, should be done at least thrice and it is not a one–time job. The purpose of first time questionnaire is to have an idea about the disease, which system is involved, whether it is chronic or acute disease, what structure is predominantly involved, etc. The other purpose of first time history is to reduce the number of possibilities to a reasonable extent. Second time history is to be taken after completion of physical examination. As for example, if you get left-sided pleural effusion then specific questions should be asked to find out the probable causes of left-sided pleural effusion like pancreatitis. The points you have not asked previously. The second time history taking is to explore the possibilities that could explain the physical signs. A third time history is to be taken after completion of investigations. As for example, after investigation you get usual interstitial pneumonia, and then detail history is to be taken to exclude other causes of usual interstitial pneumonia (UIP) pattern before diagnose the case as idiopathic pulmonary fibrosis. The purpose of third time history is to reach a final diagnosis by interpreting clinical manifestations and investigation results. Investigation results may open up a new window and that may demand further clarification.
History taking is an art and it depends on your communication skill. Sometimes you may have to ask very personal questions and that demands a good rapport and trust. You must make patient comfortable before asking private questions. A good history taking requires knowledge and experience. Everybody cannot be a master of an art as it comes from within. Though history taking is an art, the process can be improved by a methodical approach. To ensure proper history taking a format has been designed and followed, worldwide.
Patient may have many complaints or may have no complaint (patient may come with an abnormal chest X-ray done for routine check-up). Chief complaints are one or two (rarely three) important complaints among them and those will be determined by doctor not by patient. As for example, many elderly patients will complain of constipation and that cannot be their chief complaint. But in intestinal obstruction, constipation is the chief complaint.
History of Present Illness
Onset of disease: History should start with how the disease has been started, the onset. Diseases may have insidious onset (when patient cannot point out when the disease has been started) and that indicates a chronic diseases like tuberculosis (TB), chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), etc. Acute onset (patient can say when the disease has started) indicates acute disease occurring over days as for example, fever for 10 days. Sudden onset means patient can pin point the exact onset by time or by event (while reading newspaper I develop chest pain). Sudden onset means before a particular moment he was healthy. Sudden onset diseases are mainly vascular diseases like acute myocardial infarction, stroke, pulmonary thromboembolism (PTE), and pneumothorax, foreign body inhalation, etc.
Progression: Secondly, history should include the progress of illness like disease progressed to reach a plateau and then decreases in severity (closed pneumothorax, collapse); continuous deterioration of disease (COPD, ILD), intermittent or episodic with intervening symptoms-free period (asthma), having sudden deterioration (acute exacerbation of COPD, ILD), or change in character of previous symptoms or addition of symptoms (bronchogenic carcinoma over COPD).
Sequence of events: Thirdly, the sequence of events should be clearly noted even they are of same duration. Sudden onset pleuritic chest pain after a bout of cough and that is followed by dyspnea indicates pneumothorax.
Duration of illness: Chronic diseases may persist for months or years (usually more than 6 weeks) like COPD, asthma, some ILD. Acute diseases usually last for days to weeks. In our country, TB should be suspected in all patients with cough for more than 2 weeks. Duration of illness more than 1 year usually excludes lung cancer except bronchioloalveolar cell carcinoma.
Analysis of symptoms: There are six respiratory symptoms (cough, expectoration, hemoptysis, dyspnea, wheeze and chest pain) and few general symptoms (fever, swelling, weight loss, weakness, etc.) those are important in respiratory medicine. Permutation and combination of those six respiratory symptoms will give an idea about the disease. Dyspnea with wheeze usually indicates airway disease but sometimes the combination may be found in left ventricular failure and even in interstitial lung disease.
Cough: Cough is the most common respiratory symptom. Cough may indicate infection, irritation, inflammation of airways, lung parenchyma, upper airways and pleura. Cough is a reflex with receptors present in the respiratory tract from pharynx to smaller bronchi and pleura. Center is in the medulla. During coughing respiratory muscles constrict vigorously with closed glottis; as a result intrathoracic pressure is increased; then glottis is suddenly opened up; and there is sudden expulsion of content of airways. Cough arising from larynx is harsh, barking and may be painful. Tracheal cough is harsh, dry and painful. Cough arising from airways (bronchitis) is usually associated with wheeze. It is important to know the onset, progression of cough, diurnal and seasonal variation of cough, and whether cough is associated with expectoration. Children, elderly, sick patients and often female patients cannot expectorate; then it is important to note the sound of cough to be sure whether it is actually dry cough.
Expectoration: When expectoration is present then the amount (scanty, copious); color (whitish, pinkish, gray, yellow or green), character (serous, mucoid, mucopurulent or purulent), and odor (foul smelling) are to be noted. It is also important to know whether expectoration has a postural relation or diurnal variation. Macroscopic examination of expectoration often gives important clues: mucoid/mucopurulent sputum in COPD, bronchiectasis, lung abscess; scanty, blackish tenacious sputum in asthma, pink frothy sputum in left ventricular function (LVF), rusty sputum in pneumococcal pneumonia, etc.
Hemoptysis: Hemoptysis may be frank hemoptysis (bronchiectasis, tuberculosis), blood streaks expectoration (tuberculosis, bronchitis), blood- stained expectoration (red currant jelly sputum in Klebsiella infection) and rusty sputum (pneumococcal pneumonia). Severity of hemoptysis is to be assessed by asking whether hemoptysis causes hemodynamic instability, demands hospitalization or blood transfusion.
Chest pain: Pain arising from pleura is sharp, pin-pricking or stabbing in character, found in the lateral side of thorax that increased with deep inspiration and coughing. Mediastinal pain is usually dull-aching, poorly localized central chest pain. Myocardial pain is compressive or oppressive in the retrosternal area that increased with exertion and decreased with rest. Pericardial pain is due to inflammation of adjacent pleura (pericardium has no pain fiber) and has same characteristic of pleural pain. Lung has no pain fiber and pain in lung diseases is due to involvement of pleura, chest wall or mediastinum. The following points should be noted for chest pain: character of pain (pleuritic, dull aching); location of pain (central, lateral or back of chest wall), pattern of pain (built over minutes or immediately, fleeting) provoking and alleviating factors, referred pain or radiation of pain, severity of pain, frequency or periodicity of pain, and associated symptoms.
Dyspnea: Dyspnea is an unusually uncomfortable awareness of breathing. Dyspnea may be produced by disproportionate increase in work of breathing, or stimulation of receptors (J receptor) in the lung. It is said to be arising from signals in distorted muscle spindle. It is very important to differentiating dyspnea of cardiac origin from that of respiratory origin though it is often not possible. Cardiac dyspnea may be associated with exertion, palpitation, paroxysmal nocturnal dyspnea, orthopnea, etc. Dyspnea with wheeze suggests airway disease. Dyspnea with serous, mucoid or mucopurulent, scanty tenacious expectoration usually suggests lung disease. Whereas, pinkish and frothy expectoration suggests LVF. It is important to note the onset, duration, progression, aggravating and relieving factors and associated symptoms of dyspnea.
Wheeze: Wheeze is a noisy sound occurring with respiration and usually occurs in obstructive airway diseases. It should be differentiated from stridor a predominantly inspiratory sound due to localized obstruction of upper air ways.
Fever: Maximum normal oral temperatures are 37.2°C (98.9°F) at 6 AM and 37.7°C (99.9°F) at 4PM. Temperature above that should be considered as fever. Fever is classically described as continuous, remittent and intermittent. But in today's era of antibiotics and anti-pyretic, those classical typing is rarely possible. Acute onset of high fever with cough suggests pyogenic respiratory infection. In high fever, due to liberation of exogenous pyrogens or endogenous cytokines thermal regulation center is set at a higher level; to achieve that goal body first preserves heat by peripheral vasoconstriction causing a sensation of chill, and then body produces heat by muscle constriction causing rigor. Fever with chill and rigor suggest organisms have entered bloodstream like viremia, bacteremia or parasitemia. Insidious onset of low-grade fever with cough suggests chronic infection due to tuberculosis, fungal disease. Evening rise of temperature is typically described for tuberculosis but it is not specific and it can be found in any chronic inflammation. It represents normal diurnal variation of temperature (minimum in the morning and highest in the evening). In low-grade fever, temperature crossed the threshold limit in the evening and thereby it is felt by patients. In chronic infection patient may be habituated with temperature and may not complain it. On the other hand, patient may have feverishness (sometimes an expression of weakness) not actual fever. It is always important to record temperature sublingually.
Other symptoms: Swelling of face may occur in renal diseases, hypothyroidism, corticosteroid therapy (moon face) or superior vena cava (SVC) syndrome. In renal disease swelling usually starts from face; whereas in heart failure it starts from feet. In SVC syndrome swelling is associated with congestion whereas in other conditions swelling is associated with pallor. Pedal edema may be found in malabsorption in abdominal tuberculosis. Weight loss may be indirectly evident from loosening of garments. Weight loss is found in tuberculosis, lung cancer, acquired immunodeficiency syndrome (AIDS), anorexia and anxiety. Weight loss with normal or increased appetite may be found in diabetes mellitus or hypothyroidism.
When present illness is not associated with or is a sequel of previous illness, the previous illness should be put in past history. When present illness is same or a continuation of previous illness then previous illness should be put in present history.
Past history of major medical, surgical and gynecological illness should be taken. Special emphasis is to be given on past history of tuberculosis. It should be remembered that in our country TB is often over diagnosed. So, it is important to note how the tuberculosis was diagnosed; whether TB was diagnosed by sputum examination or by chest X-ray; how TB was treated, regime, drugs, doses, duration, intermittent or daily regime and from government or private set-up. It is utmost important to assess the regularity of ATD intake.
History of other illnesses like measles, whooping cough, pneumonia, influenza, major trauma/accident, hospital admission, blood transfusion, etc. are to be taken. Some specific history should be asked for specific conditions/diseases. As for example, history of malabsorption in cystic fibrosis, symptoms of meningeal irritation in miliary TB, etc.
Personal history should include the following things:
- Smoking history including type of smoking (cigarette, biri, etc.); amount of smoking and duration of smoking (measured as smoke index or pack-year); duration of smoking cessation for ex-smokers.
- Other addiction including alcohol, intravenous drugs, chewing tobacco
- Marital history including offspring
- Menstrual history
- Present or previous occupation
- Socioeconomic history
- Exposure history and lifestyle
- Habits, travels, pets, etc.
Family history includes contact history with cases of tuberculosis; history of atopy or allergic diathesis in family; liver diseases for suspected alpha1 anti-trypsine deficiency.
In general survey, some points are more important for respiratory medicine and they need special emphasis.
General look, signs of dyspnea, gross deformity: When patient enters your chamber the first look is very important. Following points are to be noted like patient coming walking without support, with support, by wheel-chair or by stretcher. Patient's level of consciousness and orientation should be assessed while taking history. Signs of dyspnea should be looked for and those include tachypnea, activity of accessory muscles of respiration, suprasternal suction and intercostal suction. Any gross deformity and abnormalities should be noted. As for example, an amputation of limb may be due to osteosarcoma and present lung problem may be secondary to that.
Facies, decubitus, built, nutrition, body mass index (BMI): Anxious facies is the usual presentation. A toxic and seek look indicates serious illness. Swelling of face and neck may be suggestive of SVC syndrome. Patient may be orthopnic or prefers lying down in bed or prefers a particular lateral decubitus position. It is always important to note why he preferred that particular position. It is important to calculate BMI (weight × height2) measured in Kg/m2. Normal BMI is between 19 to 26 and more than 30 is obesity. Nutrition is generally assessed by measuring BMI, muscle bulk by mid-arm circumference, subcutaneous fat by skin fold thickness over triceps or below the scapula and by looking for signs of vitamin deficiencies.
Blood pressure (BP), pulse, respiratory rate, temperature: BP is important to assess whether patient is hypertensive (note history of antihypertensive medications) or hypotension (systolic <90 and diastolic <60 mm of Hg). Hypotension is a measurement for shock. Pulse for assessing tachycardia (>100/min) or bradycardia (<60/min). Respiratory rate to assess tachypnea. Temperature is for assessing fever or hypothermia.
Neck vein and peripheral lymph nodes: Neck veins are generally examined, though not mandatory, at 45° angle. Among waves prominence of ‘a’ wave suggest increased right atrial/ventricular pressure in cor pulmonale. Absence of pulses wave is important and it indicates SVC obstruction. Engorgement of neck veins may be found in right ventricular failure (with presence of venous pulses to be confirmed by hepato/abdomino-jugular reflux); and engorged vein without pulsation is suggestive of SVC syndrome.
Peripheral lymph nodes (cervical, axillary, epitrochlear, inguinal, popliteal) are to be examined. Lymph node enlargement may be seen in tuberculosis, pyogenic infection, lymphoma and malignancy. Tubercular lymph nodes are usually multiple, matted (due to periadenitis), usually in cervical areas, soft to firm and sometimes with sinus formation. Pyogenic infection of lymph nodes has signs of inflammation and a source of infection in the draining area. Lymphoma usually has discrete lymph nodes (pseudo-matting may be found due to rapid enlargement of lymph nodes), rubbery in consistency and are not fixed to skin or deeper structure. Malignant lymph nodes are firm to hard and fixed to skin or deeper structures. Tubercular lymph nodes usually affect nodes of posterior triangle whereas secondary lymphadenopathy from bronchogenic carcinoma usually affect supraclavicular group in cervical region and rarely axillary lymph nodes.
Pallor, polycythemia, cyanosis, clubbing, jaundice, edema: Both pallor and polycythemia may be associated with COPD. Any chronic respiratory disease and malignancy may cause pallor as a result of anemia of chronic disease. Anemia due to hemoptysis is not common but it can be seen in diffuse alveolar hemorrhage. Polycythemia is not an uncommon finding and it is usually related to chronic hypoxia of respiratory disease. Cyanosis is usually central and due to hypoxia. Peripheral cyanosis may be found in cor pulmonale with right heart failure. Clubbing may be present in any chronic suppurative condition of thorax and bronchogenic carcinoma. Jaundice is usually drug-induced (mainly ATDs), due to liver metastasis and sometimes with severe pneumonia. Pedal edema may be found in cor pulmonale with right ventricular failure, malnutrition and abdominal tuberculosis. Unilateral or unequal edema may suggest deep vein thrombosis. Looking for calf muscle tenderness may be dangerous and should not be attempted.
EXAMINATION OF RESPIRATORY SYSTEM
Examination of respiratory system is divided into two parts: examination of upper respiratory tract and examination of lower respiratory tract.
Examination of Upper Respiratory Tract
Examination of respiratory system must start from examination of upper respiratory tract. Upper respiratory tract is the part of airway starting from external nares to the junction of larynx with trachea. Examination of upper respiratory system includes nasal cavity, nasopharynx, nasal sinuses and oropharynx. A large part of upper respiratory tract is not visible without instrumentation, and in some situation help of ENT surgeon may be necessary. Examination of upper respiratory tract is important as it is a part of airway tree. As for example, allergic rhinitis is associated with asthma. Sarcoidosis, Wegener's granulomatosis, tuberculosis can affect upper respiratory tract. In addition, oral cavity (buccal cavity, teeth and gum) should be included in the examination of upper respiratory tract as unhealthy teeth and gum may lead to infection of lung by aspiration. Aspiration may be macroaspiration evident clearly from history and microaspiration, small amount of aspiration of upper airway secretion occurs during sleep.
All components of upper respiratory tract should be carefully examined separately.
Nose and sinuses: First inspect the nose for any deformity. Deformities of nose include fracture; red and enlarged nose in rhinophyma, depression of nasal breeze (saddle nose), etc. Destruction of nasal septum may be found in congenital syphilis. Deviation of nasal septum is most common than expected, and it can increase the risk of nasal obstruction and infection. The patency of each nostril should be examined by closing other nostril by pressing finger, and asking patient to close mouth and exhale through other nostril. Direct examination of nasal cavity and inferior turbinates is done preferably with the aid of a nasal speculum. Nasal polyp (pearly gray smooth surfaced) or bleeding points must be looked for. Paranasal sinuses can be palpated for tenderness as (i) frontal sinus—press upward beneath the medial side of supraorbital ridge; (ii) maxillary sinus—press against the anterior wall of malar prominence below the inferior orbital margin; and (iii) ethmoidal sinus—press medially against the medial wall of the orbit. Any discharge from sinuses or postnasal discharge should be looked for.
Oral cavity: Examination of oral cavity includes lips, teeth, gums, tongue, floor of mouth, cheeks, palate, tonsils and oropharynx. Those structures are carefully inspected for signs of inflammation, infection, deformity, ulcer formation and white patch (candidiasis). Pigmentation of oral cavity may suggest Addison's disease. Teeth are examined for tobacco staining, caries, discoloration, etc. Gums are examined for gum bleeding, gum hypertrophy, gingivitis, and halitosis as they may be associated with aspiration pneumonia. Tongue is examined for pallor, cyanosis, ulceration, leukoplakia and movement.
Mallampati classification: The classification is another important part of examination of oral cavity for assessing the feasibility of intubation. The assessment is performed with patient sitting up straight, mouth open and tongue proximally protruded. Mallampati classification is done as:
- Class I: Soft palate, uvula, fauces and pillars are visible
- Class II: Soft palate, uvula and fauces are visible
- Class III: Soft palate and base of uvula are visible
- Class IV: Hard palate is only visible.
Larynx: Examination of larynx is done by direct or indirect laryngoscopy and is not done by general physician. Indirect evidence of laryngeal disease should be carefully looked; for example, hoarseness of voice may indicate laryngeal palsy, vocal cord nodule or laryngeal inflammation; similarly edema of lips, tongue, around eyes, front of neck may indicate angioedema.
Examination of Lower Respiratory System
Examination of thorax has four components; inspection, palpation, percussion and auscultation. Respiratory findings of different pathological conditions are depicted in Table 1.
Inspection part is important as some findings are only appreciated during inspection. As for example, important sign of volume loss or gain (flattening or bulging) are only assessed by inspection. Some findings like movement of upper part of chest, is better observed by inspection. Inspection of front and lateral aspect of thorax is examined with patient on supine or semi-recumbent position with chest and upper abdomen properly exposed, with proper illumination and with arms sufficiently abducted to make axillary areas clearly visible. For examination of back, patients are made to sit upright with arms folded across the chest. In inspection, following points should be noted carefully.
- Respiration: It includes respiratory rate, depth, type, symmetry and special character.
- Respiratory rate: The number of breath in a full minute should be counted by observing chest wall movement after diverting patients’ attention by palpating pulse. Never put palm in patients’ thorax or abdomen, as unlike pulse rate, respiratory rate may be altered by patient voluntarily. The normal breathing rate is 10–14 breaths per minute, with an approximate 1:3 ratio of inspiration to expiration.
- Respiratory depth: It is very difficult to assess depth of respiration unless it is gross. Increased depth of inspiration (air hunger) can be seen in metabolic acidosis (ketoacidosis, uremia) and massive pulmonary embolism. It should not be confused with dyspnea of obstructive airway diseases.
- Type of respiration: In adult female respiration is thoracoabdominal where as it is abdominothoracic in male and children of any sex. Predominantly thoracic respiration may be found in bilateral diaphragmatic palsy, peritonitis, ascites, abdominal tumor, pregnancy and even in gaseous distension of bowel. Exclusive abdominal respiration is found in ankylosing spondylitis, intercostal muscle paralysis or due to pleural pain.
- Special character: (they are depicted in Table 2)
- Periodic or Cheyne–Stokes breathing is a cyclical variation of rate and depth of respiration and is characterized by periods of apnea that are interspersed between cycles of progressively increasing then decreasing respiratory rates. It occurs in left ventricular failure as a result of delay in reaching of stimulators to respiratory center in circulatory failure, and diseases of medulla due to decreased sensitivity of respiratory center.
- Kussmaul breathing is a rapid, large-volume breathing caused by acidotic stimulation of the respiratory center. It can indicate metabolic acidosis like diabetic ketoacidosis, uremia, etc.
- Biot breathing is an irregular breathing pattern alternating between tachypnea, bradypnea, and apnea. It is probably an indicator of impending respiratory failure.
- Shape of chest and deformity: Normal shape is elliptical with antero-posterior diameter and transverse diameter ratio 5:7; in flat chest the ratio may be as low as 1:2 and in barrel chest it is more than 1:1. Antero-posterior diameter may be increased in kyphosis. Deformities include flattening and bulging. Flattening or bulging is assessed in respect to normal hemithorax. For unilateral disease, hemithorax with decreased movement is considered as abnormal.
- Barrel chest: Ribs lose their typical 45° downward angle and become more horizontal, leading to an increase of the anteroposterior diameter of the chest. The ratio between anteroposterior diameter and transverse diameter is more than 1:1 and subcostal angle is more than 90°. Barrel chest is found in hyperinflation of lung like emphysema and sometimes in asthma.
Table 2 Different patterns of breathingConditionDescriptionCausesPictorial presentationNormal (Eupnea)Regular and comfortable at the rate of 12–20/minTachypneaIncreased respiratory rate >20/minFever, anxiety, exercise, shock, etc.BradypneaDecreased respiratory rate <12/minSleep, drugs, head injury, stroke, metabolic disorders, etc.ApneaAbsence of breathingDepression of respiratory center by drugs, head injury, stoke, etc. and sleep apneaHyperpnea (hyperventilation)Increased rate (>12/min) and depth of breathingAnxiety and stress, metabolic acidosis, hypoxia of any causeCheyne-Stokes breathingGradual increase and decrease of respiration with period of apneaIncreased intracranial pressure, brainstem injury, congestive cardiac failureBiots breathingIrregularly interspersed period of apnea in a disorganized sequences of various breathingSpinal meningitis, head injury, impending respiratory arrestSigh breathingFrequently interspersed deeper breathingStressful condition, excessive frequent sighing means person is hyperventilatingKussmaul's breathingRapid, deep and labored breathingMetabolic acidosis like renal failure, diabetic ketoacidosisAir trapping (obstructed breathing)Increasing difficulty in getting breath outChronic obstructive pulmonary disease (COPD)
- Pectus carinatum (pigeon chest): It is characterized by a localized prominence of sternum with adjacent costal cartilages often accompanied by indrawing of the ribs forming symmetrical horizontal grooves. It is usually a sequel of chronic respiratory illness or recurrent infection in childhood or it may be a feature of rickets in undernourished subjects.
- Pectus excavatum (funnel chest): It is characterized by either depression of lower part of sternum or whole length of sternum with attached ribs. It is usually asymptomatic; but severe form can displaced heart to left and cause palpitation. It is often congenital but may be acquired in shoe-makers (cobbler's chest).
- Thoracic kyphoscoliosis: It varies from minor variation of spinal curvature to gross deformity. Scoliosis itself can cause displacement of mediastinum with shifting of trachea and apical impulse. Gross deformity can decreases lung volumes and capacities causing increasing work of breathing, hypoxia, hypercapnea and cor pulmonale.
- Chest wall bulging/flattening: Bulging in comparison to normal hemithorax indicates volume gain as in case of pleural effusion, pneumothorax or sometimes by a large mass lesion. Flattening of chest indicates volume loss and found in lung fibrosis, collapse or fibrothorax. Degree of flattening depends on duration of illness; as a result it is less in collapse than fibrosis. Flattening and bulging are more marked in pleural diseases than lung parenchymal diseases.
- Signs of thoracic operation: They are scar of incision and signs of volume loss in lobectomy or pneumonectomy. Deformity is more marked in thoracoplasty, where ribs are cut at both ends and pushed into thorax to close a cavity or to obliterate a space.
- Cutaneous and subcutaneous lesions over chest wall: Cutaneous abnormalities should be inspected and palpated carefully as they sometimes give important clue to diagnosis like superior vena caval obstruction.
- Cutaneous lesions include eruption, rashes, purpuric spot, nodule, scar, ulcer, sinus formation, puncture marks, signs of inflammation, bruise, etc.
- Subcutaneous lesions include swelling, metastatic nodules, neurofibroma, lipoma, sarcoid nodule and subcutaneous emphysema.
- Subcutaneous emphysema cause diffuse swelling of chest wall, neck, face and arms with a crackling sensation elicited by palpation. It is usually associated with pneumothorax but it can occur without pneumothorax as an extension of mediastinal emphysema.
- Vascular anomalies include enlarged arterial channels of coarctation of aorta; spider telangiectasia of liver disease and lung cancer; and venous prominence.
- Direction of venous flow: For eliciting venous flow select a straight elongated part of superficial engorged vein without venous tributary. Then stretch the vein with two fingers and withdraw fingers one by one and see the speed of refilling of vein. Direction of rapid flow indicates the direction of venous flow. Venous filling, away from the umbilicus is found in normal persons but they are not engorged. Engorged and away from the umbilicus flow is found in cirrhosis of liver; above-downwards filling is found in superior vena caval obstruction; and upward filling occurs in inferior vena caval obstruction.
- Localized area of inflammation is to be noted. Tenderness is elicited by pressing over the area without making any inconvenience to patient. Swelling in chest wall is to be examined as per standard norms.
- Empyema necessitatis: It is a spontaneous rupture of an empyema that burrows through the parietal pleura into the chest wall to form a subcutaneous abscess that may eventually rupture through skin. Characteristically, it expands with coughing.
- Gynecomastia, development of breast tissue in men, is an important sign of female hormone secretion by lung cancer.
- Pulsation: Pulsations may be cardiac, epigastric and pulsation of other areas. Cardiac pulsation is visible over precordium and whether it is apical impulse should be confirmed by palpation. Epigastric pulsation is visible in the epigastric area of abdomen indicating right ventricular enlargement as in case of cor pulmonale and aortic aneurysm where the pulsation is expansile.
- Signs of dyspnea: Though dyspnea is a symptom there are many signs suggestive of dyspnea. Sometimes patient may complain of dyspnea without sign then the possibility of malingering should be considered. On the other hand, there may be signs of dyspnea though patient denies any complain particularly in case of chronic dyspnea where patient accommodate it by lifestyle modification. Signs of dyspnea are:
- Increased respiratory rate
- Use of accessory muscles: Accessory muscles are inspiratory and expiratory. Inspiratory muscles are mainly muscles of neck (sternomastoids, scaleni group of muscles, trapezii), allae nasi and muscles of shoulder girdle. Expiratory muscles are mainly abdominal muscles and latissimus dorsi. When abdominal muscles contract intra-abdominal pressure rises and that pushes the diaphragm upwards. Shoulder girdle muscles are used to fix the shoulder so that the neck accessory muscles can act better. In obstructive airway diseases inspiratory accessory muscles exert more. Conditions where elastic recoil of lungs is decreased accessory muscle of expiration works to push the diaphragm and helps in expiration.
- Suprasternal, supraclavicular, intercostal and epigastric suction with inspiration that suggest increased negative pressure in the thorax as a result of airway obstruction and vigorous respiratory effort.
- Paradoxical movement of chest wall: Indrawing of chest wall during inspiration as a result of fracture of two ends of multiple ribs and sternum.
- Purse-lip breathing: Expiration through a near closed mouth will increase the time of expiration and increases the intrabronchial pressure, thereby preventing closer of bronchi during expiration.
- Examination from back:
- Scapula: Whether two scapula are symmetrically placed or rotated is to be noted. Winging of the scapula, where the distances of scapular angles from thoracic spine are different. The distances are to be measured with measuring tape to document that finding.
- Examination of spine: Whether spine is straight or curved. Normally dorsal spine is curved anteroposteriorly with concavity anteriorly. Thoracic kyphosis is the condition in which that curvature is increased. Kyphosis causes an increase in anteroposterior diameter. Appearance of lateral curvature is scoliosis and it should be documented by marking the tips of spinous processes. Postural scoliosis is to be ruled out by asking the patient to stand straight and looking from the back of patient. In volume loss like fibrothorax, scoliosis occurs with concavity towards diseased side.
- Any other abnormality in the back should be noted.
- Thoracic movement: It is a combined inspiratory and expiratory finding as movement of upper part of thorax that moves upwards (pump handle movement) is better visible than palpable. On the other hand, movement of lower part thorax that moves laterally (bucket handle movement) is better palpable than visible. Ideally movement should be inspected from the foot end of bed with window light coming from the head end of patient. Movement should be looked for transentially keeping examiners’ eye at that level of thorax. Bilateral movement is assessed by chest wall expansion and unilateral movement is assessed by comparing movement of disease side with normal side. Asymmetry of movement is seen from foot end of bed and transentially. Apical movement can be better observed from back looking downwards from above as patient is sitting in a tool.
- Specific inspiratory signs:
- Hoover's sign: Indrawing of lower chest wall due to contraction of low flat diaphragm in emphysema that draw lower chest wall inwards.
- Sternomastoid sign (Trail sign): Shifting of trachea causes prominence of sternomastoid of that side.
- Tripod sign: COPD patients often sit straight with arms stretched and supported on tool with the aim to fix shoulder girdle muscles.
- Knuckle sign: Cornification of knuckle of fingers in COPD patients due to prolong sitting in tripod position.
- Tietz's syndrome: Inflammation of the costochondral joints of the upper part of chest causes swelling and tenderness of those joints. Costochondritis also involves same joints of chest wall but it is not associated with swelling of joints.
- Superficial palpation: It should include temperature, tenderness, etc.
- Examination of trachea: Upper 4-5 cm of trachea can be felt in the neck between cricoid cartilage and suprasternal notch. Thyroid enlargement can cause displacement of trachea. In COPD trachea may be dragged into thorax during inspiration.
- Tracheal position: We should remember certain facts before examining trachea; (i) trachea is a movable structure—so examine it gently, (ii) lowest palpable part of trachea better reflects mediastinal position and (iii) trachea moves with movement of head. For examination of trachea; first fix head with left hand, then palpate trachea from above downwards upto suprasternal angle, then gently push finger between trachea and sternomastoid muscles on both sides to feel the gaps. Trachea shifting is indicated by reduction of gap. Normal tracheal position is central (slight right anatomical shift at the level of bifurcation is not clinically appreciable). Ipsilateral shifting of trachea occurs in fibrosis or collapse involving upper lobe whereas contralateral shifting occurs in case of a mass (lung, thyroid, lymph node etc.) pushing trachea and pleural diseases (pneumothorax and pleural effusion).
- Tracheal movement: Trachea moves downwards during inspiration normally but that is not clinically appreciable. In obstructive airway disease the movement gets prominence. Finger is placed just below cricoid cartilage, the distance between suprasternal notch and cricoid cartilage will decrease during inspiration. Cricoid cartilage may be tugged down with sufficient force to squeeze the finger.
- Tracheal tug: The sign is found in aneurysm of arch of aorta as arch of aorta encircles left main bronchus. Tracheal tug can be elicited by standing behind the patient, grasping the trachea with fingers and holding it up after patient swallows water. In aortic aneurysm, the trachea will be pull down with each heartbeat.
- Apical impulse: Apical impulse should be palpated in anatomical position (standing or seating). In ill patients it can be palpated in supine position. It should be remembered that apical impulse is the most downward, most lateral and definite cardiac impulse palpable over precordium. Normal position of apical impulse is 1cm medial to left midclavicular line. Apical impulse can be shifted towards left in fibrosis or collapse of left lower lobe; pleural effusion, pneumothorax of opposite side; cardiomegaly and rarely in pectus excavatum and congenital absence of pericardium. Apical impulse is shifted to right in fibrosis or collapse of right lower lobe. Pleural effusion, pneumothorax, hydropneumothorax can cause shifting of mediastinum towards opposite side; whereas pleural fibrosis can cause mediastinal shifting towards same side. Same side shifting of both trachea and apical impulse can occur in fibrosis or collapse of whole lung.
- Movement of chest: To elicit movement of thorax inequality, we compare movement of both sides considering the fact that diseases side will move less. For palpating movement, palm should be placed over the area firmly but not too lightly so that you cannot feel the movement. Do not place your palm too tightly as that may hamper chest wall movement. Do not use your fingers instead use your palm. Taking a skin fold is not absolutely necessary and it is taken to demonstrate movement.
- Movement at the lower anterior chest is done placing the palms over costal margins, thumb finger looking to the xiphoid process, a loose fold of skin between two thumbs may be taken. The movement of both sides is assessed by feeling the movement of two sides and observing the movement of thumbs.
- Movement at the infrascapular areas: Here inspection is seldom helpful. The movement of these areas is assessed by asking the patient to sit erect and taking deep breath; palms are placed below scapula and tips of both thumbs are brought together in the region of 10th thoracic spine.
- Movement of the apex of lungs: Is better seen from the back and looking from above and patient is sitting erect and symmetrically. Palpation of movement of apex was done by placing palms firmly over the middle third of trapezius with fingers directing towards clavicles, and by feeling the upward movement of trapezius.
- Chest wall expansion: Expansion of thorax is measured at lower two-third of chest by recording the maximum difference between full inspiration and full expiration. Expansion should be above 5 cm. A low chest wall expansion is found in COPD, asthma, diffuse parenchymal lung diseases and ankylosing spondylitis.
- Vocal fremitus: It is a crude test and has no added advantage over vocal resonance. It is assessed by placing ulnar side of palm over the intercostal space, feeling the vibration and compared with corresponding side while patient is uttering one-one-one. Ulnar surface of palm is preferred as it is said to be more sensitive and it can be better placed over the intercostal areas. Similarly, vibration of low-pitched rhonchi (usually from large bronchus) or pleural rub (usually chronic than acute pleurisy) may be palpable.
- Crowding of ribs: The inter-space between ribs of diseased side is compared with normal side by insinuating fingers in the intercostal spaces. Rib crowding is found in pleural fibrosis and less commonly in lung parenchymal fibrosis. Over-ridding of ribs, where one rib rides over other ribs, found exclusively in pleural fibrosis.
- Palpation of cardiovascular abnormalities: Apart from apical impulse, any superficial pulsations should be palpated for confirmation as well as to elicit its expansile nature. Venus flow should be noted and any bruise should be palpated. Pulmonologist should not forget to palpate a palpable pulmonary component of second heart sound in the left 2nd intercostal space just lateral to sternum; and parasternal heave, a sign of right ventricular enlargement, over left parasternal area.
- Subcostal angle: It is the angle between two costal margins and it should be less than 90°. It is increased in COPD (barrel chest).
- Chest wall expansion: Measured as difference between chest wall perimeter during full inspiration and full expiration. It is normally more than 5 cm. Thoracic expansion is reduced in diseases of chest wall, neuromuscular diseases, pleural, lung parenchyma or airway diseases.
- Hemithorax expansion: Decrease movement of one hemithorax can be documented by measuring chest wall expansion of each hemithorax separately (from tip of the spine in back to mid of sternum in front) and comparing them with other side.
During percussion three things should be noted: (i) sound/note, (ii) feeling of resistance and (iii) tenderness. Percussion is done by hammering with the right middle finger (at 90° angle and movement coming from right wrist joint) over the second phalanx of left middle finger firmly placed over the area to be percussed. Left index and ring fingers must not touch chest wall as it will decrease vibration of chest wall producing sound. Normal percussion note over chest is resonant as lungs mainly contain air. Lung note losses its resonance in pleural diseases other than pneumothorax and in consolidation, fibrosis, collapse, etc. where lung air is replaced. Percussion note over consolidation is usually impaired to dull; it is dull over solid organs (heart, liver, spleen) and it is stony dull (dull + sense of resistance) over pleural effusion. On the other hand, it is hyper-resonant in presence of excess air like pneumothorax, emphysema, large cyst, superficial cavity, etc. Bilateral hyper-resonant note is indirectly assessed by absence of normal dullness over liver and heart. Tympanitic note is found over a hollow organ like fundus of stomach, distended guts and over pneumothorax.
Chest percussion is usually superficial. Deep percussion is done to delineate the margin of solid organ and in the back. Percussion is done placing left middle finger perpendicular to the border of organ to be delineated and then moving vertically towards the organ. Direct percussion is done over clavicle (over medial third of clavicle to be done after stretching skin down by fingers of left hand) and sternum to assess mediastinum (normally manubrium sterni and sternal angle are through and through are resonant). Comparison of sound is done for each intercostal space with same space of other side. Universal rule of clinical medicine is applicable here and normal side should be percussed first. Percussion is done placing finger in the intercostal places through well-defined lines. Usually percussion is done from second to sixth intercostal space in midclavicular line; from fourth to seventh space in midaxillary line and from angle of scapula to tenth space in the back along scapular line.
- Percussion through midaxillary line: Midaxillary line is a vertical line drawn from axilla at the midpoint between anterior and posterior axillary folds. Percussion along midaxillary line is done with patient in sitting position and raising both hands straight over the side of head.
- Percussion of back: Patients’ position is sitting with arms crossed over the chest directing towards opposite shoulder.
- Percussion in suprascapular area: It is done by placing fingers vertically in the suprascapular areas and percussion is done from medial to laterally.
- Percussion in intrascapular area: Here percussion is done by placing fingers horizontally from above downwards.
- Percussion through scapular line: Scapular line is a vertical line from the tip of angle of scapula. In these lines percussion is done placing fingers obliquely directing medially and upwards.
- Percussion in Kronig's isthmus: Kronig's isthmus is a place bounded medially by neck muscles, anteriorly by clavicles, laterally by acromian process and posteriorly by trapezi. The area represents the apex of lungs. Percussion is done from back with fingers placing over the middle third of trapezi with tip of fingers directing towards clavicle. Dullness over the area is found in any lesion of apex of lungs like tuberculosis, Pancoast tumor, apical cap, etc.
- Percussion for liver dullness: It is a deep percussion over right midclavicular line to find out the upper border of liver dullness. It is not effective in presence of fluid in right pleural space.
- Percussion of Traube's space: Traube's space is a typhanitic area over the left lower chest anteriorly, bounded medially by left border of liver, above by left dome of diaphragm and below by costal margin. The normal typhanitic node is obliterated in left-sided pleural effusion, pericardial effusion, hepatomegaly, splenomegaly, tumor over fundus of stomach. Traube's space may be pushed upwards in collapse and fibrosis of left lung, diaphragmatic palsy or eventration. Diagnosis of left-sided pleural effusion should be revisited if Traube's is not obliterated.
- Cardiac percussion: Cardiac percussion to delineate the cardiac boundary is not done as there is a risk of dislodgement of thrombi. For pulmonary medicine deep percussion over left parasternal line is done to notice the presence or absence of cardiac dullness in the 4th and 5th spaces. Left parasternal line is resonance in emphysema and shifting of heart to right.
- Right parasternal percussion: It is usually resonant. Dullness may be found in anterior mediastinal mass or sometimes in 4th and 5th space in rightward shifting of heart or dextrocardia.
- Tidal percussion: It is a crude method to demonstrate diaphragmatic movement. It is done by deep percussing over back in the scapular line to delineate the lowest border of lung resonance. Then the difference between the resonance at full inspiration and forceful expiration is noted. It is usually one intercostal space difference. Tidal percussion is negative in severe emphysema. Paradoxical movement of the diaphragm occurs in unilateral diaphragmatic palsy.
- Percussion for hydropneumothorax:
- Horizontal fluid level: Percussion is done anteriorly, laterally and in back and the highest points of dullness are marked. Patients’ position is sitting preferably in a tool. The line connecting the upper levels is horizontal in hydropneumothorax. Horizontal level does not mean same intercostal space. In classical pleural effusion the highest point of that line should be in the midaxillary line.
- Shifting dullness: It is done in the midaxillary line of the disease side. At first the dullness is delineated while patient is in sitting position. Then keeping the finger placed at that area, patient is asked to lie down in lateral decubitus position. Then wait for three normal breaths and percuss over the area. A resonant node indicates replacement of fluid by air. Then ask patient to sit again and percuss over the area. A dull node indicates replacement of air by fluid. Shifting dullness is classically found in hydropneumothorax. Rarely, It can be found over a large superficial cavity with fluid, hydropneumo-pericardium and herniation of gut. Delayed shifting dullness may be found in pleural effusion and when detected it indicates free fluid and healthy underlying lung.
- Mediastinal percussion: Mediastinal percussion is done over sternum. Manubrium sterni is usually resonant and if it is dull it indicates anterior mediastinal mass. Body of sternum is usually dull and it may be resonant in emphysema, tension pneumothorax and mediastinal emphysema.
Auscultation is done over areas of thorax and comparing them with other side. Areas are infraclavicular, mammary and inframammary anteriorly; axillary and infraaxillary laterally; and suprascapular, interscapular and infrascapular in the back. During auscultation, patient must be taught how to breathe, how to pronounce notes and how to whisper. Then confirm, whether patient is doing it properly, by hearing patients voice without stethoscope. In auscultation the following points should be noted: breath sound, vocal resonance, added sound and special sound.
- Breath sound: Breath sound is produced in the large airways by turbulent airflow. Air flow is linear in smaller airways. As tracheostomy patient produces breath sound the previous concept, vocal cords produce breath sound, is now ruled out. The intensity and frequency pattern of sound, thus produced, changes as it passes through normal lung structures.
- Vesicular breath sound: It is characterized by rustling in character, no gap between inspiration and expiration, and expiratory phase less than inspiratory phase. Breath sound increases its intensity during inspiration and quickly fades away during expiration. Vesicular breath sounds are of four types.
- Diminished vesicular breath sound: Breath sound is normal but low in amplitude and it is usually found in pleural diseases, hyperinflation of lung (emphysema).
- Vesicular with prolong expiration: Where expiratory phase of vesicular breath sound is as long as or more than inspiratory phase, and it is found in obstructive airway diseases.
- Harsh vesicular breath sound (bronchovesicular): When the inspiratory part of breath sound is of bronchial character and expiratory part is of vesicular character. It is found in compensatory hyperinflation of lung where a normal lung is doing extra work.
- Bronchial breath sound: When the part of lung between large airway and chest wall is solidified then the original sound that is heard over trachea may be heard over chest wall. Bronchial breath sound is blowing in character with a gap between the end of inspiration and start of expiration. In bronchial breath sound the expiratory part of sound is as long and as loud as inspiratory sound and inspiratory and expiratory sounds are equal in pitch and intensity. Bronchial breath sounds are of three types.
- High-pitched bronchial (tubular) breath sound: It is typically found over trachea is characteristically found in consolidation and as transmitted sound in case of tracheal shifting.
- Low-pitched bronchial (cavernous) breath sound: It is typically found over a cavity.
- Amphoric breath sound: When breath sound traverse though an air containing cavity, the sound may acquire a resonating amphoric quality, resembling the sound produced by blowing across the top of a bottle. It is a low pitch sound with a metallic character typically found in pneumothorax with bronchopleural fistula and rarely may be found over a large superficial cavity with a communicating bronchus.
- Vocal resonance: Vocal resonance is the voice sound heard over chest wall. Patient is asked to pronounce repeatedly syllables like ‘one-one-one’ and the sound is heard over chest wall with stethoscope. The sound is compared with normal side.
- Normal vocal resonance
- Decreased and absent vocal resonance: Mainly found in pleural diseases and emphysema
- Increased vocal resonance: Usually found over consolidation, transmitted sound due to shifting of trachea, upper border of pleural effusion, etc.
- Bronchophony: It is an increase in vocal resonance
- Egophony: It is a nasal intonation of vocal resonance typically found over upper border of pleural effusion and consolidation.
- Added sound:
- Rhonchi: It is a dry, continuous/uninterrupted and musical sound that lasts more than 250 milliseconds. Rhonchus is a latinized version of Greek rhonchus, meaning wheeze. Its use should be restricted to musical sound produced by narrowed bronchi. It has been suggested that rhonchi should be replaced by wheeze, but wheeze is normally used to sound that can be heard without stethoscope. Rhonchi can be classified as:
Rhonchi/wheeze is now classified as:
- High-pitched (sibilant) rhonchi with frequency > 400 Hz, is found in obstruction in smaller airways.
- Low-pitched (sonorous) rhonchi with frequency < 200 Hz, is found in obstruction in large airways.
- Monophonic wheezing consists of a single musical notes starting and ending at different times. It can be:
- Fixed monophonic: Wheeze has a constant frequency and a long duration; it is found in intrabronchial tumor, foreign body, bronchostenosis and mucus accumulation.
- Random monophonic: Wheeze has a varying frequency and duration presenting in both phases of respiration. It is seen in asthma.
- Polyphonic wheezing consists of multiple musical notes starting and ending at the same time and is typically produced by the dynamic compression of the large, more central airways. Polyphonic wheeze confined to the expiration only. It is found in COPD.
- Crepitation: Crepitation derived from Latin word ‘crepitare’, meaning crak or rattle. It is unambiguously used for nonmusical, short, explosive crackling sound that lasts less than 20 milliseconds. It is also described as moist-nonmusical, lathery sound mainly audible during inspiration. Some prefers to use crackles over crepitation. Fine crackles are produced within small airways, medium crackles are caused by air bubbling through mucus in small bronchi and coarse crackles arise from large bronchi or the bronchiectatic segments.
The timing of crackles is also important and accordingly crackles are classified as:
- Fine crackles are due to opening up of closed airways. Fine crepitation is softer, shorter in duration and higher in pitch than coarse crackles. Fine crackles are heard on mid to late inspiration and occasionally on expiration, unaffected by cough, gravity dependent and not transmitted to mouth. Late inspiratory crepitation previously called Velcro crepitation (sounds like opening of Velcro straps) is typically found in diffuse parenchymal lung diseases (interstitial lung diseases). It is also seen in pulmonary edema and pneumonia.
- Early inspiratory crackles: Crackles start early in inspiration and usually end before the midpoint of inspiration. They are usually due to secretions within large airways and disappear on coughing. They are found in chronic bronchitis.
- Late inspiratory crackles: Crackles appear any time after the beginning of inspiration and last till the end of expiration. They are found in diffuse parenchymal lung diseases, pneumonia and pulmonary edema.
- Biphasic crackles: Crackles are predominantly inspiratory and continued during expiration. They are found in COPD, bronchiectasis and idiopathic pulmonary fibrosis.
- Crackles of bronchiectasis are found and present in both phases of respiration. Crackles start early in inspiration, continued to mid-inspiration and fade by the end of inspiration. In pneumonia, crackles are mid-inspiratory and fairly coarse. However, during resolution phase crackles are more late inspiratory and shorter in duration.
- Post-tussive crackles: They are not present normally on auscultation but appear after coughing as cough dislodges the thick secretions. They were classically described for tubercular cavities. They are also found in early pneumonia, lung abscess and lung parenchymal fibrosis.
- Post-tussive suction: It is a hissing sound heard over a collapsible cavity after a bout of coughing.
- Pleural rub: It is a friction sound, biphasic occurring at the end of inspiration and just after starting of expiration. The main difference between pleural rub and coarse crepitation is that it does not change in quality or quantity after coughing.
- Succussion splash: A splashing sound heard over the chest directly or by stethoscope at the air-fluid level with sudden sharp movement of thorax. This sign should not be elicited as it may push fluid from pleural space to lung in presence of bronchopleural fistula.
- d'Espine sign: It is described as bronchial breath sound and whispering pectoriloques heard over the spinous processes below T3 vertebrae in adult. It implies continuity between the main stem bronchus and the vertebrae by mass, usually by lymphadenopathy. The sign suggests malignancy, lymphoma, metastatic cancer, tuberculosis, sarcoidosis and other causes of lymphadenopathy.Reverse d'Espine sign: It is also described as anterior d'Espine sign. It is described as bronchial breath sound and bronchophony heard over supracardiac area due to large anterior mediastinal mass/lymphadenopathy between trachea and sternum.
Some important manifestations should be described as they are important in some diseases but not applicable in all types of cases.
Stidor: It is a loud high-pitched musical sound produced by the turbulent flow in the upper airways. It is louder over the neck than over chest wall. Stridor is mainly inspiratory sound. It is heard without stethoscope and may be heard from a distance. Stridor is inspiratory when it is associated with extrathoracic lesions (laryngomalacia, laryngeal and vocal cord diseases including tumors, tracheal stenosis including post-extubation lesions, etc.). Stridor may be heard over-expiration when it is associated with intrathoracic lesions (tracheomalacia, bronchomalacia, external compression of trachea and main bronchus).
Coin test: It was described as a sign for tension pneumothorax. To elicit the sign—place a metallic coin flat against the chest wall just below the mid clavicle, strikes the coin with the edge of another metal coin with the help of an assistant or by patient himself, place the diaphragm of stethoscope at the opposite corresponding point in the posterior wall of chest of the affected side. Coin test is positive if high-pitched metallic and bell-like sounds are heard. It is occasionally found in pneumothorax, large cavity and large bulla.
Scratch sign: The test can be done with patient in either sitting or supine position, place the diaphragm of stethoscope at the midpoint over the sternum, scratch with finger or a blunt object over lateral wall of both side of chest at equidistant points and sounds of two sides are compared. A positive sign consists of a considerably louder and harder sound on the side of pneumothorax.
Hamman's sign: The sign was described by Louis Hamman in 1939. The sign is found in pneumomediastinum and left-sided pneumothorax. The presence of free air between heart and chest wall produces a crunching, cracking sounds that are synchronous with each cardiac cycle and best heard over the precordium from 3rd to 5th intercostal spaces. The contraction of heart within the mediastinum leads to displacement of air bubbles and produces this classic raspy sound.
Subcutaneous crepitation: Subcutaneous emphysema produces an unusual cracking sensation under the skin when pressed with fingers due to presence of air in the subcutaneous tissue. Subcutaneous/surgical emphysema over chest wall, neck and face is found in chest trauma, pneumothorax, rupture esophagus and commonly due to complication of intercostal tube drainage.
Forced expiratory time (FET): It is a simple, inexpensive and sensitive test to detect airflow obstruction at bed side. FET is defined as the time taken for an individual to complete forceful exhalation after maximum inspiration. It is assessed by placing the bell of stethoscope in the suprasternal notch and measuring the duration of audible expiration. If the duration exceeds 6 seconds, it indicates obstructive airway diseases. A FET less than 5 seconds indicates FEV1/FVC ratio more than 60%, a FET more than 6 seconds indicates FEV1/FVC ratio less than 50%.
EXAMINATION OF OTHER SYSTEMS
Examination of Cardiovascular System
Special emphasis should be given on pulmonary component of second heart sound (P2) and its spitting. In pulmonary hypertension, P2 is loud, may be palpable and spitted but not fixed (the gap between aortic and pulmonary components of second heart sound varies with phases of respiration). Parasternal heave and epigastric pulsations may be found in cor pulmonle. Cardiac percussion is now obsolete as it has the risk of dislodging a clot. In respiratory medicine deep percussion over left and right parasternal line is sometimes required to assess shifting of heart when apical impulse is not palpable. Gallop heart beat (suggest heart failure) and murmur (suggestive of underlying heart disease) if present should be noted. Pulmonary ejection systolic murmur and tricuspid regurgitation murmur may be heard in corpulmonale.
Examination of Gastrointestinal, Lymphoreticular and Genital System
Special emphasis should be given on venous prominence over abdomen that is suggesting vena caval obstruction or cirrhosis; hepatomegaly (lymphoma, disseminated TB, sarcoidosis, drug-induced hepatitis, liver metastasis); splenomegly (lymphoma, disseminated TB, sarcoidosis, cirrhosis); ascities (may cause right sided pleural effusion and abdominal TB may present with ascities); signs of pancreatitis (in left-sided pleural effusion) and any abdominal lump. Examination of lymphoreticular system includes examination of lymph nodes, liver, spleen, skin for signs of hemorrhage and sternal tenderness. Female genital tract including breast in female and testes in male should be examined.
Examination of Nervous System
Level of consciousness and abnormal behavior should be assessed. Detailed neurological examination is not usually necessary and sometimes specific signs are to be elicited if they are indicated. As for example, signs of meningeal irritation for disseminated TB, signs of myasthenia gravis for anterior mediastinal syndrome, signs of metastasis and paraneoplastic syndrome for bronchogenic syndrome, and signs of paraplegia for spinal TB.