101 Cases in Respiratory Medicine Supriya Sarkar
Page numbers followed by f refer to figure, and t refer to table
Abdominal diseases 257
Abdominal lymphadenopathy 379
Abdominal viscera 61
Abdomino-thoracic respiration 282
Abnormal chest X-ray 2
Abnormal inhomogeneity 204
Absorption collapse 332
Accidental discovery of irregular calcification 41
case report 41
discussion 41
right sided pleural calcification 42f
Accumulation of fluid 257
Acellular collagen 42
Acetyl hydrazine 213
Acetylators group 213
Acid fast bacilli 48, 110, 218
Acinar dysplasia 112
Acinetobacter species 147
Acquired immunodeficiency syndrome 5
Actinomycosis 352
Acute exacerbation of COPD 120, 126
Acute inflammatory demyelinating polyneuropathy 144
Acute myocardial infarction 2, 118, 235
Acute onset of dyspnea in SLE 156
bilateral dense centrilobular nodules 158f
bilateral diffuse nonhomogeneous opacities 157f
case report 156
discussion 156, 158, 159
management 159
methylprednisolone sodium succinate 159
Acute respiratory distress syndrome 148
Acute respiratory failure
life-threatening 113
non-life-threatening 113
Acute silicoproteinosis 71
Adenocarcinoma 364
Adenocarcinoma of lung 39, 344, 346, 362, 364, 389
Adenomatoid proliferation 111
Adhesive collapse 332
Aeroallergens 89, 91
Air-bronchogram 152, 285, 286, 337, 338
Air hunger 11
Alae nasi 14, 294
Albendazole 6566, 292293, 312
Alkaline phosphatase 321
angiitis granulomatosis 93, 198
bronchopulmonary 88, 94, 198
rhinitis 7, 31
Alpha fetoprotein 382
Alpha-1 antitrypsin deficiency 1, 102
Alprazolam 110, 347
Alveolar macrophages 34
Alveolar microlithiasis 45
Alveolar proteinosis 152
Amikacin 147, 327
Aminoglycosides 298
Amosite 43
Amoxicillin–clavulanic acid 297
Amphiboles 43
Ampicillin-sulbactam 298
Amyloidoma 37
Anaerobic empyema 264
Analysis of symptoms 2
Anaplasia 267
Anaplasia of tumor 133
Anchovy sauce 271
Anhidrosis 366
Ankylosing spondylitis 11, 78
Anorexia 5
Anterior mediastinal mass 380
case report 380
discussion 381, 383, 384
fat densities pushing heart to right 382f
large mass in left hemithorax 381f
management 384
obscuring retrosternal space 381f
Anticoagulation agents 235
Anti-cyclic citrullinated peptides 202
Antifibrotic effects 173
Antiphospholipid antibody syndrome 232
Antipseudomonal fluoroquinolones 298
Anti-pseudomonas antibiotics 117, 265
Antipsychotic drugs for obsessive compulsive disorder 249
Antiretroviral treatment 256
Antitubercular drugs 79, 92, 231, 236
ethambutol 230
isoniazid 230
pyrazinamide 230
rifampin 230
Antitubercular medicine with INH 212
Antitubercular treatment 221
Anxiolytic drug 224
Aortic body paraganglioma 383
fibrosis 57
impulse 16
Apnea 12
Apoptosis 96
Appetite 5
Arabino-galactan layer 34
Arterial blood gas 114
Arteriovenous malformation 36
Arthralgia 156, 162, 164
Asbestosis 171
Aspergilloma 47, 78
Aspergillus fumigatus 93, 94
Asplenia 298
Asthmatic patient came with hemoptysis 90
bilateral central bronchiectasis 94
bilateral perihilar opacity 93f
case report 90
discussion 91, 92, 93
management 94
Asymptomatic lady wants to go home 285
case report 285
discussion 285, 286
management 286
Asymptomatic man with hilar calcification 33
case report 33
management 35
primary complex with large hilar 33f
Asymptomatic SPN in smoker 38
case report 38
discussion 39, 40
heterogeneous SPN in right 39
management 40
Asystole 63
Atelectasis 338, 367
Atorvastatin 341
Atrial septal defect 44
Atrial septal defect with multiple nodular opacities 388
case report 388
CECT-thorax dilated pulmonary arteries 390f
dilated pulmonary arteries 390f
discussion 389, 391
management 391
Atypical bacterial coverage 217
Atypical carcinoma 373
Atypical mycobacteria 111
Atypical mycobacterial infection 209, 240
Auramine-Rhodamine staining 225
Auscultation 20
added sound 22
breath sound 20
vocal resonance 21
Autoamputation 164
Autoinflammatory disease 96
Autologous bone marrow transplantation 202
Autophagy 96
Axillary lymph node 277
Azathioprine 157, 178, 358
Aztreonam 328
Azygoesophageal recess 101
Bacilli 34
Back examination of 14
scapula 15
shoulder 14
spine 15
Bacteroides fragilis 319
Bagassosis 182
Banyan tree 41
Barrel chest 18
pattern of calcification 37
teratoma 384
tumor 38, 383
Berylliosis 211
Beta-blocker atenolol 165
Beta-human chorionic gonadotropin 394
airspace opacities 158
basal 176
consolidation 159
bilateral lower zone consolidation 160f
case report 159
discussion 161, 162
lower lobe consolidations 162f
management 162
treatment and outcome 160
diaphragmatic palsy 283
diminished thoracic expansion 354
empyema thoracic 281
boil in the back 284f
case report 281
discussion 282, 283, 284
management 283
extensive miliary opacities 226
hilar lymphadenopathy 209, 211
case report 48
discussion 49, 50, 51
management 50
with ill-defined parenchymal opacities 49f
hyperresonant nodes 354
perihilar 152
alveolar opacity 89
opacities 152
pneumonia 162
pneumothorax 285
polyphonic rhonchi 99
reticulonodular dense 44
reticulonodular opacities 80, 188
Bi-level positive airway pressure 113
Biliary surgery 321
Bilious expectoration 309f
case report 309
cavity with fluid level in right
lower zone 311f
discussion 310
lung abscess in right lower lobe 311f
management 312
multiple fluid-filled cysts 312
Biot breathing 11, 12
Biphasic cells 386
Biphasic crepitation 66
Bleomycin 165
Blood biomarker levels 395, 396
Blood pressure 6
Blood-stained expectoration 157
Blouse 219
Blunt non-penetrating trauma 60
Body mass index 6
Borders of lung lobules 363
Bradypnea 11, 12
Brain metastases 396
Breathing, different patterns of 12
Bromocriptine 42
Bronchial adenoma 328, 373
Bronchial breath sound 21
amphoric breath sound 21
high-pitched bronchial 21
low-pitched bronchial 21
Bronchial carcinoid tumor 373
cavity 111
segments 22
Bronchiolar walls 204
Bronchiolitis obliterance - organizing pneumonia 185, 204
Bronchioloalveolar cell carcinoma 2, 37, 326
Bronchoalveolar lavage 50, 116, 159, 228, 262
Bronchoalveolar lavage 50
Bronchobiliary fistula 310
Bronchogenic carcinoma 6, 85, 226, 328, 341, 360, 368
Bronchogenic cysts 290
Bronchophony 21
Bronchopleural fistula 109, 238, 279, 316, 326
Bronchopulmonary segment 171
Bronchorrhea 326
Bronchoscopic biopsy 37, 307f, 357
Bronchoscopic lavage 185, 247
Bronchoscopy 82
Bronchovesicular 21
Buccal cavity 7
Bullae 288
Bullous emphysema 290
Bupropion 340
Cachectic 299
Calcification in solitary pulmonary nodule 35
case report 35
discussion 35
management 37
solitary pulmonary nodule 36f
Calcinosis cutis 165
Calf muscle tenderness 232
Candidiasis 8
Candle wax 41
Capillary blood glucose 62
Capitonnage 65
Carbapenems 320
Carboplatin 343, 367, 375
Carcinoid syndrome 374
Carcinoid tumors 373, 386
Cardiac diseases 98
Cardiac percussion 19
Cardiac silhouette 362
Cardiogenic pulmonary edema 90, 152
Cardiophrenic angle 53, 362
Cardiothoracic surgeon 391
Cardiovascular, abnormalities palpation of 17
Carina 265, 362
Cartridge based nucleic acid amplification test 92, 185, 376
Caseating epithelioid granuloma 376
Caseating necrosis 218, 219
Caseous necrosis 34
Castleman disease 202
Catalase-peroxidase 215
Cavernous 21
Cavitary tuberculosis 78, 209
CECT-thorax mediastinal window 39f
Cefepime 147
Cefixime 225
Cefoperazone 280, 327
Cefoperazone sulbactam 110, 160
Cell division 29
Cell mediated immunity 34
Cell wall 34
Central caseous necrosis 34
Central mediastinum 354
Central venous catheterization 59
Centriacinar emphysema 195
Centrilobular 71
Centrilobular nodules 178, 182, 218, 378
Cervical lymphadenopathy and pneumothorax 187
atypical histiocytes 190f
bilateral reticulonodular opacities 189f
case report 187
cystic spaces of bizarre shaped 190f
discussion 189, 191
extensive scarring and sinus formations 188f
management 192
Cervical spondylitis 85, 358, 364
case report 364
discussion 366, 367
management 367
MRI scan of cervical spine 365f
Changing diagnosis 263
case report 263
discussion 264, 266
management 266
nodule in the trachea at the level of carina 265f
Chest and deformity shape of 11
barrel chest 11
chest wall bulging 13
funnel chest 13
pigeon chest 12
thoracic kyphoscoliosis 13
Chest pain 3, 330
Chest radiology 33
Chest wall expansion 17, 18, 282
Chest wall in the axillary area 258
Chest wall swelling
case report 349
discussion 350, 351, 352, 353
homogeneous opacity in right mid zone 350f
management 353
tumors 352
Cheyne–Stokes breathing 11, 12
Chlamydia pneumoniae 296
Chlamydia psittaci 296
Chloroquine 157
Cholecystectomy 33
Cholelithiasis 320
Choriocarcinoma 383
Choroidal tubercle 228
Chronic aspiration 171
Chronic berylliosis 210
Chronic cholecystisis 38
Chronic hypersensitivity pneumonia 171
Chronic infections 226
Chronic nonspecific symptoms 51
case report 51
discussion 52
management 54
mass lesion in right cardiophrenic angle 54f
right lower zone opacity 52f
Chronic obstructive pulmonary disease 2, 28, 170, 368
Churg-Strauss syndrome 88, 93, 187
Cicatricial collapse 332
Ciliospinal reflex 366
Ciprofloxacin 147, 247, 298
Cirrhosis 13, 25, 270
Cisplatin 165, 367, 374, 375
based regimes 332
Clarithromycin 183, 247, 297
Classical tuberculous pleural effusion 257
case report 257
discussion 257
left-sided pleural effusion with left-sided transverse fissure 259f
management 259
uniqueness 259
Clindamycin 264, 298
Clinical data analysis
eighth step clinical expertise 30
fifth step positive and negative clues 28
first step collection of clinical
information 26
fourth step course of clinical
manifestation 28
fundamental governing theories of clinical medicine
clinical bias 31
diseases flock together 31
evidence-based medicine 31
explain by single pathology 31
ninth step clinical reasoning 30
second step piercing through individual manifestation 27
seventh step clinical setting 29
seventh step epidemiology of disease 29
sixth step pattern identification 29
tenth step clinical judgment 30
third step grouping of clinical data 27
Clonidine 340
Clubbing 7
Coamoxyclav 299
Coarse crackles 22
Coccidioidomycosis 211
Coin test 24
Collapse lung border 57
Common presentation of a rare disease in adult 108
Community-acquired pneumonia 296, 314
Comorbidities 31
Concave lateral margins 221
Concentric calcification 37
Congenital cystic adenomatoid malformation 111
Connective tissue diseases 171
Contralateral chest wall metastasis 352
patient with type II respiratory failure
case report 123
discussion 124, 125, 126
management 125
refined ABCD assessment tool 124f
with raised left dome of the diaphragm 353
case report 353
discussion 354, 356
management 357
raised left dome of the diaphragm 355f, 356f
with rapid change in chest radiology 112
absence of nodular opacity 115f
bilateral reticulonodular opacities 114f
case report 112
discussion 113, 115
management 116
Cor pulmonale 6
Costochondral joints 15
Costophrenic angle 66, 260, 279, 333
Costophrenic sulci 195
Cotrimoxazole 247
Cough 3
Covert clue 28
Coxiella burnetii 296
biphasic crackles 23
bronchiectasis 23
early inspiratory crackles 23
late inspiratory crackles 23
post-tussive crackles 23
Craniocaudal predilection 186
Crepitation 22
Crocidolite 43
Crowding of ribs 17
Cryotherapy 375
Cryptogenic organizing pneumonia 186
Cuirass 120
Cutaneous lesions 13
Cyanosis 7, 8
Cyclophosphamide 163, 192, 375, 379, 380
Cycloserine 238
Cysplatin 266
Cystic adenomatoid malformation 292
Cystic fibrosis 5, 107
Cystic hygroma 383
Cytochromal enzyme 213
Cytokines 282
Decortication 238
Decubitus position 6, 20, 78, 316, 317, 326
Deep hyperchromatic nucleus 335
Deep vein thrombosis 7, 118119, 232234f
Deglutition 85
Delayed-type hypersensitivity 34
Dendritic cells 34
Dense reticulonodular opacities 70
Dermatome nerve supply 258
Dermatomyositis 185
Dermoid cyst 63, 64, 383
Dermoids 371
Desquamative interstitial pneumonia 200
Dexamethasone suppression test 131
Dextrocardia 19
Diabetes insipidus 191
Diabetic ketoacidosis 145
Diaphragmatic hernia 288
Diffuse alveolar hemorrhage 158
Diffuse interstitial lung disease with severe chest pain 357
bilateral basal reticular opacities 357f
case report 357
discussion 358, 360
erosions of left 2nd and 3rd ribs 359f
honey combing at both lung bases 358f
management 360
opacity encircling left apex of lung 359f
Diffuse parenchymal lung disease 164, 166, 169
bilateral reticular patterns with fuzzy cardiac 169f
case report 169
discussion 169
discussion 172, 173
management 172
predominantly reticular pattern 171
presented like tuberculosis 183
bilateral mainly reticular opacities 184f
bilateral reticular opacities 186f
case report 183
discussion 184, 185
management 187
step II 185
with changing diagnosis 174
case report 174
discussion 174, 177, 178
management 179
relatively clear lung bases 177f
reticular opacities 175f
with systemic manifestation 164
bilateral ground-glass opacities 166f
bilateral reticulonodular opacities 166f
case report 164
discussion 164, 167
management 168
sclerodactyly and autoamputation 164f
Discoid rash 156, 206
Domperidone 273
Dopamine 139
Doxorubicin 375, 379
Doxycycline 247
Draining bronchioles 247
Drug-induced lung diseases 171
Drugs causing PIE
chlorpropamide 198
gold salts 198
hydralazine 198
indomethacin 198
isoniazid 198
nitrofurantoin 198
penicillin 198
sulfonamides 198
thiazides 198
tricyclic antidepressants 198
Dry-powder inhaler 97
Dyslipidemias 97
Dysmotile cilia syndrome 107, 108
Dysphagia 60
Dyspnea 4, 6, 183, 208, 267, 294, 299, 330, 333, 368
Early onset COPD or late onset asthma 98
case report 98
discussion 99, 100
management 102
paraseptal emphysema 101f
Ecchynococcus multilocularis 292
Ectoderm 382
Edema 7
Efavirenz 155, 256
Eggshell calcification 71
Egophony 21
Elderly COPD patient with leukocytosis 117
case report 117
discussion 117, 118, 119
management 119
Elderly lady had a concealed truth 266
case report 266
discussion 267, 269
management 269
Elderly lady with respiratory acidosis
case report 137
discussion 137, 138, 139
final outcome 139
Elderly man with acute over chronic respiratory insults
case report 66
discussion 66, 68
fibrocalcified lesion in right upper zone 67
insults management 68
Elderly man with metabolic alkalosis 131
case report 131
discussion 131, 133, 134
management 133
PET positive nodule in right upper lobe 132f
small nodule in right upper lobe 132
Elderly man with right lung collapse
case report 330
discussion 330, 332
management 332
with metastases in left lung 331f
Elevated serum lactate 380
Embolectomy 235
Embryonal carcinoma 383
Empyema fluid 254
Empyema necessitatis 14
Emtricitabine 155, 256
Encysted pleural effusion 283, 335
Encysted pleural effusion with liver cyst 274
case report 274
discussion 275, 277
management 277
massive encysted pleural effusion 276f
right-sided encysted pleural effusion 274f
hamartomas 37
spread of tuberculosis 218
tuberculosis 291, 328
ultrasonography 50, 209, 251
Endocyst 63
Endoderm 382
Endogenous cytokines 4
Endothelium 150
aspirate 147
electrocautery 123
Enophthalmos 366
Enoxaparin 233, 235
Entamoeba histolytica 272
Enterobacteriaceae 147
Enucleation 65
Enzyme-linked immunosorbent assay 64
Eosinophilia 291
granuloma of bone 191
inflammation 100
lung disease 187
Epidemiologic clues 296
Epigastric suction 14
Epithelioid cells 34
Epithelioid granuloma 218
Epitrochlear 6
Epituberculosis 35
Erythematous circular 206
Escherichia coli 148
Esophagoscopic procedures 59
Etamsylate 328
Etanercept 154
Ethambutol 305
Ethionamide 238
Ethmoidal sinus 8
Etoposide 192, 266, 375
Excessive mineralocorticoid secretion 133
Exertional dyspnea 184, 202
Exogenous pyrogens 4
Expectoration 3
Expiratory positive airway pressure 120
Extended-spectrum beta-lactamases 328
Extensive ground glass abnormality 170
Extensive peribronchiolar macrophage 201
Extrapulmonary tuberculosis 214, 231, 245
Extravascular compartment 139, 300
Extrinsic allergic alveolitis 182
Exudative pleural effusion 215
Facial anhidrosis 366
Fever 4
Fiberoptic bronchoscopy 59, 265, 328, 332, 355, 373
Fibrinolytic therapy 234, 235
Fibrocavitary disease 316, 326
Fibrocavitary lung disease 106
Fibro-optic bronchoscopy 122
Fibrosing mediastinitis 307, 369
Fibrothorax 360
case report 360
discussion 362
encysted pleural effusion 363f
lung mass the level of carina 364f
lung window of CT-thorax 363f
management 364
opacity 361f
Fibrotic sarcoidosis 78
Fibrous layer 63
Fine-needle aspiration cytology 39
Flattening 13
Fluroquinolone 237
Fluticasone 113, 205
Fondaparinux 235
Forced expiratory time 24
Formoterol 97
Fossa ovalis 389
Fractioned radiotherapy 375
Fracture neck femur 83
case report 83
discussion 84, 86
homogeneous opacity 85f
management 85
surrounding rarefaction of bones 84f
Frank blood 372
Frank empyema 254
Frequent exacerbations of COPD
bronchiectatic changes 104f
case report 102
discussion 103, 104
management 105
Frontoparietal 395
Fundal gas 61, 107
antigens 198
granuloma 37
spores 182
Fusobacterium 319
Fusobacterium nucleatum 319
Fuzzy cardiac 169
Gallbladder surgery 35
Ganglions 366
Gas under the diaphragm 320
case report 320
discussion 321, 323
management 322
obliterating right costophrenic angle 322f
Gastroesophageal reflux disease 88, 291
Gentamicin 147
Germ cell tumor 220, 383, 386
Glucocorticosteroids 157
Glycopyrrorium combination 97
Goodpasture's syndrome 158
Granulomatous inflammatory diseases 386
Group A Streptococcus 265
Guillain-Barré syndrome with ventilatory failure 144
case report 144
discussion 144, 146, 147
management 146
bleeding 8
hypertrophy 8
Gynecomastia 14
Haemophilus influenzae 155, 265, 296, 313
Hamartoma 37
Hampton's hump 233
Hand-Schüller-Christian disease 191
Healthcare-associated pneumonia 296
Hematogenous 63
Hemithorax 18, 360
disturbance 288
instability 122
Hemoptysis 3
Hemorrhagic pleural effusion 261
Hemorrhagic pleural effusion with low adenosine deaminase 260
case report 260
discussion 260, 262
management 262
Henoch-Schönlein purpura 158
Hepatitis 25, 155, 29, 212213
WHO graded drug-induced 212
Hepatobilliary fistula 272
Hepatocellular carcinoma 214
Hepatomegaly 19
Hepatosplenomegaly 261, 333
Hepatotoxic drugs 213, 237
Hereditary hemorrhagic telangiectasia 75
Heterogeneous opacities 110f, 237
High density lipoprotein 141
High-frequency ventilation 150
Highly active antiretroviral therapy 155
Hilar enlargement 211
Hilar glandular 35
Hilar lymph nodes 34, 35
Hilar lymphadenopathy 49
Histoplasma antigen 308
Histoplasma capsulatum 306
Histoplasma yeasts 308
Hoarseness of voice 343
Holter monitoring 62
Honeycombing 176
Horner's syndrome 366
Hospital-acquired pneumonia 296
Humidifier lung 182
Hydatid cyst 63, 276
Hydatidosis 292
Hydrocortisone 335
Hydrophilic molecules 34
Hydropneumothorax 16, 55, 56, 57
Hydroxychloroquine 157, 160
Hydroxyurea 380
Hypercarbia 114
cells 394
nuclei 396
nucleus 275
Hypercoagulability state 232
Hyperhomocysteinemia 232
Hyperlucency 287
Hyperlucent right lung 287
case report 287
discussion 288, 289
management 290
Hyperpnea 12
Hypogammaglobulinemia 107, 386
Hypokalemia 131
Hypothyroidism 4
Hypoxia with bilateral lung infiltrates 151
bilateral parahilar opacities 153f
case report 148
case report 151
discussion 151, 152, 154, 155
management 155
respiratory alkalosis 152
Hypoxic respiratory failure
discussion 148
lower zone paracardiac opacity 148f
management 150
Idiopathic interstitial fibrosis 171, 176, 200
IgE-mediated hypersensitivity 198
Illicit drug use 296
Imipenem 147, 298, 320
Immature stromal tissue 394
Immunosuppressant drugs 157
Indacaterol 97
Infarction or granuloma 37
Inflam-aging 31
Inflammatory granulomas 37
Infliximab 154
Influenza 29
Influenza-like prodrome 186
Infraaxillary 335
Infraclavicular areas 16, 179
Inframammary 74, 270, 335
Infrascapular areas 17, 253, 270, 278
Inguinal 6
Inhaled corticosteroids 96
Inhaled salmeterol-fluticasone combination 137, 140
Inspection 8
flow resistance property 150
muscles 14
phase 21
positive airway pressure 120
Intercostal muscle paralysis 11
Intercostal suction 6
Interleukin-1 282
Interlobular lines 363
Interlobular septal thickening 71
Intermediate neuroendocrine carcinoma 373
Interscapular area 278
Interstitial alveolar infiltrate 182
Interstitial lung disease 2, 169, 283, 358
Interstitial pneumonia 1, 177
Interventricular septum 118
Intervertebral disk 279
Intrabronchial hamartoma 37
Intracellular signaling 173
blockage 329
causes 328
growth 362
lesion 39, 110
organizing fibrosis 187
tumor 375
Intrathoracic lymphoma 263, 379
Intrathoracic malignancy 43
compartment 300
metastasis 219
Intravenous methylprednisolone 140
Invasive aspergillosis 78
Invasive mechanical ventilation 124
Ipratropium 113, 120, 135
Ipsilateral hilar
lymphadenopathy 226
prominence 226
Ipsilateral lung
metastases 352
nodules 352
Irinotecan 375
Iron lung 120
Ischemic heart diseases 97
Isoniazid 305
Itraconazole 168, 308
Jacket ventilator 120
Japanese scientist for panbronchiolitis 219
Jaundice 7, 322, 368
J receptor 4
Jugular venous pressure 139
Juxtaphrenic lung 195
Kanamycin 238
Keratoconjunctivitis 51
Keratotic scaling 206
Ketoacidosis 11, 12t
Klebsiella infection 3
Klebsiella pneumoniae 109, 280, 296, 327, 328, 337
Kronig's isthmus 19, 79
Kussmaul breathing 11, 12
Kyphosis 11, 15
Lactic dehydrogenase 382
Laminated hyaline membrane 63
Lamivudine 155, 256
Landouzy septicemia 228
Langerhan giant cells 34
Langerhans cell histiocytosis 190
Langerhans cells 191
Langerhans histiocytosis 201
Laparotomy 320
Larynx 8
Laser therapy 375
Lassitude 261
Latissimus dorsi 14
Left hemithorax 259, 260, 285, 335
Left hilar lymphadenopathy 351, 352
Left infrascapular area 327, 372
Left lower interscapular area 257
Left lower lobectomy 111
Left midaxillary line 257
Left midclavicular line 257, 372
Left sided air-fluid level
case report 55, 56
discussion 55, 57
management 58
stomach in the thorax 57f
Left ventricular
ejection fraction 97
failure 88
function 3
Left-sided pleural effusion 333
case report 333
discussion 334, 335
left-sided homogeneous opacity 333f
management 335
Legionella pneumonia 222
Legionella pneumophila 296, 337
Legionella species 296
Leprosy 210
Letterer-Siwe disease 191
Leukamoid blood picture 313
Leukocytosis 138, 139, 147
Leukopenia 147
Leukoplakia 8
Leukotriene 134
Levofloxacin 146, 147, 238, 297, 298
Levosalbutamol 127
Life-threatening episode associated with tuberculosis 229
bilateral patchy opacities 230f
case report 229
discussion 230, 232, 233
extensive deep vein thrombosis 234f
final diagnosis 235
management 233
pleural-based triangular opacity 234f
Ligamentum arteriosum 341
Ligeonella 296
Linezolid 147, 284
Linezolid 298
Lingular segment 176
Lipase levels 261
Little mucoid expectoration 353
disease 13
enzyme levels 321
function test 249
metastasis 25
Lobectomy 65, 133, 391
Lobulation 221
Localized rhonchi in adult 344
air-tapping in right upper lobe with right hilar mass 345f
case report 344
discussion 344, 346
hyperlucency in right upper zone 345f
Localized rhonchi in adult management 346
Loeffler's syndrome 187, 197, 198
Long-acting beta-2 agonist 96
Long journey seeking treatment 236
case report 236
discussion 236, 237, 238
management 238
Low-pitched rhonchi 17
Luminal block 328
abscess 326
cancer 13, 39
infections 294
interstitium 203
malignancy 363
parenchyma 82
parenchymal lesion 35, 222
window 362
Lymph node 63
Lymphangiomyomatosis 182
Lymphocyte neutrophil 259, 261
Lymphocytic 267
exudative 376
pleural effusion 254
pleural fluid 260
Lymphohematogenous route 228
Lymphoid interstitial pneumonia 202
Lymphoma 25
Lymphoplasmacytes 172
Lymphoreticular system 25, 267
Macleod's syndrome 81, 288
Macroaspiration 7, 317
Macronodule 214
Malar rash 156, 167
Malignancy 37
germ cell tumors 383
lymph nodes 6
teratoma 383
tumor 366
Mallampati classification 8
Man with chest wall mass 346
case report 346
discussion 347, 349
heterogeneous mass in left hemithorax 348f
homogeneous opacity in left mid zone 348f
management 349
Mandible 191
Mantoux test 50, 82, 209, 220, 249
Manubrium 368
Masked metabolic acidosis in ICU 129
case report 129
discussion 129, 130
final outcome 130
Massive hemoptysis with past history of pulmonary TB 75
case report 75
change of position of air crescent 77f
discussion 76, 77
management 78
non-homogeneous opacity in left upper zone 76f
Mature teratoma 383
Mean arterial pressure 63
adenopathy 307
emphysema 13
fat line 382
germ cell tumor 335, 383
lymph nodes 307
lymphadenopathy 222
mass 382
pain 3, 85
percussion 20
pleura 367, 383
shifting 253, 258
window 53
Mediastinum 16
Mediatinal tumor 382
Melioidosis 29
Mendelson's syndrome 317
Meninges 229
Meropenem 127, 320
Mesenchymal tumor 383
Mesoderm 382
Mesothelial cell 254, 258, 277
Mesothelioma 261, 267, 360, 364
Metabolic alkalosis 131, 145
Metabolic syndrome 141
Metachronous 398
Metamyelocyte 313
Metastatic liposarcoma 37
Metformin 140
Methicillin resistant Staphylococcus aureus 298
Methotrexate 42, 157, 192, 308
Methyl prednisolone 172
Methylprednisolone 129, 159, 162
Methysergide 42
Metronidazole 273, 320, 322
Microaspiration 7
Microbiologically confirmed tuberculosis 230
Microconidia 307
Microliths 45
Midclavicular line 263, 310, 368
Middle-aged lady with a round opacity 222
case report 222
discussion 224
management 224
with central lucency 223f
Middle-aged man presented with consolidation 336
case report 336
discussion 337, 338
management 338
sharp lateral margin in right lower zone 336
Mild centrilobular nodules 201
Miliary opacities 228
Miliary tuberculosis 69, 179, 228, 229
Mimic thymoma 386
Mineralocorticoid excess syndrome 133
Minocycline 247
Miosis 366
Mitomycin 42
Mitral stenosis 44, 184
Mixed connective tissue disease 167
Mixed density inhomogeneous 395
Monitoring intrinsic peep 125
Mononuclear cells or neutrophils 203
rhonchi 344
wheezing 22
Montelukast 134
Moraxella catarrhalis 296, 313
Morgagni hernia 53, 63
Mosaic attenuation pattern 204
Movement of chest 16
Moxifloxacin 247, 298
Mucoid expectoration 219, 229, 245, 247, 263, 330, 336
Mucopurulent expectoration 326, 388
Müller's muscles 366
Multidrug resistant (MDR) TB 238
amikacin 238
cycloserine 239
ethionamide 239
fluoroquinolone 239
kanamycin 238
kapreomycin 238
Multilobar involvement 112
Multiorgan dysfunction syndrome 139
Multiple air-fluid levels 313
case report 313
discussion 313, 314, 315
final diagnosis 315
management 314
multiple air-fluid levels in right hemithorax 314
multiple bulla 315f
Multiple bullae 316
Multiple cannon ball metastases 392
Multiple cystic spaces 111
Multiple discharging sinuses 188
Multiple fluid-filled cysts 291
case report 291
discussion 291, 292
management 292
Multiple hydatid cysts 292
Multiple myeloma 352
Multiple rib erosions 242
case report 242
discussion 243, 244
final diagnosis 245
healed rib erosions 244f
management 244
posterior end of right 2nd rib and left 6th rib 242f
Multisystemic involving lungs 191
Multisystemic presentations 156
Multivitamine tablet 309
Myalgia 261
Myasthenia gravis 386
Mycobacterial growth indicator tube 240
Mycobacterial protein 215
Mycobacterium intracellulare 247
Mycobacterium tuberculosis 34, 92, 208, 211, 238, 240, 376
Mycolic acids 34
Mycoplasma pneumoniae 296
Myocardial pain 3
cavity 7
polyp 7
speculum 7
Nasogastric tube suction 59
National Tuberculosis Control Program 79
Nebulized bronchodilator 113, 135
Necrotizing pneumonia 217, 218, 319
Neucleotide reverse transcriptase inhibitors 155
Neuroendocrine tumors 373
Neutralize acidosis 130
Neutralize gastroesophageal reflux 173
Neutrophil 137
Neutrophilic leukocytosis 103, 237, 270
Nevirapine 155, 256
Nintedanib 173
Nintedanib inhibits tyrosine kinases 173
Nitrofurantoin 171
Nocardia infection 209
Nocardiosis 218
Nodular opacities 43, 363
case report 43
dense nodules of alveolar microlithiasis 45f
discussion 43
ill-defined parahilar opacities 44f
lung opacities with relatively lucent heart 45f
management 46
Nodules behaving differently 391
case report 391
CT-brain, multiple metastases 396f
discussion 392, 394, 395, 397
FNAC from right upper lobe mass 397f
large heterogeneous mass in right upper lobe 393
management 395
multiple cannon ball opacities 392
multiple contrast-enhanced masses of different sizes 393f
persistence of right upper lobe tumor 395f
testicular tumor 397f
Non-invasive ventilation 89, 120
Nonnucleoside reverse transcriptase inhibitors 155
Nonresolving pneumonia 338
Non-responding dyspnea 87
case report 87
disappearance of round tumor 90
discussion 87, 88
management 90
round opacity in right mid-zone 89f
Non-small cell lung cancer 332
Nonspecific interstitial pneumonia 167, 177
Nontender lymph nodes 276
Normal alveolar-arterial oxygen 146
Nortriptyline 340
Nose and sinuses 7
Nuclear-cytoplasmic ratio 29
Nucleolar pattern 206
Obese lady with metabolic syndrome 140
case report 140
discussion 140, 143
management 143
right lower zone homogenous opacity 141f
Obstructive airway diseases 87
Obstructive lung disease 96
Obstructive sleep apnea 143
Old man with suspected lung cancer 323
Old man with suspected lung cancer
aortic indentation over esophagus 325f
case report 323
discussion 324, 325
management 324
right paratracheal opacity 324f
Omazulimab 134
Omeprazole 172
Oncogenes 398
Opaque left hemithorax 384
case report 384
discussion 385, 386, 387
large homogeneous mass 387f
lymphoid cells suggestive of thymoma 387f
management 386
shifting of mediastinum to right 385f
Oral cavity 8
Orchiectomy 335
Ornidazole 273
Oropharyngeal secretions 317
Osteomyelitis 352
Osteomyelitis of distal phalanges 165
Osteosarcoma 6, 37
Oval pleomorphic 396
Overt clue 28
Paclitaxel 367
Palliative radiotherapy 343
Pallor 7, 368
Panbronchiolitis 115
Pancoast syndrome 366
Pancoast tumor 366, 367
Pancreatitis 1, 261
Pancytopenia 162
Pantoprazol 309
Paracetamol 159, 217, 281, 309, 313, 320321
Paradoxical movement 14
Paraneoplastic syndrome 133
Parapneumonic effusion 217, 267, 279
Paraseptal emphysema 101
Parasitic cysts 290
adenoma 383
mass 53
Parenteral anticoagulant 235
pericardium 367
pleura 42
Parieto-occipital region 395
Paroxysmal nocturnal dyspnea 91
Partial eventration 196
Peak expiratory flow rate 134
Peak inspiratory pressure 150
Pectus excavatum 16
Pedal edema 4, 368
Pegion shaped 106
Penetrating chest trauma 59
Penicillamine 204
Peptidoglycan layer 34
Percussion 18
hydropneumothorax 20
in Kronig's isthmus 19
liver dullness 19
of back 19
through midaxillary line 19
traube's space 19
Periadenitis 6
interstitial space 89
noncaseating granulomas 182
Peribronchovascular 50
predominance 170
cyst 383
effusion 19, 35
invasion 386
involvements 179
pain 85
Pericarditis 206
Pericardium 3, 16, 85, 229
Perilymphatic 363
Perilymphatic and random 182
Peripheral blood examination 109
Peripheral cyanosis 7
Peripheral lung opacities 195
bilateral peripheral opacities 196f
bilateral peripheral patchy consolidations 197f
case report 195
discussion 196, 197
management 198
Peripheral lymph nodes 6
Peripheral lymphadenopathy 261, 267
Peripheral vascular opacities 390
Persistent cough in
rheumatoid arthritis 202
case report 202
discussion 203
management 205
mosaic attenuation 204f
bilateral nonspecific opacities 200f
case report 199
cystic spaces 201f
discussion 199, 201
management 202
Persisting cavity despite treatment 245
case report 245
discussion 246, 248
management 248
thin-walled cavity in right midzone 246f
Phagolysosomes 34
Phagosomes 34
Phantom tumor 90
Photodynamic therapy 375
Physiochemical regulation 391
Pinpricking 187
Piperacillin-tazobactam 129, 140, 264
Pirfenidone 173
Planning invasive investigation 261
Plateau pressure 125
diseases 257
effusion 73f, 310
fibrosis 41, 276
fluid examination 257
fluid favored malignancy 254
fluid glucose 162
plaque 42
rub 23
Pleuritic chest pain 261
Pleuritis 206
Pleuropericardial cyst 53, 63
Pleuropneumonectomy 238
Pleuropulmonary amebiasis 272
Pleuro–pulmonary blastoma 290
Pleuropulmonary disease 253
case report 253
discussion 254, 255, 256
left-sided pleural effusion 255f
management 256
Pneumatocele 300f, 301
Pneumococcal pneumonia 3, 29, 296
Pneumocystis jirovecii 154155
Pneumocystis pneumonia 152, 154
Pneumocystis cysts 154
Pneumonia management of
antibiotics for outpatient treatment 297
duration of therapy 298
in patient admitted in ICU ward 298
in patient admitted in non- ICU ward 298
outcome of treatment 298
Pneumonia severity index 294
Pneumothorax with reticulonodular opacities 68
bilateral reticulonodular opacities 69f
case report 68
discussion 69, 70
eggshell calcification in right hilum 71
management 71
Polycythemia 7, 98, 118, 341342
Polygonal lines 363
Polymorphonuclear leukocytes 162, 182
Polymyositis 185
Polyphonic wheezing 22
Polyserositis 162
Polysomnography 143
Popliteal 6
Porphyromonas 319
Post-cardiopulmonary bypass 149
Postobstructive pneumonia 291
Post-tussive crepitation 67
Potential pathogenic microorganisms 103
Praziquantel 65
Precordium 16
Precordium intermittently 344
Prednisolone 159, 162, 174, 202, 379
Prevotella 319
Profuse micronodules 170
Profuse serous expectoration 326
Progressing pneumonia 216
case report 216
consolidation in posterior segment 218f
consolidation right midzone 216f
deteriorating radiological opacities 217f
discussion 217, 218
management 219
Progressive dyspnea 179
Progressive massive fibrosis 71, 209
Prophylactic cotrimoxazole 256
Proteinuria 206
Prothrombin 233
Proton pump inhibitors 52
Proximal extent 338
Proximal intraluminal growth 262
Pseudomonas aeruginosa 264, 265, 266, 296
Pseudotumor 214
Ptosis 366
Puerperal fever 219
case report 219
discussion 220, 221
management 221
superior mediastinal widening with patchy opacities 220f
Pulmonary arterial hypertension 167, 389
Pulmonary capillary wedge pressure 149
Pulmonary edema 152, 153
Pulmonary infarct 36
Pulmonary Langerhan's cell histiocytosis 171, 191, 200201
Pulmonary lymphangioleiomyomatosis 193
Pulmonary neoplasms 373
Pulmonary thromboembolism 2, 28, 73, 118, 232
Pulmonary thromboendarterectomy 235
Pulmonary toxicity 375
Pulsation 14
Pulse 6
Pure intrathoracic lymphoma 261
Pure red cell aplasia 386
Purpuric spot 13
Purse-lip breathing 14
Pyloric obstruction 341
Pyogenic cavities 318
Pyogenic empyema 281
Pyogenic infection 260, 318, 342
Pyogenic liver abscesses 214
Pyogenic respiratory infection 4
Pyrazinamide 305
Quantitative bacterial cultures 296
Quantitative-culture approach 147
Quinacrine 157
Radiation-induced lung diseases 171
Radiolucent 287
Radiolucent area 321
Radiolucent left hemithorax 60
Rare cause of shock 62
case report 62
discussion 63, 65
empty cyst at right cardiophrenic angle 62f
filled up cyst at right cardiophrenic angle 65f
Rasmussen's aneurysm 47
Raynaud's phenomenon 165, 167, 168
Recurrent hemoptysis 371
case report 371
complete clearance of opacities 374f
discussion 372, 373, 375
heterogeneous opacities in left lower lung field 372f
management 374
opacity in left hilum 373f
Recurrent pneumothorax 192
bilateral lower zone opacities 194f
bilateral thin-walled round cysts 194f
case report 192
discussion 193
management 195
Recurrent right paratracheal lymphadenopathy 249
case report 249
discussion 249, 251, 252
large partly necrotic lesion 252f
management 251
paratracheal mass with areas of low attenuation 250f
paratracheal opacity 252f
right paratracheal opacity 250
Relaxation collapse 332
Respiration 11
respiratory depth 11
respiratory rate 11
special character 11
types of respiration 11
alkalosis 145, 232
bronchiolitis 200, 201, 204
diseases 33
disorder 125
fluoroquinolone 297
problems in intensive care unit 117
system clinical approach 1
system different patterns of breathing 12
system examination of 7, 25
gastrointestinal 25
genital system 25
lower respiratory system 8
lymphoreticular 25
nervous system 25
upper respiratory tract 7
system general survey 5
system history taking 1
chief complaints 2
family history 5
history of present illness 2
past history 5
personal history 5
opacities 169
pattern 182
chest pain 330
extension 371
goiter 220, 221, 382
thyroid 371
Revised National Tuberculosis Control Program 219, 230
Revisiting a diagnosed case 205
bilateral nodular opacities 207f
case report 205
centrilobular in distribution 207f
conglomerated opacity 208f
discussion 205, 206, 208, 209
management 209
arthritis 161, 171, 202
pleural effusion 29
pleuritis 254
Rheumatologic symptoms 307
Rhinophyma 7
Rhodamine stain 224
Rhonchi 22, 89
Rhonchus 22
Rifampicin 305
Right costophrenic angle 300
Right hilar lymphadenopathy 344
Right lower lobe lung abscess 316
bodyache 316
case report 316
discussion 316, 317, 319
large thick-walled cavity 318f
management 320
Right midclavicular line 354
Right-sided loculated empyema 269
case report 269
discussion 270, 272, 273
management 273
reddish-brown fluid 271f
right-sided multiloculated hydropneumothorax 271
subphrenic abscess 270
Rigid bronchoscope 222
Rupture hydatic cyst 63
Rupture of caseous materials 247
Salbutamol 135, 174, 255
Salbutamol inhalation 99
Salmeterol 113
Salmeterol-fluticonazole inhaler 357
Sarcoid granulomas 215
Sarcoidosis 7, 25, 50, 51, 171, 210, 221
treatment of 51
with pleural effusion 209
bilateral hilar lymphadenopathy 210f
case report 209
discussion 209, 212, 214
large liver abscess 214f
management 213
Satellite lesions with tree in bud pattern 218
Scaleni group of muscles 14
Scanty mucoid expectoration 187, 384
Sclerodactyly 165
Sclerosis of finger 165
Scolices 312
Scolicidal agent 292
Scoliosis 15
Segmental collapse 373
Segmentectomy 65
Seminoma 335, 383, 394
Serositis 157
Serum alkaline phosphatase level 214
Serum angiotensin-converting enzyme 50
Severe pulmonary arterial hypertension 142
Severe sepsis 138
Shifting dullness 20
Shock with pleural effusion 72
case report 72
discussion 73, 74
management 75
MRI-angiogram 74f
right sided massive pleural effusion 72f
Sigh breathing 12t
Sign of
air crescent 77
airway obstruction 103
cor pulmonale 99
d'Espine 23
dyspnea 14, 268, 282, 285
empty pericyst 64
Grave 234
Hallo 224
Hamman's 24
hemorrhage 25
Homans’ 232
Hoover's 15
hyperinflated lung 103
inflammation 8
Knuckle sign 15
long-standing pain 46
case report 46
discussion 47
final diagnosis 48
management 48
pellets inside and outside lungs apart 47f
McConnell's sign 232
metastasis 25, 39
Mimicking hydropneumothorax 58
Palla's sign 233
pleural fibrosis 67
reverse d'Espine 23
Scratch sign 24
Signet-ring sign 106
Silhouette 318
thoracic operation 13
thorax in respiratory pathology/diseases 9t
Tripod sign 15
underlying lung collapse 275
Westermark's sign 233
Sildenafil citrate 168
Silicosis 70
Silicotuberculosis 209
Simple case suddenly got astonishing attention
case report 105
dextrocardia 107
discussion 106, 108
management 108
Simple parapneumonic effusion 281
Sjögren syndrome 202, 204
Small cell lung cancer 373
Small thoracotomy 176
Small-cell neuroendocarcinoma 373
Solitary calvarial lesion 191
Specular 206
Spider telangiectasia 13
Spirometry 35
Splenomegaly 19, 270
Splenomegly 25
Spontaneous breathing trial 125
Spontaneous pneumothoraxes 193
Sputum examination 331
Squamous cell carcinoma 251, 268, 337
Squamous epithelial cells 296
Staphylococcus aureus 147, 188, 284, 296, 301
Staphylococcus infection 100
Stereotactic body radiation therapy 339
Sternal tenderness 25
Sternomastoids 14
Stidor 24
Stone-blusting industry 207
Streptococcus pneumoniae 155, 265, 296, 313, 337
Subcostal angle 18
crepitation 24
lesions 13
Subphrenic abscess 321, 323
Subpleural areas 363
Subsegmental bronchi 277
Substernal thyroid tumors 386
Subtrochanteric fracture 133
Succusion splash 23, 55
Sudden onset respiratory distress 81
case report 81
discussion 82
foreign body in right intermediate bronchus 83f
management 83
Superinfections 264
Superior mediastinal
opacity 221
widening 220
Superior vena cava syndrome 367
case report 367
discussion 368, 371
management 371
mass taking radioactive iodine 370f
mediastinal widening 369f
round mass pushing trachea 370f
Superior vena caval obstruction 368
Supraclavicular 14
angle 16
suction 6
Swine flu 29
Swyer–James syndrome 290
Syndrome of 15
acquired immunodeficiency 5
acute respiratory distress 146, 148, 228
anterior mediastinal 25
antiphospholipid antibody 232
bronchogenic 25
carcinoid 374
Churg-Strauss 88, 93, 187, 197, 198
clinic-pathological 186
dyskinetic cilia 108
dysmotile cilia 107, 108
endocrine paraneoplastic 133
gastroesophageal reflux 199
Goodpasture 158, 200
Guillain-Barré 144146
hepatopulmonary 151
Horner's 365, 366
hypereosinophilic 197, 198
immotile cilia 108
immune reconstruction 256
Kartagener 108
Loffler 187, 197, 198
Macleod's 81, 288, 290
Mendelson's 371
metabolic 97, 140143
Miller-Fisher 144
mineralocorticoid excess 131, 133
multiorgan dysfunction 139
obese lady with metabolic 140
open negative 247
Pancoast's 366
paraneoplastic 25, 133
pulmonary infiltrates with eosinophilia 197
Rendu-Osler-Weber 75
Sjögren 202, 204
superior vena cava (SVC) 4, 6, 307, 349, 353, 367, 371, 392, 395
Swyer–James 290
systemic inflammatory response 138
Tietz's 15, 52
upper airway cough 88, 93, 199, 291
Young 108
Systemic lupus erythematosus 205
Systemic spillage of inflammatory cytokines 356
Tachyarrhythmias 63
Tachycardia 118
Tachypnea 12
Tachypnea 6, 11, 139
Tazobactam 147
TB bacilli 34
Telangiectasia 165
Telmisartan 315, 341
Tenofovir 155, 256
Tension pneumothorax 288
Teratoma 53, 371, 383
Terrible lymphoma 53
Tertiary syphilis 210
Testicular tumor 335, 394
Theophylline 335
Thermophilic bacteria 182
Thoracentesis 59
malignancy 330
movement 15
sequel of past SIN 278
sequel of past SIN
bronchiectasis 281
case report 278
discussion 279, 280, 281
homogeneous opacity in right mid and lower zones 278
lung abscess 281
management 280
opacity with air-fluid level posteriorly 280f
Thoracoabdominal 11
Thoracotomy 371
Thrombocytopenia 206
Thrombophilia 232
cysts 386
hyperplasia 386
mass 220
Thymoma 53, 386388
abation therapy 371
hormone 371
tissues 371
Tidal percussion 19, 354
Tinidazole 273
Tiny nodular opacities 226
Tissue hypoxia 130
Tissue plasminogen activator 235
Tissue-binding autoantibodies 156
T lymphocytes 34
Tobramycin 147
Topoisomerase antibody 166
Tortuous vessels 53
Toxemia 225, 299
case report 225, 299
discussion 226, 228, 229
management 229
miliary nodules with few areas of conglomerated lesions 227f
miliary opacities 227f
right hilar prominence with ill-defined 226f
Toxic granules 299
movement 16
position 16
tug 16
Tracheostomy tube 121
Traction bronchiectasis 176
Tramadol 347
Tranexamic acid 110
Transbonchial lung biopsy 202
Transbronchial 176
fine needle aspiration 304
lung biopsies 228
lung biopsy reports 50
Transdiaphragmatic 63
Transforming growth factor 173
Transient ischemic attack 63
Transthoracic core needle biopsy 37
Trapezii 14
Traube's space 19, 28, 257, 341, 354, 355, 385
Trendelenburg position 78
Triangular opacity behind heart 326
case report 326
discussion 326, 327, 328
management 328
triangular opacity behind the heart 327f
Tricuspid regurgitation 161
Trilobed left lung 259
Trimethoprim-sulfamethoxazole 155
Triotropium bromide 113
Trophoblastic tissue 394
Troponine t test 235
Tube thoracostomy 263
Tubercle bacilli sensitive 251
liver abscess 214
lymph nodes 6
pleural effusion 42
pleural management 43
Tuberculine test 35
Tuberculoma 214
Tuberculosis 2, 216
drugs 92
drugs classified 241
treatment 79
with sudden onset of dyspnea 78
bilateral nodular lesion 80f
case report 78
discussion 79, 80, 81
management 81
pleural effusion 254
Tubular 21
doubling time 36
node-metastasis 39
suppressor gene 398
Tympanitic note 18
Typical lobar pneumonia 294
air-bronchogram in apical segment of left lower lobe 295f
assessment of severity 294
case report 294
discussion 296, 297
examination 294
homogeneous opacity in left lower and mid zone 295f
investigation 295
management 297
Ulnar surface 17
Uncommon prevascular tumors 383
Unfractionated heparin 235
Unilateral pleuroparenchymal disease 376
case report 376
discussion 376, 378, 379, 380
lung window of CT-thorax 377f
management 379
mediastinal window of CECT-thorax 378f
Unresolved pneumonia 301
approach to nonresponding 303
case report 301
chest radiology 304
clinical manifestation 307
diagnosis 308
discussion 302, 306
examination 301
final outcome 308
invasive procedures 305
investigation 301
management 308
progressive disseminated histoplasmosis 308
progressive pneumonia 303
right paratracheal and subcarinal lymphadenopathy 305
right-sided pleural effusion with right paratracheal opacity 305
treatment 302
Unresponsive COPD 95
case report 95
discussion 96, 97
management 97
Unusual associate disease in COPD 119
case report 119
discussion 120, 123
management 123
tracheal tumor obstructing tracheal lumen 122
Upper abdominal pain 33
Upper airway cough syndrome 88, 291
Upper lobe cavity 339
case report 339
discussion 340, 341, 343
heterogeneous opacity in left upper zone 340f
management 343
thick walled cavity 342f
Upper respiratory tract 147
Uremia 11
Urticarial rash 64
Usual interstitial pneumonia 27, 167, 172
Vancomycin 146, 147, 315
Varenicline 340
anomalies 13
marking 81
Vasoactive mediators 232
Venous flow direction of 13
Ventilated patient with opaque left hemithorax 126
case report 126
collapse of left lung and endotracheal tube 128f
discussion 127
management 129
Ventilator associated pneumonia 126, 146
Ventilator-associated lung injury 149
Venturi mask 124
Vesicular with prolong expiration 21
Vietnam 29
Vinblastin 192
Vincristine 375, 379, 380
Viral infections 29
Visceral pleural invasion 338
Vivax malaria 30
Vocal cord dysfunction 88
Vocal fremitus 17
Warfarin sodium 233
Wegener's granulomatosis 7, 78, 158
Weight loss 4
Wheeze 4, 169
Whispered pectoriloquy 21
Wright-Giemsa stains 154
XDR tuberculosis 239, 256, 298
Xpert gene TB 251
Young asthmatic with deteriorating ABG
bilateral intercostal tube drainage 136f
case report 134
discussion 134, 135, 137
management 136
subcutaneous emphysema 136f
Young man had a road traffic accident 59
case report 59
discussion 59, 60
management 61
stomach in thorax 61f
tip of nasogastric tube 60
Young man with non-responsive TB 239
case report 239
discussion 239, 241
final diagnosis 241
management 241
Zidovudine 155, 256
Ziehl-Neelsen (ZN) stain 185, 219, 225, 239, 296
Chapter Notes

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Clinical Approach to Respiratory SystemCHAPTER 1

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 demands2 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.
Chief Complaints
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 general3 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) provoking4 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, lung5 cancer, acquired immunodeficiency syndrome (AIDS), anorexia and anxiety. Weight loss with normal or increased appetite may be found in diabetes mellitus or hypothyroidism.
Past History
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
Personal history should include the following things:
  1. 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.
  2. Other addiction including alcohol, intravenous drugs, chewing tobacco
  3. Marital history including offspring
  4. Menstrual history
  5. Present or previous occupation
  6. Socioeconomic history
  7. Exposure history and lifestyle
  8. Habits, travels, pets, etc.
Family History
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.6
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.7
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 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 bleeding8 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.9
Table 1   Table showing physical signs of thorax in respiratory pathology/diseases
Trachea apical impulse
Breath sound
Vocal resonance
Added sound
Special feature
Pleural effusion
Decreased same side
Shifted contra-laterally
Stony dull
Absent or diminished
Absent or diminished
Nil or pleural rub
Fullness of hemithorax
Decreased same side
Shifted contra-laterally
Fullness of hemithorax
Hydropneumo thorax
Decreased same side
Shifted contra-laterally
Horizontal fluid level and shifting dullness
Succussion splash
Pleural fibrosis
Decreased same side
Shifting ipsi-laterally
Thoracic deformity
Decreased over that area
No shift
Bronchial (Tubular)
Whispered pectoriloquy
Fever, toxicity
Absorption Collapse
Decreased same side
Shifting ipsi-laterally
Absent/Transmitted sound
Finding of lung cancer
Pulmonary fibrosis
Decreased same side
Shifting ipsi-laterally
Normal/ bronchial /cavernous
Flattening of chest wall
Usually no shift
Normal/crack pot resonance
Cavernous / normal
Coarse crackles
Post-tussive suction
Normal or decreased
No/same side shifting
Normal/ impaired
Vesicular /prolong expiration
Coarse crackles
Decreased bilaterally
No shift
Normal/ hyper-resonance
Diminished vesicular with prolonged expiration
Polyphonic rhonchi/ random monophonic rhonchi
Normal to sign of hyper-inflation
Decreased bilaterally
No shift
Hyperresonance and obliteration of dullnesses
Diminished vesicular with prolonged expiration
Polyphonic rhonchi
Accessory muscles working
Chronic bronchitis
No shift
Diminished vesicular prolong expiration
Polyphonic rhonchi, few early crepitation
Signs of right ventricular enlargement
Interstitial lung diseases
Reduced chest expansion
No shift
Normal vesicular/may be decreased
End inspiratory crackles mainly basal
Manifestations of etiological conditions
Space occupying lesion in lung
No/contra-lateral shifting
Normal/ impaired/dull
Normal/ diminished/ absent
Normal/ diminished/ absent
Manifestations of lung malignancy
  • 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.12
      Table 2   Different patterns of breathing
      Pictorial presentation
      Normal (Eupnea)
      Regular and comfortable at the rate of 12–20/min
      Increased respiratory rate >20/min
      Fever, anxiety, exercise, shock, etc.
      Decreased respiratory rate <12/min
      Sleep, drugs, head injury, stroke, metabolic disorders, etc.
      Absence of breathing
      Depression of respiratory center by drugs, head injury, stoke, etc. and sleep apnea
      Hyperpnea (hyperventilation)
      Increased rate (>12/min) and depth of breathing
      Anxiety and stress, metabolic acidosis, hypoxia of any cause
      Cheyne-Stokes breathing
      Gradual increase and decrease of respiration with period of apnea
      Increased intracranial pressure, brainstem injury, congestive cardiac failure
      Biots breathing
      Irregularly interspersed period of apnea in a disorganized sequences of various breathing
      Spinal meningitis, head injury, impending respiratory arrest
      Sigh breathing
      Frequently interspersed deeper breathing
      Stressful condition, excessive frequent sighing means person is hyperventilating
      Kussmaul's breathing
      Rapid, deep and labored breathing
      Metabolic acidosis like renal failure, diabetic ketoacidosis
      Air trapping (obstructed breathing)
      Increasing difficulty in getting breath out
      Chronic 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.13
    • 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.14
    • 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:
    • Shoulder: Position of shoulder should be looked from the back, whether they are at same level or there is asymmetry. Dropping of shoulder when one shoulder is at a lower level than other is a sign of volume loss or thoracic deformity.15
    • 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.16
    • 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 infraclavicular areas is done in supine position, head resting on pillow, head and trunk in straight line, shoulder are17 relaxed and in symmetric position and see the movement tangentially. Movement can also be palpated but that is less effective. Some physically avoid that maneuver.
    • 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.
  • Measurements:
    • Anteroposterior diameter and transverse diameter: They are measure by placing cardboards and measuring the maximum diameters. Normal18 chest is elliptical with ratio between anteroposterior and transverse diameters 5:7.
    • 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 midclavicular line: Midclavicular line is a vertical line from midpoint between middle of sternal notch and acromian process.19 Percussion along midclavicular lines is done in patient lying in supine and symmetrical position or patient in sitting position.
  • 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 negative20 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.
      • Normal vesicular: The breath sound heard over normal lungs.21
      • 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.
      • Whispered pectoriloquy: When whispered sound is audible distinctly without any alteration and individual syllables can be clearly recognized. It is found over consolidation.22
  • 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:
      • 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.
      Rhonchi/wheeze is now classified as:
      • 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.
      • 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.
      • Coarse crackles are heard on early inspiration and throughout expiration, affected by cough and transmitted to mouth. It is caused by bubbling of air through secretions. It is found in bronchiectasis, chronic bronchitis, fibrosis and cavities.23
      The timing of crackles is also important and accordingly crackles are classified as:
      • 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.24
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%.25
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.