Clinical Examination in Respiratory Disorders

Cough with or without expectoration, chest pain, dyspnea and hemoptysis are the most frequent respiratory symptoms. Cough with expectoration is a prominent symptom in inflammatory lesions such as bronchitis and pneumonia or in irritative and allergic lesions of the respiratory tract. Pharyngitis, laryngitis, tracheitis and early stages of bronchitis give rise to cough without expectoration. In some infections like Bordetella pertussis and Klebsiella, paroxysms of cough are followed by a long inspiratory whoop caused by laryngeal spasm. Cough elicited by change of posture (Postural Cough) is characteristic of bronchiectasis, lung abscess, and bronchopleural fistula, “Bovine Cough” or “gander Cough” is the term used to denote cough devoid of its explosive (tussive) phase. This occurs in bilateral adductor paralysis of the vocal cords. In asthma cough and dyspnea tend to recur regularly at night. In left sided heart failure with pulmonary edema, cough occurs in the recumbent posture. Development of a sudden and uncontrollable paroxysm of cough in an otherwise healthy person should suggest the possibility of an aspirated foreign body.

Cough is generally a protective reflex designed to keep the airway patent and clear the exudates. Sometimes irritant cough becomes troublesome, interfering with sleep and causing severe annoyance to the patient. Other unto-wards effects of cough include syncope (cough syncope), penumothorax, mediastinal and surgical emphysema and rib fractures (cough fracture). In children paroxysmal cough may lead to sub-conjuctival hemorrhage.

Sputum
The material expectorated from the respiratory tract is called sputum. In healthy individuals the secretion of the respiratory passages is less than 100ml in 24 hours. And this is just adequate to provide a protective lining, and there is no expectoration. Expectoration in excess of 10-25 ml of sputum in 24 hours, should raise the possibility of disease. Copious amounts in excess of 300 ml are seen in bronchiectasis and lung abscess. Character of the sputum often suggests the underlying pathology. Sputum is serosanguinous in pulmonary edema, mucoid and sticky in asthma and chronic bronchitis, thick and purulent in bronchiectasis and lung abscess, creamy yellow in pulmonary tuberculosis, blood stained in carcinoma, tuberculosis, bronchiectasis, mitrial stenosis and pulmonary infarction, rusty in pneumonia and black in coal worker’s pneumoconiosis. Foul smelling sputum is suggestive of bronchiectasis, lung abscess or gangrene of the lung.

Presence of blood in the sputum is termed “hemoptysis”. In true hemoptysis blood is derived from the airways or the lungs. The quantity of blood may be small as in mitral stenosis or massive as in cavitary pulmonary tuberculosis or neoplasm. Sometimes blood is derived from the upper respiratory passages or mouth and this is termed “spurious hemoptysis”. Hemoptysis is a manifestation of serious underlysing disease warranting full investigation. Though rare, massive hemoptysis results in considerable loss of blood demanding emergency management in non-respiratory hypertension occurring in mitral stenosis, acute pulmonary edema, pulmonary infarction, trauma and hemorrhagic diseases. Rarely massive and fatal hemoptysis may develop when an aortic aneurysm erodes into the trachea or a bronchus. Spurious hemoptysis is commonly resorted to by hysterical individuals to attract medical attention.

management of hemoptysis:
The patient should be hospitalized as an emergency and a rapid clinical examination is done to determine the cause. It is important to avoid percussion, which may worsen the hemoptysis. The patient is put to bed and sedated with diazepam 10mg administered intramuscularly. Respiratory depressants such as morphine should be avoided since they impair expectoration. Blood loss and its effects are assessed by monitoring the volume of blood expectorated and the pulse, respiration and blood pressure. If the blood loss exceeds 200-300ml in 24 hours and it is persistent, blood transfusion is indicated.

In the majority of cases the underlying cause can be made out by clinical examination and chest radiography. Specific treatment is instituted early (e.g antituberculosis drugs in abscess, etc) in conditions where such treatment is available, majority of cases subside with rest, sedation, and blood transfusion. In conditions like pulmonary neoplasms, bleeding tends to persist, In such cases emergency bronchoscopy is done to locate the lesion and bleeding is located and the opposite lung is normal, induction of collapse by artificial pneumothorax serves to arrest bleeding promptly.

Digital clubbing (Hippocratic fingers)
This is caused by increase in the volume of soft tissue in and around the distal phalanges of the fingers and toes, especially the nail beds. This leads to increased curvature of the nails. Severity of clubbing varies and this has been graded for clinical purposes.
Grade 1: Fluctuation of the nail can be elicited on the nail bed.
Grade 2: The normal angle between the nail and nail bed is lost.
Grade 3: The terminal portion of the phalanx and nail appears as a drumstick or a parrot beak.
Grade 4: In addition to digital clubbing, other regions show pulmonary osteo-arthropathy.

Causes
• Respiratory diseases- suppurative lesions like bronchiectasis, lung abscess, emphysema, and infected cysts; advanced tuberculosis with bronchiectatic changes, bronchoganic carcinoma, pneumoconiosis, fobrosing alveolitis, and pleural fibroma.
• Cardiovascular disorders- Cyanotic congenital heart diseases and infective endocarditis.
• Alimentary disorders- Malabsorption states, ulcerative colitis, cirrhosis of the liver, hepatomas and amoebic live abscess.
• Miscellaneous groups- Clubbing may develop in thyroxicosis. At times it may occur nonpathologically in several members of a family (familial clubbing). Repeated trauma to the finger tips as occurring in carpenters and blacksmiths leads to occupational clubbing.

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