1. MEDICAL SEMEIOTICS: DISEASES OF THE LUNGS
Antonio Abbate, MD,PhD

2. INTRODUCTION TO SEMEIOTICS
DISEASES OF THE LUNGS
Common symptoms
Hypoxia
Cough
Stridor and Wheezing
Dyspnea
Crackles and ronchi
Chest pain
Deformities and asymmetry
Common physical signs
Breve intro
INTRODUCTION TO SEMEIOTICS
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3. COUGH: A main indicator of airway disease
COUGH – A coordinated (involuntary or voluntary) series of events leading to explosive expiration for clearance of particles from the airway
It is about irritation (somewhere in airway, respiratory mechanics, or CNS)
It can be productive of sputum in which case it indicates inflammation  a green/brown sputum  infection (bacterial), yellow  inflammation/infection (viral); bloody (hemoptysis)  severe infection (i.e. TB) or cancer or trauma or vasculitis; whereas non-productive cough  inflammation/infection viral, but also other things GERD, compression/invasion by tumor/cancer, but also pulmonary congestion
Acute (<1 week) cough  infection; chronic (>4 weeks)  less likely infectious
Sax
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4. DYSPNEA from RESPIRATORY DISEASE
Dyspnea refers to an uncomfortable feeling associated with breathing.
Is dyspnea is a symptom? sign? or syndrome?
Triggers for dyspnea:
Mechanical
 effort
Compression
Chemical
CO2 pH O2
Central (CNS)
Dyspnea is different from:
Tachypnea
Sign, breathing fast
Hypoxia
Sign, low O2sat
Apnea
Sign, pauses in breaths
Antonio
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5. DYSPNEA from respiratory causes
Characteristics of respiratory dyspnea:
Generally gradual onset, often chronic
Exertional dyspnea (similar to cardiac)
Associated symptoms
Cough (very very common)
Fever (if infection)
Altered mental status (if hypoxia or acidosis)
Associated signs
Exam is rarely normal
Tachypnea
Stridor, wheezing, ronchi
Crackles
Abnormal expansion
Acute respiratory dyspnea:
Asthma attack
Pneumothorax
Pulmonary embolism
Laryngospasm
Antonio
INTRODUCTION TO SEMEIOTICS
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6. DYSPNEA from cardiac causes
Characteristics of cardiac dyspnea:
Exertional dyspnea
Orthopnea, nocturnal cough
Paroxysmal nocturnal dyspnea
Associated symptoms
Angina
Fatigue
Associated signs
Exam can be normal at rest
Edema
JVD
Rales (diffuse end-expiratory wet crackles)
Antonio
INTRODUCTION TO SEMEIOTICS
Date

7. COUGH: A main indicator of airway disease
COUGH – A coordinated (involuntary or voluntary) series of events leading to explosive expiration for clearance of particles from the airway
It is about irritation (somewhere in airway, respiratory mechanics, or CNS)
It can be productive of sputum in which case it indicates inflammation  a green/brown sputum  infection (bacterial), yellow  inflammation/infection (viral); bloody (hemoptysis)  severe infection (i.e. TB) or cancer or trauma or vasculitis; whereas non-productive cough  inflammation/infection viral, but also other things GERD, compression/invasion by tumor/cancer, but also pulmonary congestion
Acute (<1 week) cough  infection; chronic (>4 weeks)  less likely infectious
Sax
INTRODUCTION TO SEMEIOTICS
Date

8. CHEST PAIN from respiratory causes
Pain derives mostly from PLEURAL IRRITATION/INFLAMMATION
Characteristics of pleuritic pain:
Sharp, acute
Worse with respirations
Positional
Associated symptoms
Cough (very common)
Dyspnea (common)
Fever (sometimes)
Associated signs
Tachypnea
Changes at percussion
Pleural rub
Causes of pleuritic pain:
Pneumonia
Pleurisy or pleuritis
Pneumothorax
Pulmonary embolism
Antonio
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9. ANGINA PECTORIS
Angina pectoris refers to chest pain that derives from an imbalance in oxygen demand and supply to the myocardium
Chest Pain (squeezing, crushing, tightness)
Central, radiated to the L arm
Brought by exertion, relieved by rest
Lasts minutes
Worse after a meal, or cold exposure
Associated symptoms (dyspnea, fatigue, nausea/vomiting, dizziness)
More common in males >50 yrs of age
Associated with tobacco use
 SUPPLY
 DEMAND
Antonio
Oxygen
Causes of
increased demand:
exertion, fever,
pressure overload
tachyarrhythmia
Causes of
impaired supply:
coronary artery disease,
aortic stenosis,
severe comorbidities
(such as hypoxia anemia,
hypotension)
Myocardial
hypoxia
Adenosine
Receptors
 Pain
ATPADPAMP
Adenosine
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10. RESPIRATORY PHYSICAL EXAM
The respiratory physical exam, like any exam, starts with a general examination and an analysis of the vital signs.
Alterd mental status  poor prognosis, hypoventilation (high CO2?)
Distress or lack thereof -- Position and gait  if a patient is sitting laying forward will indicate a different process that one in which he/she is sitting comforably, i.e. in the first case he may be dyspneic and trying to max expand the lun
Hypotension  poor prognosis --- Tachycardia  indicated a state of enhanced sympathetic drive
Hypoxemia  poor prognosis and suggests either that:
large area of lungs affected (bilateral pneumonia, edema)
hypoventilation (CNS, trapping, bronchospasm, PNX, mucus)
AV shunt (pulmonary embolism, trauma)
Fever or hypothermia  suggest infection
Pain may indicated the underlying problem
Sax
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11. RESPIRATORY PHYSICAL EXAM
At difference of the heart, for the lungs, each of 4 steps of the physical exam is essential – because the chest wall is clearly visible and the lungs are full of air, ready to be percussed.
Observation – notice size, dimensions, symmetry, deformities of the chest wall, use of accessory muscles [neck/abdomen], retractions in inspirations, cyanosis/pallor  “pink puffer and blue bloater”
Palpation – notice discontinuation of the chest wall, position of the trachea, movement/expansion of the apex and base bilat
Antonio
Percussion – Very important to differentiate between different disease processes. The lung when percussed emit a characteristic resonant sound as they are made by >99% of air. Lack of resonance indicates abnormal consolidation.
INTRODUCTION TO SEMEIOTICS

12. RESPIRATORY PHYSICAL EXAM
Auscultation is however where the money is!!!
Auscultation – the sound(s) of the air movement as it expands the lung parenchyma are characteristics of the different conditions.
At the base of the lungs – Normal Vescicular Sounds
On the trachea  Normal Tracheal Sound
Abnormal sounds
Stridor –a high-pitched inspiratory breath sound resulting from turbulent air flow in the upper respiratory airways  indicates obstruction
Wheezing - high-pitched expiratory breath sounds resulting from turbulent air flow in the lower respiratory airways  indicates bronchial obstruction, usually diffuse due to bronchospasm. Ronchi refer to lower pitched inspiratory sounds also related to turbulent flow, can be also expiratory, or w/ expiratory wheezing.
Crackles – low-pitched inspiratory breath sounds – very common, often discontinuous – they can be normal if few and cleared by cough, if not they are divided in End-Inspiratory Fine Crackles (or dry crackles) deriving from the expansion of the stiff lung parenchyma or Coarse crackles (or rales) deriving from presence of fluid in the airway as a result of pulmonary edema or bronchitis
Antonio
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13. RESPIRATORY PHYSICAL EXAM
Deformities worth reviewing Barrel chest – Acquired changes due to hyperinflation related to air- trapping in emphysema: increase in AP diameter. Kyphosis – Acquired changes in the curvature of the T spine. Pectus excavatum – Congenital deformity of the chest wall Flail chest – Acquired traumatic injury to the chest wall Tracheomalacia  congential or acquired lack of cartilage of the trachea leading to collapse in expiration
Antonio
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