1. Signs and Symptoms in Pulmonary Disease פרופ' נוויל ברקמן מכון הריאה ביה"ח האוניברסיטאי הדסה עין-כרם

2. Dyspnea
Subjective feeling of air hunger / abnormally uncomfortable awareness of breathing.
When does it occur? (rest or exercise).
Associated symptoms – pain etc.
Quantitation - effort tolerance – level, incline, steps, 6-minute walk.
New York Heart Association I - IV

3. Dyspnea – cont. Dyspnea at rest. Duration Changes over time:
sudden onset: pneumothorax, pulmonary emboli, anxiety.
Changes over time:

4. Dyspnea- differential diagnosis
Respiratory –
Airways obstruction – large, small
Parenchymal disease
Vascular disease
Chest wall
Heart disease
Anemia
Anxiety

5. Dyspnea- cont.
Orthopnea – dyspnea when lying down (heart failure, COPD, diaphragmatic paralysis).
Paroxysmal nocturnal dyspnea.
Platypnea
Sleep apnea

6. Cough Acute or chronic Dry or productive Intermittent or continuous
Is it worse at night?
Change in nature of chronic cough
Associated symptoms, medications

7. Cough – cont. Acute infections – bronchitis, pneumonia, pertussis
Chronic infections – bronchiectasis, TB, CF
Airway disease – asthma, chronic bronchitis, post nasal drip
Parenchymal disease – interstitial fibrosis, sarcoidosis, emphysema
Tumours
Foreign body
Cardiovascular – CHF, PE, aortic aneurysm
Drugs- ACE inhibitors
Other- reflux, aspirations, middle ear pathology

8. Chest Pain
Pleuritic pain- sharp, stabbing in nature, worsened by cough, deep breathing.
Usually indicates inflammation or tumour.
“Mediastinal” pain- cardiac, esophageal, aneurysm.
Musculoskeletal
Neuralgia

9. Wheezing High-pitched continuous whistling sound.
Inspiratory or expiratory or both.
Indicated airway obstruction.
Should be differentiated from stridor.

10. Hemoptysis Coughing up of blood. Always significant!
R/O hematemesis, nose bleeding.
Bronchitis, bronchiectasis, pneumonia, cancer; seldom tuberculosis, PE, vasculitis.

11. Other Smoking- including passive, time since cessation. Travel
1 pack year = 20 cigarettes/day for 1yr.
Travel
Family history
Drugs, hobbies
Sexual habits

12. Occupation What work do you do? Are your symptoms better at weekends?
Does anyone else at work have similar symptoms?
Pneumoconioses, moulds, bakers etc.

13. Physical examination
The respiratory system cannot be viewed in isolation: respiratory disease often presents with extrapulmonary signs or symptoms and extrapulmonary disease may present with respiratory findings!!

14. Vital signs in ALL patients
pulse
Blood pressure, pulsus paradoxus
respiratory rate!
temperature
conciousness (hypercapnia cause sedation, hypoxemia causes restlessness)
Respiratory pattern
Cheyne-Stokes respiration
Kussmaul’s respiration

15. Physical examination Inspection
Cough – sputum.
Cyanosis – central, peripheral.
Clubbing
Flapping tremor
Chest- deformation, scars, symmetry (pectus excavatum, carinatum). Barrel-shaped chest in emphysema.
Chest movement (including abdominal movement).
Use of accessory muscles.

16. (כחלון) - Cyanosis Blue skin colour
Indicates the presence of >5g/100ml of deoxygenated hemoglobin.
Central cyanosis - seen on the tongue. Indicates hypoxemia.
Peripheral cyanosis – indicates poor perfusion.

20. Clubbing - differential diagnosis
Malignancy - lung cancer, mesothelioma.
Pulmonary fibrosis.
Chronic suppurative lung disease: bronchiectasis, lung abscess, empyema.
Cyanotic congenital heart disease.
Subacute bacterial endocarditis.
Cirrhosis, inflammatory bowel disease, hyperthyroidism (acropachy).

21. Physical examination Inspection
Cough – sputum.
Cyanosis – central, peripheral.
Clubbing
Flapping tremor
Chest- deformation, scars, symmetry (pectus excavatum, carinatum). Barrel-shaped chest in emphysema.
Chest movement (including abdominal movement).
Use of accessory muscles.

23. Physical examination Palpation
Trachea
Cardiac apex
Chest excursion
Lymphadenopathy
Signs of right-sided (and left-sided) cardiac disease/ failure.

24. Physical examination Percussion
Cardiac dullness, liver, diaphragms
Dull - indicates consolidation or atelectasis.
Stony dull – indicates fluid.
Hyperresonance – pneumothorax, emphysema or bullae.
Vocal fremitus – “44”

25. Vocal fremitus Increased - consolidation.
Decreased – pleural effusion or thickening, emphysema, pneumothorax, atelectasis

26. Physical examination Auscultation
NATURE of breath sounds: vesicular or bronchial.
INTENSITY of breath sounds/ air entry.
DURATION of breath sounds.

27. Vesicular breath sounds
Heard over normal lung.
Expiration softer and longer than inspiration
Pause between inspiration and expiration.
lung sounds
lung sounds

28. Bronchial breathing
“Tracheal” sounding: inspiration and expiration are of equal intensity.
Normal over right anterior superior chest.
Present in consolidation, atelectasis, above pleural effusion.

29. Adventitious sounds
WHEEZE (צפצופים) - sibilant or high pitched continuous sound arising from medium or small airways, indicate obstruction.
RHONCUS- sonorous or low-pitched rhoncus arising from large airways.
FRICTION RUB – continuous creaking noise, indicates pleural inflammation.

30. Adventitious sounds- Crackles (rales, crepitations) (חרחורים)
Discontinuous sound. Caused by secretions or small airspace opening / closure.
Fine - pneumonia, cardiac failure, fibrosis.
Coarse – bronchiectasis.
(Wet or dry)
Inspiratory, expiratory or both.

31. Auscultation Bronchophony (vocal resonance) Egophony “e” to “a”
Whispering pectoriloquy

32. Findings in common lung conditions
Bronchial breathing
Breath sounds
קולות נשימה
Fremitus
פרמיטוס
Percussion
ניקוש
Pneumothorax
Pleural effusion
Consolidation

34. Emphysema Accessory muscles, “pursed-lip” breathing.
Barrel chest, reduced excursion, reduced crico-sternal distance.
Loss of cardiac dullness, low liver, low diaphragms.
REDUCED AIR ENTRY “Faulty stethoscope sign”
Prolonged expiration, wheeze.

35. Asthma Respiratory rate. Talking dyspnea Accessory muscles
Pulsus paradoxus
Air entry
Wheezing

36. Pulmonary fibrosis Clubbing End- inspiratory crackles.
Small lungs, reduced excursion.