RESPIRATORY SHORT CASES;
Always look for four important causes of almost any respiratory presentation; 4 Cs which include Cancer/Connective Tissue / Clot (PE)/Consolidation. So look at
HANDS (clubbing, tight skin/rash, arthritis ,wasting is intrinsic muscles of hands, hypertrophic osteoarthropathy etc), look at FACE & NECK for lymphadenopathy/Horner/SVC syndrome. Also look at CALVES for DVT.
Look for 4 complications of any respiratory disease:
AF,
CO2 Narcosis ( Flapping)
Cor-Pulmonale ( JVP, edema),
Pulmonary HTN( loud P2, right ventricular heave).
If trachea is central, it means most likely pathology is in lower lobes, so start chest examination from backside. If trachea is deviated , pathology is in the upper lobe, so start from front.
If you don’t find any focal lung disease like consolidation/collapse/mass/effusion etc, you can skip focal resonance and fremitus as they are changed only in focal disease.
Always listen to find wheezing. If not audible , ask the patient to cough while you are auscultating, it may become evident. Monophonic localised wheezing mean mass lesion causing focal airway obstruction. Generalised and polyphonic wheezing means diffuse airway disease like Asthma/COPD/Bronchiectasis etc. Clubbing and asymmetrical coarse crepitations with wheezing makes Bronchiectasis more likely if patient isn’t having Malignancy. Crepts without clubbing can also be due to Supper added infection if patient is febrile.
B/L crepitations which are symmetrical means diffuse disease like ILD, APO, Pneumonitis or ARDS etc. presence of Orthoptera or other signs of heart failure can help excluding APO. ARDS isn’t meant for exams. Too sick to be there like APO. Absence of infective symptoms /signs may exclude Pneumonitis. So think of ILD. ILD with clubbing is IPF. ILD with Airway disease/Lymph adenopathy or other systemic signs may indicate sarcoidosis etc. berylliosis can also mimic like sarcoidosis.ILD May be secondary to connective tissue like SLE/RA/Scleroderma/CREST etc, so look for that. Drugs related ILD is important to remember. Occupation and organic dust exposure are imp causes.
Grossly Asymmetrical or Unilateral crepitations are almost always coarse and cause is focal like Infection, malignancy, PE etc. so look for signs of these problems like fevere, weight loss, clubbing, lymphadenopathy etc etc. bronchial breathing means consolidation and causes are almost same.
Bilateral effusions are most likely transudate and cause is either heart failure, volume overload or hypoalbumineia. Unilateral effusions or grossly asymmetrical bilateral effusions are most commonly exudate unless proven otherwise and cause are infection/malignancy/PE etc.
Pleural rub or pleural thickening is NOT a feature of volume overload rather it indicates focal pleural pathology like infection/malignancy/PE etc.
Reduced air entry at base(s) with dull percussion is effusion, where as if percussion is hyper resonant it’s likely PTX.
Use of accessory muscles, tracheal tug, intercostal recession, prolonged expiration , inability to talk in complete sentences etc usually indicate airway narrowing of significant level.
So in summary, kook at
1: HANDS: Clubbing, wasting, hypertrophic osteoarthropathy, clues for connective tissue disorder, CO 2 narcosis and AF.
2: FACE: Horner, polycythemia, anemia.
3: NECK; lymph nodes, JVP, SVC syndrome, use of accessory muscles, tracheal tug etc
4: CHEST; start from back if trachea in central. Look for various signs as discussed
5:CALVES: edema, DVT.
Hope it should help. Please feel free to discuss.