breath sounds). These signs can be confirmed by asking the
patient to generate laryngeal sounds deliberately (‘Please say “one,
one, one” each time I move my stethoscope on the skin’) and
listening on the chest wall in the same sequence of sites used
for breath sounds. The spoken sound is muffled and deadened
over healthy lung, but the spoken sound is heard loudly and
clearly through the stethoscope over consolidation or fibrotic
lung scarring. Consistent with absent breath sounds, vocal
resonance is absent or greatly diminished over pneumothorax
‘Whispering pectoriloquy’ may be used to confirm the same
changes in sound conduction. Whispered speech is muffled to
silence by normal lung but may be heard over consolidated or
Interpretation of the findings
Review your findings and assemble the positive features you
have uncovered. On completion of the history and examination
you should have a broad idea of the category of respiratory
illness with which you are dealing. As with any system, consider
as you go the likely categories of disease and how these affect
presentation. This approach is summarised in Box 5.6.
Selecting the relevant investigation depends on the clinical problem
revealed on history and examination. Investigations are costly
and many carry risks, so choose tests capable of distinguishing
the likely diagnoses and prioritise the most decisive ones. In
respiratory disease, imaging of the lungs is fundamental, but
respiratory function testing is equally important to distinguish
obstructive disease of the airways from the restrictive pattern
seen in many parenchymal diseases, and to quantify the degree
of abnormality. A summary of the appropriate initial investigations
according to the type of respiratory presentation is included in
There are three common added sounds: wheezes, crackles
and rubs. Wheeze is a musical whistling sound accompanying
airflow and usually originates in narrowed small airways. It is
most commonly expiratory, due to dynamic airway narrowing
on expiration, but can also occur on inspiration. Usually, multiple
wheezing sounds are heard together (polyphonic wheeze); this
sign is common in asthma, bronchitis and exacerbation of COPD.
A solitary wheeze that is present consistently with each breath and
does not clear with coughing suggests a possible fixed bronchial
obstruction and can be an important sign of underlying cancer.
Crackles accompanying deep breathing are thought to
represent the sudden opening of small airways but sometimes
may indicate secretions in the airways or underlying lung fibrosis.
In healthy people, gravitational compression of the dependent
lung bases often causes a few crackles on the first few deep
breaths; these are of no pathological significance. Crackles that
persist after several breaths and do not clear with a deliberate
cough are pathological. They are graded as ‘fine’, meaning soft,
multiple crackles, to ‘coarse’, indicating loud, scanty crackles
that tend to change with each breath. Showers of fine crackles
during inspiration, resembling the sound made by peeling a
Velcro fastener, are characteristic of interstitial pulmonary fibrosis,
and are most commonly heard at the lung bases posteriorly
and laterally. Fine crackles also occur in pulmonary oedema and
some viral pneumonias. Coarse crackles are generally heard in
patients with significant purulent airway secretions such as those
with bronchopneumonia or bronchiectasis. Inspiratory crackles
are also often heard over the areas of incompletely inflated lung
immediately above a pleural effusion.
Pleural rub is a rasping, grating sound occurring with each
breath and sounding superficial, just under the stethoscope, like
two sheets of sandpaper rubbing together. It indicates pleural
inflammation, usually due to infection, and is often accompanied
Breath sounds normally reveal the presence of consolidation or
fibrosis (bronchial breath sounds) or pleural air or fluid (absent
5.6 Categories of respiratory disease and associated features on history and examination
Category of problem Suggestive features on history Suggestive features on examination
Acute bronchitis Wheeze, cough, sputum Wheeze
Exacerbation of chronic obstructive
Acute-on-chronic dyspnoea Hyperinflation
Pneumonia Pleuritic pain, rusty sputum, rigors If lobar, dull to percussion and bronchial breathing
Malignancy Insidious onset, weight loss, persisting pain
Cervical lymphadenopathy, clubbing, signs of lobar/lung
Pulmonary fibrosis Progressive dyspnoea Tachypnoea, inspiratory fine crackles at bases, cyanosis
Pleural effusion Progressive dyspnoea Unilateral basal dullness and reduced breath sounds
Large Sudden, severe dyspnoea Normal breath sounds
Multiple small Progressive dyspnoea Raised jugular venous pressure, right ventricular heave,
Asthma Atopy, hay fever, pet ownership, variable
Polyphonic expiratory wheeze, eczema
5.7 Selecting investigations for different respiratory presentations
Likely problem from history and examination Appropriate initial investigations Diagnostic value
(e.g. acute bronchitis, exacerbation of COPD
Assessment of respiratory failure
Malignancy Chest X-ray Identification of masses
CT scan thorax + abdomen Staging of extent
Bronchoscopy if central Diagnostic pathology
CT-guided biopsy if peripheral Diagnostic pathology
Respiratory function Fitness for radical therapies
Pulmonary fibrosis/interstitial lung disease Chest X-ray Bi-basal reticular shadows
High-resolution CT thorax Extent and type of disease
Respiratory function Quantification; identification of restrictive pattern
Autoantibodies Identification of any associated connective tissue disease
Pleural effusion Chest X-ray Dense basal fluid pool
Ultrasound-guided aspiration Culture for infection
Cytology to identify malignancy
Protein to identify transudate or exudate
CT thorax + abdomen Identification of underlying tumour
Pulmonary embolism d-Dimer Normal if not pulmonary embolism
CT pulmonary angiogram Detection of emboli
Echocardiogram Detection of right ventricular strain
O2 saturation or ABG Assessment of respiratory failure
O2 saturation or ABG Assessment of respiratory failure
IgE, allergen skin tests Detection of allergic stimuli
IgE, immunoglobulin E; WCC, white cell count.
OSCE example 1: Respiratory history
Mrs Walker, 55 years old, presents to the respiratory clinic with cough and wheeze.
• Introduce yourself and clean your hands.
• Ask an open question about why this person has come to the clinic.
• Explore each presenting symptom:
– Productive? If so, characterise sputum volume and colour, and any blood.
– Time pattern – nocturnal (suggests asthma or reflux)?
– On angiotensin-converting enzyme inhibitors?
– What exactly does the patient mean by ‘wheeze’?
– When does it occur – at night or during exercise?
– Provoking factors – infection, environment, contact with animals, dust, beta-blockers?
– Any relieving factors – inhalers?
– Associated respiratory symptoms – breathlessness, chest pain, fevers/rigors, weight loss.
• Ask about any known allergies.
• Take a social history: smoking, occupation, contact with animals.
OSCE example 2: Respiratory examination
Mr Tate, 82 years old, reports increasing breathlessness over several weeks.
Please examine his respiratory system
• Introduce yourself and clean your hands.
• Note clues around the patient, such as oxygen, nebulisers, inhalers or sputum pots.
• Observe from the end of the bed:
• Scars, chest shape, asymmetry, pattern of breathing, accessory muscle use.
• Chest wall movement, paradoxical rib movement, intercostal indrawing.
• Examine the hands: clubbing, tar staining, muscle wasting.
• Measure respiratory rate unobtrusively.
• Examine the face: anaemia, cyanosis, Horner’s syndrome and superior vena cava obstruction.
• Examine the neck: jugular venous pressure, tracheal deviation, cricosternal distance.
• Examine the anterior chest wall:
• Palpate: apex beat, right ventricular heave, expansion of the upper and lower chest.
• Percuss: compare right with left, from top with bottom, then axillae.
• Ask the patient to sit forwards.
• Inspect the back for scars, asymmetry and so on.
– Chest expansion of the upper and lower chest.
• Check for pitting oedema over the sacrum and lumbar spine.
• Thank the patient and clean your hands.
base. A small scar suggests prior pleural aspiration.
Suggest a differential diagnosis
Signs suggest a large right pleural effusion.
empyema and tuberculous effusion.
Suggest initial investigations
Pleural aspiration for cytology, culture and biochemical analysis.
OSCE example 1: Respiratory history – cont’d
• Establish whether there is a family history of respiratory disease (including asthma).
• Ask about any other patient concerns.
• Thank the patient and clean your hands.
Suggest a differential diagnosis
Suggest initial investigations
Integrated examination sequence for the respiratory system
• Introduce yourself and seek the patient’s consent to chest examination.
• Observe from the end of the bed:
– Time spent in inspiration and expiration.
• Chest wall movement, paradoxical rib movement, intercostal indrawing.
• Clubbing, tar staining, muscle wasting.
• Measure respiratory rate unobtrusively.
• Check for anaemia, cyanosis, Horner’s syndrome and signs of superior vena cava obstruction.
• Jugular venous pressure, tracheal deviation and cricosternal distance.
• Examine the anterior chest wall:
• Palpate: apex beat, right ventricular heave, expansion of upper and lower chest.
• Percuss: compare right with left, from top to bottom, then axillae.
• Examine the posterior chest wall: ask the patient to sit forwards so that you can:
• Inspect the back for scars, asymmetry and so on.
– Expansion of the upper and lower chest.
• Check for pitting oedema over the sacrum and lumbar spine.
OSCE example 1: Abdominal pain and diarrhoea 116
Integrated examination sequence for the gastrointestinal system 117
94 • The gastrointestinal system
and 2000 kcal/day for females. Reduced energy intake arises
from dieting, loss of appetite, malabsorption or malnutrition.
Increased energy expenditure occurs in hyperthyroidism, fever
or the adoption of a more energetic lifestyle. A net calorie
deficit of 1000 kcal/day results in weight loss of approximately
8 Appendix (in pelvic position)
Fig. 6.1 Surface anatomy. A Abdominal surface markings of
non-alimentary tract viscera. B Surface markings of the alimentary tract.
C Regions of the abdomen. E, epigastrium; H, hypogastrium or
suprapubic region; LF, left flank or lumbar region; LH, left hypochondrium;
LIF, left iliac fossa; RF, right flank or lumbar region; RH, right
hypochondrium; RIF, right iliac fossa; UR, umbilical region.
6.1 Surface markings of the main non-alimentary tract
Liver Upper border: fifth right intercostal space on full
Lower border: at the costal margin in the mid-clavicular
Spleen Underlies left ribs 9–11, posterior to the mid-axillary line
Gallbladder At the intersection of the right lateral vertical plane and
the costal margin, i.e. tip of the ninth costal cartilage
Pancreas Neck of the pancreas lies at the level of L1; head lies
below and right; tail lies above and left
Kidneys Upper pole lies deep to the 12th rib posteriorly, 7 cm
from the midline; the right is 2–3 cm lower than the left
The gastrointestinal system comprises the alimentary tract,
the liver, the biliary system, the pancreas and the spleen.
The alimentary tract extends from the mouth to the anus and
includes the oesophagus, stomach, small intestine or small bowel
(comprising the duodenum, jejunum and ileum), colon (large
intestine or large bowel) and rectum (Figs 6.1–6.2 and Box 6.1).
The abdominal surface can be divided into nine regions by the
intersection of two horizontal and two vertical planes (Fig. 6.1C).
Gastrointestinal symptoms are common and are often caused by
functional dyspepsia and irritable bowel syndrome. Symptoms
suggesting a serious alternative or coexistent diagnosis include
persistent vomiting, dysphagia, gastrointestinal bleeding, weight
loss, painless, watery, high-volume diarrhoea, nocturnal symptoms,
fever and anaemia. The risk of serious disease increases with age.
Always explore the patient’s ideas, concerns and expectations
about the symptoms (p. 5) to understand the clinical context.
Bad breath (halitosis) due to gingival, dental or pharyngeal infection
and dry mouth (xerostomia) are common mouth symptoms.
Rarely, patients complain of altered taste sensation (dysgeusia)
or of a foul taste in the mouth (cacogeusia).
Anorexia is loss of appetite and/or a lack of interest in food.
In addition to enquiring about appetite, ask ‘Do you still enjoy
Weight loss, in isolation, is rarely associated with serious
organic disease. Ask how much weight has been lost, over
what time. Loss of <3 kg in the previous 6 months is rarely
significant. Weight loss is usually the result of reduced energy
intake, not increased energy expenditure. It does not specifically
indicate gastrointestinal disease, although it is common in
many gastrointestinal disorders, including malignancy and liver
disease. Energy requirements average 2500 kcal/day for males
Dyspepsia is pain or discomfort centred in the upper abdomen.
In contrast, ‘indigestion’ is a term commonly used by patients
for ill-defined symptoms from the upper gastrointestinal tract.
• exacerbating and relieving factors, such as food and
• associated symptoms, such as nausea, belching, bloating
Clusters of symptoms are used to classify dyspepsia:
• reflux-like dyspepsia (heartburn-predominant dyspepsia)
• ulcer-like dyspepsia (epigastric pain relieved by food or
• dysmotility-like dyspepsia (nausea, belching, bloating and
Often there is no structural cause and the dyspepsia is
functional. There is considerable overlap, however, and it is
impossible to diagnose functional dyspepsia on history alone
without investigation. Dyspepsia that is worse with an empty
stomach and eased by eating is typical of peptic ulceration. The
patient may indicate a single localised point in the epigastrium
(pointing sign), and complain of nausea and abdominal fullness
1 kg/week (7000 kcal ≅ 1 kg of fat). Greater weight loss during
the initial stages of energy restriction arises from salt and water
loss and depletion of hepatic glycogen stores, not from fat
loss. Rapid weight loss over days suggests loss of body fluid
as a result of vomiting, diarrhoea or diuretics (1 L of water =
1 kg). Check current and previous weight records to confirm
apparent weight loss on examination (loose-fitting clothes, for
Causes of sore lips, tongue or buccal mucosa include:
• deficiencies, including iron, folate, vitamin B12 or C
• dermatological disorders, including lichen planus
• inflammatory bowel disease and coeliac disease,
Heartburn is a hot, burning retrosternal discomfort.
To differentiate heartburn from cardiac chest pain, ask about
• precipitating factors: lying flat or bending forward
• waterbrash (sudden appearance of fluid in the mouth
due to reflex salivation as a result of
gastro-oesophageal reflux disease (GORD) or, rarely,
• the taste of acid appearing in the mouth due to reflux/
When heartburn is the principal symptom, GORD is the most
Left adrenal gland Right kidney
Fig. 6.2 Normal computed tomogram of the abdomen at L1 level.
Fig. 6.3 Some causes of a painful mouth. A Lichen planus. B Small,
‘punched-out’ aphthous ulcer (arrow).
96 • The gastrointestinal system
Colicky pain lasts for a short time (seconds or minutes), eases
off and then returns. It arises from hollow structures, as in small
or large bowel obstruction, or the uterus during labour.
Biliary and renal ‘colic’ are misnamed, as the pain is rarely
colicky; pain rapidly increases to a peak and persists over several
hours before gradually resolving. Dull, constant, vague and poorly
localised pain is more typical of an inflammatory process or
infection, such as salpingitis, appendicitis or diverticulitis (Box 6.2).
Pain radiating from the right hypochondrium to the shoulder or
interscapular region may reflect diaphragmatic irritation, as in
acute cholecystitis (see Fig. 6.5). Pain radiating from the loin
to the groin and genitalia is typical of renal colic. Central upper
abdominal pain radiating through to the back, partially relieved by
that is worse after fatty or spicy meals. ‘Fat intolerance’ is common
with all causes of dyspepsia, including gallbladder disease.
Odynophagia is pain on swallowing, often precipitated by drinking
hot liquids. It can be present with or without dysphagia (see below)
and may indicate oesophageal ulceration or oesophagitis from
gastro-oesophageal reflux or oesophageal candidiasis. It implies
intact mucosal sensation, making oesophageal cancer unlikely.
Characterise the pain using SOCRATES (see Box 2.2). Ask about
the characteristics described here.
Visceral abdominal pain from distension of hollow organs,
mesenteric traction or excessive smooth-muscle contraction is
deep and poorly localised in the midline. The pain is conducted
via sympathetic splanchnic nerves. Somatic pain from the parietal
peritoneum and abdominal wall is lateralised and localised to the
inflamed area. It is conducted via intercostal nerves.
Pain arising from foregut structures (stomach, pancreas, liver
and biliary system) is localised above the umbilicus (Fig. 6.4).
Central abdominal pain arises from midgut structures, such as
the small bowel and appendix. Lower abdominal pain arises
from hindgut structures, such as the colon. Inflammation may
cause localised pain: for example, left iliac fossa pain due to
diverticular disease of the sigmoid colon.
Pain from an unpaired structure, such as the pancreas, is
midline and radiates through to the back. Pain from paired
structures, such as renal colic, is felt on and radiates to the
affected side (Fig. 6.5). Torsion of the testis may present with
abdominal pain (p. 232). In females, consider gynaecological
causes like ruptured ovarian cyst, pelvic inflammatory disease,
endometriosis or ectopic pregnancy (p. 218).
Sudden onset of severe abdominal pain, rapidly progressing to
become generalised and constant, suggests a hollow viscus
perforation (usually due to colorectal cancer, diverticular disease
or peptic ulceration), a ruptured abdominal aortic aneurysm or
Torsion of the caecum or sigmoid colon (volvulus) presents
with sudden abdominal pain associated with acute intestinal
Fig. 6.5 Characteristic radiation of pain from the gallbladder,
sitting forward, suggests pancreatitis. Central abdominal pain that
later shifts into the right iliac fossa occurs in acute appendicitis.
The combination of severe back and abdominal pain may indicate
a ruptured or dissecting abdominal aortic aneurysm.
Anorexia, nausea and vomiting are common but non-specific
symptoms. They may accompany any very severe pain but
conversely may be absent, even in advanced intra-abdominal
disease. Abdominal pain due to irritable bowel syndrome,
diverticular disease or colorectal cancer is usually accompanied
by altered bowel habit. Other features such as breathlessness
or palpitation suggest non-alimentary causes (Box 6.3).
Hypotension and tachycardia following the onset of pain
suggest intra-abdominal sepsis or bleeding: for example, from a
peptic ulcer, a ruptured aortic aneurysm or an ectopic pregnancy.
During the first 1–2 hours after perforation, a ‘silent interval’
may occur when abdominal pain resolves transiently. The initial
chemical peritonitis may subside before bacterial peritonitis
becomes established. For example, in acute appendicitis, pain
is initially periumbilical (visceral pain) and moves to the right iliac
fossa (somatic pain) when localised inflammation of the parietal
peritoneum becomes established. If the appendix ruptures,
generalised peritonitis may develop. Occasionally, a localised
appendix abscess develops, with a palpable mass and localised
pain in the right iliac fossa.
Change in the pattern of symptoms suggests either that the
initial diagnosis was wrong or that complications have developed.
In acute small bowel obstruction, a change from typical intestinal
colic to persistent pain with abdominal tenderness suggests
intestinal ischaemia, as in strangulated hernia, and is an indication
for urgent surgical intervention.
Abdominal pain persisting for hours or days suggests an
inflammatory disorder, such as acute appendicitis, cholecystitis
No comments:
Post a Comment
اكتب تعليق حول الموضوع