Chronic obstructive pulmonary disease physical examination: Difference between revisions

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Latest revision as of 20:58, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Philip Marcus, M.D., M.P.H. [2]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [3]

Overview

Chronic obstructive pulmonary disease can be diagnostically evaluated by physical examination through auscultation. Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases. Findings on general physical examination can be cyanosis, tachypnea, use of accessory respiratory muscles, paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign), elevated jugular venous pulse and peripheral edema. Pulmonary examination in can be barrel chest (emphysema), wheezing, hyperresonance, crackles and rhonchi

Physical Examination

Physical examinations are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases.^[1]^[2]^[3]^[4]^[5]

Appearance of the Patient

Cyanosis
Tachypnea
Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)
Elevated jugular venous pulse (JVP)
Peripheral edema can be observed.

Lungs

Inspection

Hyperinflation (barrel chest)

Percussion

Hyperresonance

Auscultation

Prolonged expiration; wheezing
Diffusely decreased breath sound
Additional sounds - coarse crackles with inspiration

	Specific Features of Emphysema	Specific Features of Chronic Bronchitis
Appearance of the Patient	General appearance: Pursed lips, adopting a tripod position, using accessory muscles. Thin patient with barrel chest Barrel chest may cause distant heart sound Pink puffers This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why mild emphysema patients do not appear cyanotic as chronic bronchitis (another COPD disorder) sufferers often do; hence they are "pink puffers" (able to maintain almost normal blood gases through hyperventilation) and not "blue bloaters" (cyanosis; inadequate oxygen in the blood). However, any severely chronically obstructed (COPD) respiratory disease will result in hypoxia (decreased blood partial pressure of oxygen) and hypercapnia (increased blood partial pressure of Carbon Dioxide)	Blue bloaters they are so named as they have almost normal ventilatory drive (due to decreased sensitivity to carbon dioxide secondary to chronic hypercapnia), are plethoric (red face/cheeks due to a polycythemia secondary to chronic hypoxia) and cyanotic (due to decreased hemoglobin saturation). Signs of right heart failure or cor pulmonale such as edema and cyanosis can be seen.
Lungs	Inspection Hyperinflation (barrel chest) Tachypnea Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign) Percussion Hyperresonance Auscultation Prolonged expiration; wheezing Diffusely decreased breath sound Additional sounds - coarse crackles with inspiration Examination of the chest reveals increased percussion notes (particularly over the liver) and a difficult to palpate apex beat (all due to hyperinflation), decreased breath sounds, audible expiratory wheeze. Classically,clinical examination of an emphysematic patient reveals no overt crackles, however, in some patients the fine opening of airway 'popping' (dissimilar to the fine crackles of pulmonary fibrosis or coarse crackles of mucinous or oedematous fluid) can be auscultated. This is known as "Barclay's sign".	Inspection Respiratory distress indicated by use of accessory respiratory muscles Hoover's sign, presenting as paradoxical indrawing of lower intercostal spaces, is evident Auscultation Prolonged expiration; wheezing Diffusely decreased breath sound Coarse crackles with inspiration Coarse rhonchi
HEENT	Elevated jugular venous pulse (JVP)	Elevated jugular venous pulse (JVP)
Heart	Signs of right heart failure Muffled heart sounds Due to overdistention of lungs	Distant heart sounds, sometimes best heard in the epigastrium Muffled heart sounds Due to overdistention of lungs
Extremity	Peripheral edema can be observed Clinical signs on at the fingers include cigarette stains (although actually tar) and asterixis (metabolic flap) at the wrist if they are carbon dioxide retainers (NOTE: Finger clubbing is NOT a general feature of emphysema). Cyanosis	Peripheral edema

References

↑ Sato S, Mishima M (2016). "[Diagnosis and examination for COPD; medical interview/physical finding/ blood examination]". Nippon Rinsho (in Japanese). 74 (5): 757–62. PMID 27254942.
↑ Mattos WL, Signori LG, Borges FK, Bergamin JA, Machado V (2009). "Accuracy of clinical examination findings in the diagnosis of COPD". J Bras Pneumol. 35 (5): 404–8. PMID 19547847.
↑ Burkhardt R, Pankow W (2014). "The diagnosis of chronic obstructive pulmonary disease". Dtsch Arztebl Int. 111 (49): 834–45, quiz 846. doi:10.3238/arztebl.2014.0834. PMC 4284520. PMID 25556602.
↑ Price DB, Yawn BP, Jones RC (2010). "Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care". Mayo Clin. Proc. 85 (12): 1122–9. doi:10.4065/mcp.2010.0389. PMC 2996146. PMID 21123639.
↑ Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, Sehgal IS, Yenge LB, Jindal A, Singh N, Ghoshal AG, Khilnani GC, Samaria JK, Gaur SN, Behera D (2013). "Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations". Lung India. 30 (3): 228–67. doi:10.4103/0970-2113.116248. PMC 3775210. PMID 24049265.

Template:WikiDoc Sources

[pmid27254942-1] Sato S, Mishima M (2016). "[Diagnosis and examination for COPD; medical interview/physical finding/ blood examination]". Nippon Rinsho (in Japanese). 74 (5): 757–62. PMID 27254942.

[pmid19547847-2] Mattos WL, Signori LG, Borges FK, Bergamin JA, Machado V (2009). "Accuracy of clinical examination findings in the diagnosis of COPD". J Bras Pneumol. 35 (5): 404–8. PMID 19547847.

[pmid25556602-3] Burkhardt R, Pankow W (2014). "The diagnosis of chronic obstructive pulmonary disease". Dtsch Arztebl Int. 111 (49): 834–45, quiz 846. doi:10.3238/arztebl.2014.0834. PMC 4284520. PMID 25556602.

[pmid21123639-4] Price DB, Yawn BP, Jones RC (2010). "Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care". Mayo Clin. Proc. 85 (12): 1122–9. doi:10.4065/mcp.2010.0389. PMC 2996146. PMID 21123639.

[pmid24049265-5] Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, Sehgal IS, Yenge LB, Jindal A, Singh N, Ghoshal AG, Khilnani GC, Samaria JK, Gaur SN, Behera D (2013). "Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations". Lung India. 30 (3): 228–67. doi:10.4103/0970-2113.116248. PMC 3775210. PMID 24049265.

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[2]

[3]

[4]

[5]

@@ Line 1: / Line 1: @@
+__NOTOC__
 {{Chronic obstructive pulmonary disease}}
-{{CMG}}; [[Philip Marcus, M.D., M.P.H.]] [mailto:pmarcus192@aol.com]; {{AOEIC}} {{CZ}}
+{{CMG}}; [[Philip Marcus, M.D., M.P.H.]] [mailto:pmarcus192@aol.com]; {{AE}} {{CZ}}
 ==Overview==
-Chronic obstructive pulmonary disease can be diagnostically evaluated by physical examination through auscultation.
+Chronic obstructive pulmonary disease can be diagnostically evaluated by physical examination through auscultation. Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases. Findings on general physical examination can be [[cyanosis]], [[tachypnea]], use of accessory respiratory muscles, paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign), elevated jugular venous pulse and peripheral edema. Pulmonary examination in can be barrel chest ([[emphysema]]), [[wheezing]], hyperresonance, [[crackles]] and [[rhonchi]]
 ==Physical Examination==
-Physical examination with a [[plethysmograph]] can reveal the true extent of COPD.
+Physical examinations are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases.<ref name="pmid27254942">{{cite journal |vauthors=Sato S, Mishima M |title=[Diagnosis and examination for COPD; medical interview/physical finding/ blood examination] |language=Japanese |journal=Nippon Rinsho |volume=74 |issue=5 |pages=757–62 |year=2016 |pmid=27254942 |doi= |url=}}</ref><ref name="pmid19547847">{{cite journal |vauthors=Mattos WL, Signori LG, Borges FK, Bergamin JA, Machado V |title=Accuracy of clinical examination findings in the diagnosis of COPD |journal=J Bras Pneumol |volume=35 |issue=5 |pages=404–8 |year=2009 |pmid=19547847 |doi= |url=}}</ref><ref name="pmid25556602">{{cite journal |vauthors=Burkhardt R, Pankow W |title=The diagnosis of chronic obstructive pulmonary disease |journal=Dtsch Arztebl Int |volume=111 |issue=49 |pages=834–45, quiz 846 |year=2014 |pmid=25556602 |pmc=4284520 |doi=10.3238/arztebl.2014.0834 |url=}}</ref><ref name="pmid21123639">{{cite journal |vauthors=Price DB, Yawn BP, Jones RC |title=Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care |journal=Mayo Clin. Proc. |volume=85 |issue=12 |pages=1122–9 |year=2010 |pmid=21123639 |pmc=2996146 |doi=10.4065/mcp.2010.0389 |url=}}</ref><ref name="pmid24049265">{{cite journal |vauthors=Gupta D, Agarwal R, Aggarwal AN, Maturu VN, Dhooria S, Prasad KT, Sehgal IS, Yenge LB, Jindal A, Singh N, Ghoshal AG, Khilnani GC, Samaria JK, Gaur SN, Behera D |title=Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations |journal=Lung India |volume=30 |issue=3 |pages=228–67 |year=2013 |pmid=24049265 |pmc=3775210 |doi=10.4103/0970-2113.116248 |url=}}</ref>
+===Appearance of the Patient===
+* [[Cyanosis]]
+* [[Tachypnea]]
+* [[Respiratory distress]] indicated by use of accessory respiratory muscles. [[Hoover sign]] presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)
+* Elevated [[jugular venous pulse]] (JVP)
+* Peripheral [[edema]] can be observed.
-Signs include:
+===Lungs===
-* Rapid breathing rate ([[tachypnea]])
+====Inspection====
-* Wheezing sound heard through a [[stethoscope]]
+* Hyperinflation (barrel chest)
+====Percussion====
+* Hyperresonance
+====Auscultation====
+* Prolonged [[expiration]]; [[wheezing]]
+* Diffusely decreased breath sound
+* Additional sounds - coarse crackles with [[inspiration]]
-Pulmonary emphysema is '''not''' the same as subcutaneous emphysema, which is a collection of air under the skin that may be detected by the crepitus sounds produced on [[palpation]].
+{| class="wikitable"
+!
+!Specific Features of Emphysema
+!Specific Features of Chronic Bronchitis
+|-
+!Appearance of the Patient
+|
+* General appearance: Pursed lips, adopting a tripod position, using accessory muscles.
+* Thin patient with barrel [[chest]]
+* Barrel chest may cause distant heart sound
+* Pink puffers
+**This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why mild emphysema patients do not appear [[Cyanosis|cyanotic]] as chronic [[bronchitis]] (another [[COPD]] disorder) sufferers often do; hence they are "pink puffers" (able to maintain almost normal blood gases through hyperventilation) and not "blue bloaters" ([[cyanosis]]; inadequate oxygen in the blood). However, any severely chronically obstructed (COPD) respiratory disease will result in hypoxia (decreased blood partial pressure of oxygen) and hypercapnia (increased blood partial pressure of Carbon Dioxide)
+|
+* Blue bloaters they are so named as they have almost normal ventilatory drive (due to decreased sensitivity to [[carbon dioxide]] secondary to chronic [[hypercapnia]]), are plethoric (red face/cheeks due to a polycythemia secondary to chronic [[hypoxia]]) and [[cyanotic]] (due to decreased [[hemoglobin]] saturation).
+* Signs of [[right heart failure]] or [[cor pulmonale]] such as [[edema]] and [[cyanosis]] can be seen.
+|-
+!Lungs
+|
+====Inspection====
+*Hyperinflation (barrel chest)
+*Tachypnea
+*Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)
+====Percussion====
+*Hyperresonance
+====Auscultation====
+*Prolonged expiration; wheezing
+*Diffusely decreased breath sound
+*Additional sounds - coarse crackles with inspiration
+*Examination of the chest reveals increased percussion notes (particularly over the liver) and a difficult to palpate [[apex beat]] (all due to hyperinflation), decreased breath sounds, audible expiratory wheeze. Classically,clinical examination of an emphysematic patient reveals no overt crackles, however, in some patients the fine opening of airway 'popping' (dissimilar to the fine crackles of [[pulmonary fibrosis]] or coarse crackles of [[mucus|mucinous]] or [[edema|oedematous fluid]]) can be [[Auscultation|auscultated]]. This is known as "[[Barclay's sign]]".
+|
+====Inspection====
+*Respiratory distress indicated by use of accessory respiratory muscles
+*[[Hoover's sign]], presenting as paradoxical indrawing of lower intercostal spaces, is evident
+====Auscultation====
+*Prolonged expiration; [[wheezing]]
+*Diffusely decreased breath sound
+*Coarse [[crackles]] with inspiration
+*Coarse [[rhonchi]]
+|-
+!HEENT
+|
+* Elevated [[jugular venous pulse]] (JVP)
+|
+* Elevated [[jugular venous pulse]] (JVP)
+|-
+!Heart
+|
+*Signs of right heart failure
+*Muffled heart sounds
+**Due to overdistention of lungs
+|
+* Distant heart sounds, sometimes best heard in the epigastrium
+* Muffled heart sounds
+**Due to overdistention of lungs
+|-
+!Extremity
+|
+* Peripheral edema can be observed
+*Clinical signs on at the fingers include cigarette stains (although actually tar) and asterixis (metabolic flap) at the wrist if they are carbon dioxide retainers (NOTE: Finger clubbing is NOT a general feature of emphysema).
+*Cyanosis
+|
+* [[Peripheral edema]]
+|}
 ==References==
 {{reflist|2}}
+{{WikiDoc Help Menu}}
+{{WikiDoc Sources}}
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 [[Category:Pulmonology]]
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Chronic obstructive pulmonary disease physical examination: Difference between revisions

Latest revision as of 20:58, 29 July 2020

Overview

Physical Examination

Appearance of the Patient

Lungs

Inspection

Percussion

Auscultation

Inspection

Percussion

Auscultation

Inspection

Auscultation

References

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