Idiopathic interstitial pneumonia physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2] Ahmed Zaghw, M.D. [3]
Overview
For example in emphysema the patient may appear dyspneic with pursed lips breathing and use of accessory muscles whereas, in pulmonary hypertension the patients present more with symptoms of right sided heart failure associated with ascites and peripheral edema.
Physical Examination
The appearance of the patient may give clues as to the etiology of the condition. Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases.
General examination
If patients has co-existing emphysema then the following signs could be seen.
- 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)
- Signs of right heart failure:
- Elevated jugular venous pulse (JVP)
- 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) it is is seen in 10% of cases of Idiopathic interstitial pneumonia.
- Cyanosis
- Tachypnea
The following signs on general examination could be noticed in cases of pulmonary hypertension.
Pulse
The pulse may be low volume. This usually occurs in more severe disease.[1]
JVP
Assessment of the JVP in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include:
- Prominent 'a' wave: due to forced atrial contraction
- Prominent 'v' wave: later if tricuspid regurgitation develops with right ventricular failure.
- Elevated JVP: can be present if right ventricular failure develops
- Postive Kussmaul's sign: JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure[1]
- Positive Abdominojugular reflux: JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops[1]
Lungs
Inspection
- Hyperinflation (barrel chest)
- 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".
Heart
Precordium
An holistic precordial assessment of pulmonary hypertension involves palpating the precordium for heaves and thrills and ausculatating to assess first and second heart sounds, splitting of the second heart sound and determining if there any added heart sounds or murmurs. Physical findings may include the following:
Palpation
- Parasternal heave: due to hyperdynamic right ventricle
- Palpable P2: correlates with severe disease[1]
Ausculation
First and second heart sound (S1,S2) assessment
- Loud P2 component of S2: this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration. [2]
Splitting of S2 assessment
Extra heart sounds assessment
- s4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
- s3: if right ventricular failure develops. Increased with inspiration.[1]
Additional sounds assessment
- Systolic pulmonary ejection click: increased with inspiration
Murmurs assessment
- Ejection midsystolic pulmonic murmur: increased with inspiration
- Diastolic pulmonary regurgitation murmur (Graham-Steele murmur): indicates more severe disease
- Pansystolic tricuspuid regurgitation murmur: indicates developing right ventricular failure[4]
Abdomen
Findings in the abdomen include:
- Ascites: indicates right ventricular failure
- Painful hepatomegaly: indicates right ventricular failure
- Pulsatile liver: due to tricuspid regurgitation[1]
Legs
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
- ↑ 2.0 2.1 Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan (2007). Textbook of cardiovascular medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7012-2.
- ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
- ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.