"How to examine a patient" A pocket guide to students of medicine (3rd ed)(gnv64)

A POCKET GUIDE
TO
STUDENTS OF MEDICINE
KOTHARI BOOK DEPOT

HOW TO EXAMINE
A PATIENT
A POCKET GUIDE
TO STUDENTS OF MEDICINE
BY
DR. M E N I N O DE SOUZA, M.D.
Emeritus Professor of Medicine,
Grant Medical College, Bombay,
and
Ex-Consulting Physician and Neurologist,
J.J. Hospital, Bombay.
THIRD EDITION
1970
K O T H A R I B O O K D E P O T
B O M B A Y

© D R . M E N I N O DE SOUZA
First Edition 1955
Second Edition 1960
Third Edition 1970
Printed by V. D. Limaye at the India Printing Works, 9 Bakehouse
Lane, Fort, Bombay, and published by Mohanlal B. Kothari,
Kothari Book Depot, Acharya Donde Jilarg, Parel, Bombay 12.

PREFACE TO THE SECOND EDITION
The text has again undergone a thorough revision with
greater emphasis on How to Examine a Patient and to elicit
the necessary information from the Patient so as to arrive at a
correct clinical diagnosis.
The zeal of a Modern Physician to indulge in the aid of
electro-medical gadgets might discourage a young student to
sacrifice sufficient time to elicit signs and symptoms under the
mistaken impression that the ultimate diagnosis of some diseases
rests on mechanical gadgets. This pitfall must be avoided by
one who wishes to be a successful clinician.
Bearing this in mind this book has been revised fully. Some re-
adjustment in the matter that has no bearing on the Examination
of a Patient has been deleted and new chapters on Locomotor
System and Skin and its Appendages have been added. The
size of the book, on the whole, has been reduced in- size so as
to enable the student to make it a bedside companion during
his clinical studies.
March 1970. M . DE SOUZA

This book was written for the specific needs of a student who
launches his clinical career with no experience to support him.
I am happy to note that it has found favour with him and hope
that the present format will increase its usefulness.
The main change in this edition has been the rewriting of
the old chapters and adding new ones on Blood, Genito-Urinary
System, etc., with emphasis on Methods of Examination.
History taking is an art which must be acquired by experience.
No detail is unimportant, and the correct diagnosis often rests
upon a careful balancing of probabilities. A first class history
is a necessary prelude to an accurate diagnosis. In fact, a well-
elaborated anamnesis practically establishes the diagnosis in
several cases. The converse is also true—a history taken
hurriedly and aimlessly without any data or properly obtained
facts, is not only valueless, but often highly misleading.
Time spent in questioning the patient intelligently is never
lost, but the type of questions to ask needs experience. This is
best acquired by constant clinical examination, for which read-
ing this book is only an accessory and not a substitute. Some
are endowed with a gift of extracting concise and accurate
history from a patient. Such students learn more readily than
others, but the gift can certainly be acquired by anyone who
possesses the necessary will to learn. This book is mainly
intended for those who are not gifted with this art and the
author hopes it will help them in their careers both as students
and after.
M. DE SOUZA

The title How TO EXAMINE A PATIENT probablv describes the
scope of this little book better than any other. The importance
of Methodical Examination of a Patient cannot be over-
estimated. It forms the ground-work of thorough study in all
Medical Subjects. This book aims at providing a synopsis of
the Method of Examining a Patient and to teach the student
how to obtain an accurate history of the illness and what he
should look for to arrive at a diagnosis in a logical manner.
I have endeavoured to include these points in a small space,
and hence, it is not at all my intention to replace similar books
dealing in greater details.
M. DE SOUZA

C O N T E N T S
CHAPTER I
C A S E - T A K I N G
PACE
General Scheme 1
Case-Taking 2
Complaint and Duration 2
History of the Present Illness 2
Previous Diseases 3
Personal History . . . ." 3
Family History 4
General Examination 4
Consciousness and Intelligence 4; Decubitus 5; Voice
and Speech 5; General Development and Nutrition 6;
Pulse, Respiration and Temperature 11.
CHAPTER I I
R E S P I R A T O R Y S Y S T E M
General Scheme 15
Interrogation of Common Symptoms and Signs . . . . 16
Cough 16; Dyspnoea 16; Pain in the Chest 17;
Haemoptysis 17; Hoarseness of Voice 17; Hiccough 17.
Surface Markings of the Lungs 18
Examination of the Upper Air Passages 20
Nose 20; Neck 20; Larynx 20; Trachea 20.
Examination of the Chest 21
Inspection 21; Palpation 27; Percussion 29;
Auscultation 33.
Examination of Sputum 37
Examination of Pleural Fluids 41
Manifestations of Common Respiratory Disorders . . . . 43
Cough 43; Pain in the Chest 45; Epistaxis 46;
Haemoptysis 48; Hoarseness of Voice 50; Cyanosis 51;
Dyspnoea 53.
vii

v i i i CONTENTS
CHAPTER I I I
C A R D I O - V A S C U L A R S Y S T E M
PAGE
General Scheme 61
Dyspnoea 62; Praecordial Pain 62; Palpitation 63;
Syncope 63; Giddiness 63; Venous Congestion 63.
Surface Marking of the Heart 64
Examination of the Heart 65
Auscultation 73.
Pulse 80
Abnormal Pulse 82; Irregular Pulse 84.
Blood Pressure 86
High Blood Pressure 88; Low Blood Pressure 92.
Exercise Tolerance Test
Common Cardiovascular Disorders
Cardiac Pain 94; Palpitation 99; Syncope 100; Shock 101;
Oedema 102.
Circulatory Failure
Central (cardiac) Failure 108; Peripheral Failure 110
Enlargement of the Heart
Hypertrophy 111; Dilatation 115.
Cardiac Murmurs
Functional Murmurs 115; Mitral Murmurs 116; Aortic
Murmurs 1.19; Pulmonary Murmurs 121; Congenital
Murmurs 122; Myocardial Murmurs 123; Exocardial
Murmurs 123; Vascular and Haemic Murmurs 124.
CHAPTER I V
A L I M E N T A R Y S Y S T E M
General Scheme 127
Interrogation of Common Symptoms and Signs . . . . . 128
Pain 128; Vomiting 128; Indigestion 129; Sore Tongue
129; Diarrhoea 129; Constipation 130; Haematemesis
130; Appetite 130; Thirst 130; Dysphagia 131; Jaundice
131; Blood in Faeces 131; Abdominal Swelling 132;
Flatulence 132; Eructation 132; Water-brash 132;
Heartburn 132.
93
94
107
110
115

CONTENTS ix
PACF.
Examination of the Mouth and Throat 132
Mouth 132; Lips 133; Teeth 133; Gums 133; Tongue
134; Palate 135; Breath 135.
Anatomical Landmarks of the Abdomen 136
Examination of the Abdomen 138
Mensuration 143; Auscultation 143.
Examination of the Abdominal Viscera 144
Stomach 144; Liver 144; Gall-bladder 145; Spleen 146;
Kidneys 146.
Rectal Examination 147
Examination of Faeces 147
Examination of Gastric Juice 1 51
Gastric Acidity 153
Hyperchlorhydria 153; Hypochlorhydria 153;
Achlorhydria 154.
Examination of the Peritoneal Fluid 159
Abdominal Swelling 160
Ascites 161; Tumours 166.
Abdominal Rigidity 168
Abdominal Pain 168
Colicky Pain 172; Pain in Children 173.
Common Digestive Disturbances 175
Dysphagia 175; Vomiting 178; Haematemesis 180;
Constipation 182; Diarrhoea 184; Steatorrhoea 186;
Blood in Stool 188; Melaena 191.
Intestinal Obstruction . 191
Acute Obstruction 192; Chronic Obstruction 192.
Liver 192
Enlargement 193; Jaundice 195.
Gallbladder 199
Spleen 201
CHAPTER V
C E N T R A L N E R V O U S S Y S T E M
General Scheme . 205
Interrogation of the Common Symptoms and Signs . . . 206
Fits 206; Fainting 207; Headache 207; Vertigo 208;
Paralysis 208; Neuralgic Pains 208; Tingling and Numb-
ii

X CONTENTS
PAGE
ness 209; Tremors 209; Unconsciousness 209; Diplopia
209; Tinnitus 210; Speech Defects 210; Ataxia 210.
Examination of the Nervous System 210
Intellectual Functions 210; Skull and Spine 211; Cranial
Nerves 214; Motor System 239; Sensory System 244;
Reflexes 246.
Anatomy of the Central Nervous System 256
Cerebral Circulation 257
Cerebro-Spinal Fluid 259
Common Neurological Disorders 265
Convulsions 265; Epilepsy 268; Headache 270; Coma 274;
Speech Defects 277; Tremors 282; Gaits 284; Ataxia 288.
Motor Tracts and their lesions 289
Monoplegia 290; Hemiplegia 292; Paraplegia 299.
Sensory Tracts and their Lesions 304
Extra-Pyramidal System—Basal Ganglia Lesions . . . . 307
Cerebellum and its Disorders 308
Spinal Cord and its Lesions 308
Spinal Nerves and their Lesions 312
CHAPTER V I
G E N I T O - U R I N A R Y S Y S T E M
General Scheme 315
Haematuria 316; Polyuria 316; Oliguria 316; Dysuria
31.7; Frequency 317; Incontinence 317; Pain 317.
Examination of the Kidneys and Bladder 318
Examination of Urine . . . . 3 1 9
Renal Efficiency Tests 329
Enlargement of the Kidneys 330
Abnormalities of Micturition 332
Common Urinary Disorders • 335
Albuminuria 335; Anuria 337; Dysuria 339; Frequency
of Micturition 339; Glycosuria 340; Haematuria 344;
Haemoglobinuria 347; Polyuria 348; Oliguria 349;
Melanuria 349; Pyuria 350; Uraemia 351.

CONTENTS x i
CHAPTER V I I
H A E M O P O I E T I C S Y S T E M
PAGE
General Scheme 357
Interrogation of Common Signs and Symptoms . . . . 358
Method of Blood Examination 358
Red Cells 360; White Cells 360; Haemoglobin 360;
Reticulocytes 361; Haematocritic determination 361; Red
Cell Indices 362; Platelet Estimation 365; Fragility Test
363; Sedimentation Rate 363; Coagulation Time 365;
Prothrombin Time 366. ,
Examination of the Bone Marrow 366
Blood Chemistry 368
Blood Grouping—Blood Transfusion 372
Disorders of the Red Cells 375
Anaemias 376; Polycythaemia 380.
Disorders of the White Cells 381
Leucocytosis 384; Leucopenia 385; Agranulocytosis 385;
Lymphocytosis 386; Monocytosis 387; Eosinophilia 387;
Basophilia 388.
Blood Platelets and their Disorders 388
Lymph Glands 389
Generalised Enlargement 389; Localised Enlargement 390.
CHAPTER VIII
L O C O M O T O R S Y S T E M
General Scheme 393
Interrogation 394
Muscular Disorders 394
Examination of Bones 395
Skull 395; Vertebral Column 399; Backache 400; Long
Bones 401; Small Bones 402; Nodes on the Fingers 402.
Examination of Joints 402
Arthritis 404

xii CONTENTS
CHAPTER I X
S K I N A N D I T S A P P E N D A G E S
PAGE
General Scheme 407
Examination of the Skin 408
Inspection 408; Palpation 411; Microscopic Examination
412.
Pigmentation of the Skin 409
Eruptions of the Skin 410
Haemorrhages under the Skin 410
Ulcers of the Skin 410
Examination of the Hair 412
Examination of the Nails 412
CHAPTER X
E X A M I N A T I O N O F C H I L D R E N
Family History 415
Present Illness 416
Clinical Examination 416
CHAPTER X I
E X A M I N A T I O N O F P S Y C H I A T R I C P A T I E N T S
"Main Complaint 423
Family History 423
Personal History 423
General Examination 424
A P P E N D I C E S
Appendix A: Vitamins and their Deficiencies 428
Appendix B: Endocrine Glands and their Dysfunctions 430
Appendix C: Infections 435
Animal Reservoirs 435; Insect Vectors 435; Eruptive
Fevers 436; Infestations 437.

CHAPTER I
G E N E R A L , S C H E M E
I. NAME Age ..
Sex Nationality
Occupation
Marital Status i'
Address
II. COMPLAINT AND DURATION.
III. HISTORY OF THE PRESENT ILLNESS.
IV. PREVIOUS DISEASES.
V. PERSONAL HISTORY :—
1. Marital history.
2. Occupation.
3. Environment.
4. Social history.
5. Habits.
VI. FAMILY HISTORY.
VII. GENERAL EXAMINATION.
VIII. EXAMINATION OF THE VARIOUS SYSTEMS.
IX. LABORATORY INVESTIGATIONS.
X. SPECIAL INVESTIGATIONS:—Fluoroscopy,
X-rays, E.C.G., etc.
XI. DIAGNOSTIC IMPRESSION.
XII. SUGGESTED FURTHER STUDY.
XIII. PROGRESS OF THE PATIENT.

2 HOW TO EXAMINE A PATIENT
C A S E T A K I N G
After entering the name, age, etc., proceed with the inter-
rogation of the patient systematically so as to elicit the salient
features of the disease. Be accurate and comprehensive while
examining the system affected; be concise while examining the
others.
The mental attitude of an average patient, his ability to
answer questions and his psychological make-up is within normal
limits and hence, case-taking in most cases can be considered as
fairly reliable.
C O M P L A I N T A N D D U R A T I O N
1. Briefly list presenting complaints and their duration.
2. Let the patient express the symptoms in his own words.
3. Do not ask leading questions, unless necessary.
4. Avoid negative answers, unless deemed relevant.
H I S T O R Y O F T H E P R E S E N T I L L N E S S
Give chronological story of the illness, beginning with the
exact date of onset, with special reference to the presenting
symptom, i.e. the symptom which troubles the patient more than
any other. Also determine when the patient was last well, when
he left work and when he took to bed.
Inquire into the symptoms with special reference to:
1. Their mode of onset—whether gradual, sudden or in
series of attacks; their order of appearance; the exact
location; their course, duration and progress; their after-
effects, such as weakness, loss of weight, vomiting, loss of
appetite, nervousness, prostration, etc. Intervals of free-
dom, if any.
When indicated, define the symptoms in terms of quality,
severity, radiation, continuity, etc.
2. Predisposing factors—overwork, overplay, dissipation,
miscarriage, child-birth, general illness, etc.

CASE TAKING 3
3. Factors modifying the symptoms—food, deep breathing,
posture, exercise, change of weather, etc.
4. Associated symptoms such as pains in the body, jaundice,
fits, coma, etc.
5. Treatment the patient may have taken—if so, in what
form and its effects.
6. Supposed cause according to the patient.
PREVIOUS DISEASES
Inquire into the following, with their time of occurrence,
duration and results:
1. Similar attacks previously with dates and results of treat-
ment.
2. Diseases of childhood, especially eruptive fevers, intestinal
disorders, lung diseases, etc.
3. Important illnesses like prolonged fevers, pains, epistaxis,
haemoptysis, haematemesis, cough, venereal diseases,
infectious fevers, lung diseases, jaundice, joint swellings,
abdominal diseases, marked change in weight, diabetes,
nephritis, etc.
4. Accidents and injuries, with details and disabilities
incurred.
5. Operations with dates and results.
6. In women:
(a) Menstrual history.
(b) Miscarriages and still-births.
(c) Difficulty during delivery.
(d) Abnormality of the child or foetus.
If the diagnosis of the previous diseases is not clear, describe
them in terms of symptoms, signs and duration of the illness.
PERSONAL HISTORY
1. Marital history: Duration. Age and health of consort
and children, if living, or age and cause, if dead. Former
marriages. Degree of compatibility.

2. Occupation: Nature of work and its surroundings. If
agreeable to the patient. Previous occupations. Business
affairs.
3. Environment: Conditions at home and its surroundings.
Localities where he lived before. Domestic life. Sources
of worry.
4. Social history: Education. Financial condition. Number
of dependants.
5. Habits:
(a) Food—its quality and quantity. Hours and regularity
of meals. Time taken over each meal. These details
are very necessary in Digestive Disorders.
(b) Addiction to alcohol, smoke, tea, coffee and drugs.
Their quality and intake per day.
(c) Exercise; recreation; holidays.
(d) Sexual life, if deemed relevant.
(e) Nature of sleep. If disturbed, its cause.
(f) Bowels and micturition; their frequency during day
and night.
F A M I L Y H I S T O R Y
1. Of parents, brothers, sisters and children—their state of
health; if ill, the nature of ailment; if deceased, the cause
of death and age at death.
2. In hereditary and familial diseases—especially diabetes,
cardio-vascular diseases, renal disorders, migraine, haemo-
philia, nervous and mental diseases—inquire into details
in more generations in the same family and of consangui-
nity in marriage.
G E N E R A L E X A M I N A T I O N
I. CONSCIOUSNESS AND INTELLIGENCE
Note the degree of co-operation; promptness or delay in
answering questions; appearance of apathy, lethargy or fatigue.

CASE TAKING 5
Many nervous patients, particularly those suffering from Grave's disease,
are unusually alert. Psychoneurotic patients are emotionally unstable. A
depressed patient takes long to answer questions. A patient suffering from
myxoedema is dull and apathetic. A melancholic reveals lack of interest
during examination. A hysterical patient is over-enthusiastic in answering
questions.
II. DECUBITUS
The posture a patient adopts, especially when lying in bed,
often gives a valuable diagnostic clue. He prefers to adopt an
attitude which he feels is most comfortable.
Patients suffering from severe pain often assume unusual attitude to
obtain relief.
In pleural effusion and pneumonia, patients prefer to lie on the same
side as the lesion in order to provide free expansion to the normal lung.
In early pleurisy, however, when the pain is severe, they prefer to lie on
the same side as the lesion in order to restrict the movements which are the
cause of pain.
Patients, with a cavity in the lung prefer to lie on the diseased side in
order to avoid constant or distressing cough.
When acutely ill, patients passively lie in supine posture without any
effort being made to change the position.
In severe respiratory or cardiac embarrassment the patient finds some
relief in orthopnoeic position. So also a patient prefers to sit up in
conditions like ascites that raise the intra-abdominal pressure.
In pericardial effusion, the patient finds comfort when leaning his body
forward.
In acute abdominal diseases, the patient lies on his back with one or both
legs drawn up according as the inflammation is limited to one side or is
more general. In colics and in coronary disease, the patient is very restless.
In acute intestinal colic, the patient prefers to lie on his stomach with a
pillow underneath.
In meningitis and tetanus, there is marked stiffness of the neck and often
opisthotonus.
In acute arthritis the affected limbs lie in a helpless position.
In hemiplegia, the movements of the limbs are limited on the affected
side. In paraplegia, the lower limbs are immobile.
III. VOICE AND SPEECH
The character of the voice is often helpful in arriving at the
diagnosis of a case. In infantilism, the voice is high-pitched;
in virilism, it has the tone of an adult male. In aortic aneurysm,
the voice may have a brassy quality. In laryngeal diseases, the

voice is husky and in laryngeal paralysis, it is feeble. (For
disturbances of speech see under Central Nervous System.)
IV. GENERAL DEVELOPMENT AND NUTRITION
Under this heading the following are to be considered:
1. General Appearance.
2. Body Configuration.
3. Height and Weight.
4. Examination of the Head, Neck and Face.
(a) Configuration of the Skull and Face.
(b) Facial Expression.
(c) Examination of the Eyes.
(d) Colour of the Face.
(e) Examination of the Lips.
(f) Examination of the Nose.
(g) Examination of the Ears.
5. Examination of the Skin, Hair and Nails.
6. Examination of the Lymph Glands.
7. Examination of the Genitalia and Breasts.
8. Examination of Joints and Extremities.
1. General Appearance
Note the posture and attitude of the patient, especially the
poise of the head, the slant of the shoulders, the inclination of
the trunk to the pelvis, the position of the arms and hands, the
appearance of the lower limbs, the gait (see under Central
Nervous System) and the mode of dress.
2. Body Configuration
In general, a patient may be grouped under any of the fol-
lowing groups according to his body configuration:
ASTHENIC TYPE:—Tall with long neck and flat chest, protuberant
lower abdomen, hands slender and fingers long. Such people are neurotics.
STHENIC TYPE:—Short, broad, with thick neck, hands broad with
stumpy fingers. Such patients are often hyperpietics.

CASE TAKING 7
PLETHORIC TYPE:—Same as STHENIC TYPE, but with florid com-
plexion and suffused eyes. These people often suffer from heart and kidney
diseases.
PHTHISICAL TYPE:—Same as ASTHENIC TYPE in a highly exagge-
rated form with poor nutrition.
3. Height and Weight
Relevant details may be necessary when there is rapid loss or
increase in weight in a patient.
If the patient is obese, inquire into the
(a) family history.
(b) If rapid or gradual in onset.
(c) The distribution of^fat—if generalised or localised.
(d) If there is any associated pain.
(e) Habits of diet.
(f) Exercise.
If the patient is under-nourished, find out if it is
(a) Rapid or gradual in onset.
(b) Continuous or interrupted by gain in weight.
(c) If accompanied or preceded by illness.
(d) Average weight previously.
If the stature of a patient is far above or below limits, he may be classified
as a giant or a dwarf. Endocrinc dysfunctions appear to produce the greatest
changes in the height and weight of a patient. Deficiency of testicular or
pituitary secretions in a male causes feminine characteristics with deposition
of fat at the breasts and around the hips, with scanty hair on the face.
In suprarenal cortical overactivity in females, the body contour is masculine
in appearance associated with hirsutism. In some pituitary dysfunctions,
there is generalised obesity with genital atrophy; in overfunction, the patient
is over-developed and resembles a giant.
4. Examination of Head, Neck and Face
Specially note the configuration and abnormalities of the
skull. Examine the scalp for texture of the hair, alopecia and
scars; neck for glands, scars, thyroid, rigidity, torticollis, etc.
Press over the sinuses to elicit tenderness.
While examining the face the following parts must be care-
fully examined:

(a) CONFIGURATION OF THE SKULL AND THE FACE. (See Chapter
VIII.)
(b) FACIAL EXPRESSION
The expression of a patient is mainly determined by the ap-
pearance of the eyes. They may be:
ANXIOUS—acute pain, acute illness.
APATHETIC—typhoid, psychic depression.
EXPRESSIONLESS—Parkinsonism, cretinism.
BRIGHT—hyperthyroidism.
VACANT—meningitis, encephalitis, other conditions where consciousness
is growing dull.
WILD—acute mania.
STUPID—mental deficiency, cretinism.
SHIFTY—drug addict, masturbator, giving wrong history of the illness,
self-conscious.
RESTLESS EYES—phthisis.
SELF-SATISFIED LOOK—chronic alcoholism.
FLUSHED—pneumonia.
SUNKEN—cholera, severe wasting, dehydration.
FIXED SMILE—Risus Sardonicus of tetanus.
PUFFY—renal disease, anaemia, myxoedema.
(c) EXAMINATION OF THE EYES
Examination of the eyes also includes examination of the
cornea, sclera, conjunctiva, eye-lids, eye-lashes and eye-balls.
Carefully examine them for the following abnormalities:
EYE-LIDS—for puffiness (nephritis, anaemia, angioneurotic oedema,
whooping cough); ptosis (paralysis of the 3rd cranial nerve); retraction
(stimulation of the sympathetic nerve).
EYE-BROWS—if fallen or scanty—thyroid disorders.
FISSURES—slanting in mongolism.
SCLERA—yellow in jaundice, red in haemorrhages.
CONJUNCTIVAE—pale in anaemia; red in conjunctivitis, high blood
pressure, fracture of the skull, cerebral haemorrhage, sub-acute bacterial
endocarditis.
CORNEA for scars, ulceration, arcus senilis, etc.
EYE-BALLS for tension—increased in glaucoma, diminished in diabetic
coma. If prominent, suspect thyrotoxicosis, orbital tumours, thrombosis
of the lateral sinus. If there is enophthalmos, suspect sympathetic nerve
paralysis and severe dehydration.
' VISION, PUPILS, DEVIATION, ETC.—Examine under Central Nervous
System.

CASE TAKING 9
(d) COLOUR OF THE FACE
The complexion of a patient is mainly dependent upon the
colour of the cheeks. These may take up any of the following
abnormal forms:
PALE—anaemia, aortic regurgitation (pallor).
FLUSHED—hectic fever, mitral stenosis.
CYANOSED—congestive cardiac failure, congenital heart.
YELLOW—jaundice.
LEMON YELLOW—pernicious anaemia.
MUDDY—dyspepsia.
WAXY—chronic parenchymatous nephritis.
PLETHORIC—high blood pressure, polycythaemia.
PIGMENTED—Addison's disease, cancer stomach, etc.
DEPIGMENTED—albinism, leucoderma.
TELANGIECTASES—chronic alcoholism, cirrhosis liver.
(e) EXAMINATION OF THE LIPS
The appearance of the lips may be of some importance to
judge the general condition of the patient. Look for:
(a) COLOUR—pale in anaemia, cyanosed in heart failure apd congenital
heart diseases, dusky-red in polycythaemia.
(b) SIZE—thick in myxoedema and acromegaly, thin and pendulous in
myopathies, swollen in acute nephritis and angioneurotic oedema.
(c) DEFORMITIES—hare-lip, etc.
(d) HERPES—malaria, pneumonia, meningitis, virus infections.
(e) DRY—toxaemia, high fever.
(f) STRIATIONS—riboflavin deficiency, syphilis.
(g) ULCERS—syphilis, epithelioma, nutritional disorders.
(h) PIGMENTED—Addison's disease, cancer stomach, etc.
(i) DEPIGMENTED—leucoplakia, syphilis.
(j) FISSURED—angular cheilitis, riboflavin deficiency.
(£) EXAMINATION OF THE NOSE
Examine the nose especially for size and shape. Also examine
the nostrils for septal defects, polypi, ulcers and perforation.
The nose may be:
LARGE—acromegaly and myxoedema; large and bulbous—rhynophyma.
PINCHED—adenoids.
SADDLE-SHAPED OR W I T H SUNKEN BRIDGE—congenital syphilis.

RED-TIPPED—chronic alcoholism, mitral stenosis, chronic indigestion,
acne rosacea.
"BUTTERFLY" APPEARANCE AROUND T H E NOSE—lupus erythe
matosus.
(g) EXAMINATION OF THE EARS
Carefully examine the ears including the meatus and the
mastoid for the following:
SIZE—large in mongolism.
SHAPE—ill-developed in lunatics and sometimes in epilepsy.
COLOUR—bluish in ochronosis.
TEXTURE—coarse in cretinism and myxoedema.
PRESENCE OF TOPHI—gout.
DISCHARGE FROM T H E MEATUS—otitis media.
TENDERNESS OVER T H E MASTOID—mastoiditis.
(h) EXAMINATION OF THE MUCOUS MEMBRANES
Examine the following:
(a) CONJUNCTIVAE—yellow in jaundice, pale in anaemia, congested in
conjunctivitis.
(b) LIPS—pale in anaemia, blue in cyanosis.
(c) TONGUE—for colour, evidence of glossitis, ulcers and fissures. (See
Chap. IV.)
(d) PALATE—especially for perforation as occurs in syphilis.
(e) GUMS—for bleeding, retraction, pigmentation, blue line of lead
poisoning, etc.
5. Examination of the Skin, Hair and Nails
(see Chapter IX)
6. Lymph Glands
Note their site, shape, size, consistency, mobility and tender-
ness. Look for them especially in the neck, axilla, supratro-
chlear and inguinal regions. (See Chapter VII.)
7. Genitalia and Breasts
These must be examined in every patient where there is sus-
picion of endocrine dysfunction. Note the following:

CASE TAKING 11
(a) Their development.
(b) Pubic and axillary hair.
(c) Voice.
(d) Look for discharge, ulcers, scars, tumours, etc.
8. Joints and Extremities
(see Chapter VIII)
V. PULSE, RESPIRATION, TEMPERATURE
Always end the General Examination of the patient by not-
ing down the Pulse, Respiration and Temperature.
A
For pulse, see under Cardio Vascular System.
Since breathing is the most important function of the chest,
observations regarding its depth, type and comparison on the
two sides is best noted while examining the Respiratory System.
For practical purposes the rate is taken during the General
Examination by noting the movements of the chest for full one
minute.
Temperature
Temperature in a patient is best recorded with a mercurial
thermometer which should be kept in position for about a
minute.
The usual procedure to record temperature is in the axilla,
but in a patient who is perspiring profusely, it is advisable to
take it by mouth. In rare cases, rectal temperature may have to
be recorded, especially in cholera where the skin temperature is
subnormal and rectal temperature is high.
Normal temperature is 36.5° to 37.2°C or 97.5° to 98.5°F.
Subnormal is below 36°C or 97°F.
Febrile means above 37°C or 99°F.
Hyperpyrexia means 41.5°C or 106°F.
Hypothermia means below 35°C or 95°F.

If a patient is febrile, inquire into the following:
1. Day of onset of fever.
2. Mode of onset—whether sudden or insidious.
3. If associated with rigors, vomiting, headache, coryza,
body-ache, diarrhoea, etc.
4. If continuous, remittent, intermittent or periodic.
5. Whether it comes down by crisis or lysis.
6. Whether the patient is drowsy, delirious or comatose.
7. If the patient perspires when the fever falls.
The common types of fevers may be grouped under the follow-
ing headings:
A. CONTINUOUS—the fever does not fluctuate more than about a
degree in 24 hours. Common example is lobar pneumonia.
B. REMITTENT—the daily fluctuations in the temperature exceed a
degree or two, but does not touch normal. Typhoid fever is typically
remittent in type.
C. INTERMITTENT—the fever touches normal for some hours during
the day. When the intermittence occurs daily, the type is quotidian;
when on alternate days, tertian; when two days intervene between
the attacks, the fever is known as quartan. All these three types are
typically seen in malaria.
1 t 5 • « «
FIG. I
Continuous Fever followed by Crisis. Case of Lobar Pneumonia.

CASE TAKING
FLC. 11
Remittent Fever. Case of Typhoid.
FIG. I l l
Intermittent Fever. Case of Malaria.

1.8
HOW TO EXAMINE A PATIENT
FIG. IV
Fever dropping by Lysis. Case o£ Broncho-Pneumonia.
By the time the History and General Examination of
the patient has been carefully gone into, the examiner
will be in a position to judge which system in the body
is mainly affected. Examine this System first and then
proceed to examine the other Systems.
Systems in which there are no revealing features of
involvement need not be described in detail.

CHAPTER II
R E S P I R A T O R Y S Y S T E M
A. INTERROGATION.
B. COMMON SYMPTOMS AND SIGNS.
C. EXAMINATION OF THE UPPER AIR PASSAGES.
D. EXAMINATION OF THE CHEST.
I. Inspection.
II. Palpation.
III. Percussion.
IV. Auscultation.
E. EXAMINATION OF SPUTUM.
F. EXAMINATION OF PLEURAL FLUIDS.

1.8
A. I N T E R R O G A T I O N
Particularly inquire into the family history of bronchitis,
asthma, tuberculosis and pleurisy. Also the previous history of
lung and pleural diseases, haemoptysis, glands in the neck, loss
of weight, etc. Occupation of the patient must be inquired
into to exclude industrial diseases.
In General Examination, particularly note the decubitus, the
condition of the eyes, the state and colour of the skin and lips,
the presence of emaciation and asthenia.
B. C O M M O N S Y M P T O M S A N D S I G N S
COUGH (see page 43).
Inquire into the following:
1. Its frequency.
2. Duration.
3. When worse, when better; if seasonal.
4. Its character—if paroxysmal, explosive, irritating, etc.
5. Its tone—if resonant, suppressed, husky, etc.
6. If with or without expectoration.
7. If accompanied by pain, distress, whoop, etc.
8. If associated with vomiting or haemoptysis.
9. If brought on by posture, effort, etc.
10. If there is any change in the voice.
11. Amount and character of the sputum according to the
patient.
DYSPNOEA; ORTHOPNOEA (see page 53).
1. Its description—if paroxysmal or coming on effort.
2. Mode of onset—if sudden or gradual.
3. Exciting or aggravating factors—worry, anger, excite-
ment, exercise.
4. Associated symptoms—cough, palpitation, pain, sweating,
collapse.
5. Evidence of any cardiac or respiratory diseases.

RESPIRATORY SYSTEM 17
PAIN IN THE CHEST (see page 45}.
Describe in detail:
1. Its position—whether localised or spreading.
2. Its character—stitching, stabbing, etc.
3. Its duration—if constant or intermittent.
4. Its relation to breathing, coughing, sneezing, posture,
movements.
5. Relieving and aggravating factors.
HAEMOPTYSIS (see page 48).
1. If preceded or accompanied by cough.
2. Colour.
3. Amount on first occasion and subsequently.
4. If mixed with froth and sputum.
5. Symptoms of lung or heart diseases.
HOARSENESS OF VOICE (see page 50).
Inquire as to the following:
1. Duration.
2. If associated with sore throat.
3. If progressive or improving.
4. History of tuberculosis.
5. Habits of smoking.
6. Occupation.
HICCOUGH
Inquire into the following:
1. History of gastric disturbances—eructation, vomiting,
abdominal discomfort, etc.
2. Chest disturbances—substernal pain, praecordial pain or
discomfort.
2

1.8 HOW TO EXAMINE A PATIENT
3. Nervous disturbances—neurosis, hysteria, emotion, menin-
gitis, encephalitis, hydrocephalus, etc.
4. Renal disorders—chronic nephritis, uraemia.
COMMON SIGNS
1. Cyanosis. Examine the lips, cheeks, ears, nose and nails
particularly (see page 51).
2. Clubbing of the fingers (see Chapter IX).
3. Glands in the neck (see Chapter VII).
4. Engorged veins, especially in the neck and chest.
5. Oedema (see page 102).
SURFACE MARKINGS OF T H E LUNGS
Before starting the examination of the Respiratory System it is necessary
to have some idea of the surface markings of the lungs and other important
structures.
The trachea, which begins at the level of the cricoid cartilage, bifurcates
at Ludwig's angle—a prominence at the junction of manubrium and the
body of the sternum. The bifurcation corresponds with the level of the
2nd rib in front and the 4th D.V. behind.
T h e apices are situated about an inch above the clavicles corresponding
with the neck of the 1st rib in front and 7th cervical spine behind, the
right apex being a little higher than the left. From this point, the inner
margins of the lungs slant towards the sternum meeting each other in the
middle line at the angle of Louis. On the right side the margin of the
lung continues down as far as the 6th costal cartilage where it turns out-
wards to meet the mid-clavicular line at the 6th rib, the mid-axillary line
at the 8th rib, the scapular line at the 10th rib and the paravertebral line
at the spine of the 10th dorsal vertebra. On the left side the landmarks are
the same, with the exception that the lung border turns away from the
sternum at the 4th costal cartilage and then arches outwards and downwards
to reach the 6th rib, a little outside the parasternal line.
- At the apices and along the inner margins of the lungs the pleura lies
so close to the lungs so as to follow the same surface markings, but at the
lower border of the lungs the pleura extends further, lying 4 cm. or so
below the lung borders anteriorly and posteriorly, and over 6 cm. below,
in the axilla.
The lobes of the lungs may be marked by drawing a line from the spine
of the 2nd dorsal vertebra to the junction of the 6th costal cartilage with
the sternum. This line crosses the 5th rib in the axilla. Below it, on
each side, lie the lower lobes and above it, the upper lobes. T h e upper
margin of the right middle lobe may be defined by taking a line from the
junction of the 4th costal cartilage with the sternum to meet the previous

line at the mid-axillary line. It will be recognised at once that the upper
lobes and the middle right lobe are mainly accessible from the front and
the lower lobes almost entirely from the back. In the axilla, parts of all
lobes are open to examination.
RLL—Right Lower Lobe
For the sake of convenience the surface of the chest may be divided into
the following regions: —
I. Three central regions anteriorly.
1. Suprasternal—from cricoid to superior border of the manubrium.
2. Superior sternal—from manubrium to Srd sterno-costal junction.
3. Inferior sternal—from 3rd sterno-costal junction to the end of
sternum.
II. Five antero-Iateral regions.
1. Supraclavicular—area above the clavicle.
2. Clavicular—over the clavicle.
3. Infraclavicular—area below the clavicle up to the ,?rd sternocostal
junction.
4. Mammary—bounded by the 3rd sterno-costal junction above and
the 6th sterno-costal junction below.
5. Inframammary—below the 6th rib to the costal arch.
FIG. V
RUL—Right Upper Lobe
RML—Right Middle J.obe
LUL—Left Upper Lobe
LLL—Left Lower Lobe

1.8
III. Two Iaternal regions.
1. Axillary
2. Infra-axillary )}meet each other at 6th rib.
IV. Four regions in the back.
1. Suprascapular—above the scapulae.
2. Scapular—overlying the scapulae.
(a) Supraspinous—above the scapular spine.
(b) Infraspinous—below the scapular spine.
3. Infrascapular—below the scapulae.
4. Interscapular, left and right—between the scapulae and the spine.
Important landmarks
The lower end of the sternum marks the 7th rib and corresponds with
the 9th dorsal vertebra behind.
The tip of the 9th rib is in about the mid-clavicular line.
T h e tip of the 11th rib is in mid-axillary line.
T h e most prominent spine in the back is that of the 7th cervical vertebra.
T h e lower angle of the scapula is at about the 6th or 7th interspace.
C. EXAMINATION OF THE AIR PASSAGES
1. NOSE. Look for the movements of the ala nasae.
Examine the nostrils for rhinitis, polypi, septal defects,
epistaxis and presence of foreign bodies. Examine the
sinuses for tenderness by pressing gently over them.
2. NECK. Look for enlarged glands, scars, oedema, venous
engorgement. Examine the thyroid gland.
3. LARYNX. Examine the vocal cords and look for evi-
dence of inflammation, ulcers, etc. Use spatula and do
laryngoscopic examination whenever indicated.
4. EXAMINE THE TENDONS OF STERNOMASTOIDS.
In mediastinal shift the tendon is often prominent on the
side of the shift.
5. TRACHEA.
(a) Locate its position. Insert your forefinger in the
jugular notch between the trachea and the sterno-
mastoid; the finger will slip to one side if the trachea
is deviated on to the other side. Displacement of the
trachea and the apex beat suggest that the position of

RESPIRATORY SYSTEM 2 1
the mediastinum has been altered by diseases of the
pleura, such as effusion and pneumothorax pushing
the mediastinum away from the affected side, or of
the lungs, such as fibrosis or collapse drawing it to-
wards the affected side.
(b) Tracheal tug. Extend the neck of the patient and
pull the larynx gently upwards. When there is an
aneurysmal dilatation, the pulsation of the aorta will
be distinctly felt transmitted at each systole of the
heart.
D. EXAMINATION OF THE CHEST
I. INSPECTION
This reveals the configuration of the chest, the degree of
movements on the two sides, the type and rate of respirations.
Examine the front, back and sides of the chest by standing by
the side of the patient and, if necessary, from the foot of the
bed. The back is best examined by letting the patient sit up,
if possible. Special attention should be paid to the lower inter-
costal spaces; for, normally, the soft tissues are sucked in slightly
during inspiration though the ribs themselves become more
widely separated. This sucking in is diminished or abolished
in effusion and pneumothorax; whereas it is exaggerated in
fibrosis of the lungs and very much so in pulmonary collapse due
to bronchial obstruction.
Note the following during breathing:
1. Rate of Respiration.
2. Type of Breathing.
3. .Rhythm.
4. Form of Chest.
5. Movements of Chest.
6. Presence of Veins.

1.8 HOW TO EXAMINE A PATIENT
1. RATE OF RESPIRATION
The normal rate in an adult is 16-20 respirations per minute.
It bears a definite ratio to the pulse rate of about 1 to 4. An
increase in the rate of breathing is called tachypnoea and slow-
ing is known as bradypnoea.
1. Increased rate occurs in:
Exertion.
Nervous excitement.
Fevers—in pneumonia the rate may even be as high as
the pulse.
Anoxaemia—cardiac, pulmonary, bronchial, laryngeal.
Alteration in the oxygen-carrying power of the blood—
anaemias, poisoning, diabetes mellitus, chronic neph-
ritis.
Pain while breathing—pleurisy, peritonitis.
2. Slowing of breathing occurs in:
Brain tumours.
Obstruction to the bronchi.
Narcotic drugs—in opium poisoning the respiratory rate
may be as low as 5 to 6 per minute.
2. TYPE OF BREATHING
Normal breathing in males and in some females is abdomino-
thoracic. It may be thoraco-abdominal in some females.
1. Thoracic breathing occurs in paralysis of the diaphragm,
peritonitis and severe ascites.
2. Abdominal breathing occurs in pleurisy, pleurodynia
and lung collapse.
„ 3. RHYTHM
The normal breathing is rhythmical, with inspiration longer
than expiration. Changes in the rhythm may occur as follows:
PROLONGED INSPIRATION—laryngeal or tracheal obstruction especial-
ly laryngeal diphtheria in children and mediastinal growths in older
individuals.

PROLONGED EXPIRATION—bronchial or pulmonary diseases, cardiac
and renal asthma.
DYSPNOEA—laboured breathing as occurs in congestive cardiac failure
and several other conditions. (See page 53.)
ORTHOPNOEA—exaggerated form of dyspnoea, where the patient finds
it difficult to lie in bed.
KUSSMAUL'S BREATHING—this occurs in ketosis, especially in diabetes
mellitus. The breathing is deep and perhaps a little more rapid
(air-hunger).
STERTOROUS BREATHING—occurs in apoplexy.
HISSING EXPIRATION—may be present in uraemia.
CHEYNE-STOKE'S BREATHING—this consists of rhythmical waxing
and waning of respirations—alternations of hyperpnoea and apnoea. Any-
thing that causes anoxaemia of the respiratory centre results in Cheyne-
Stoke's breathing; anoxaemia lowers its sensitivity and so abolishes
spontaneous rhythmical activity of breathing. The consequent apnoea
results in the accumulation of C02 in the body, thereby reawakening the
centre and causing hyperventilation, which in turn removes the excess of
C02 , whereupon the centre "goes to sleep again".
Causes of Cheyne-Stoke's breathing
(a) Left ventricular failure.
Essential hypertension.
Hypertension due to renal diseases.
Phaeochromocytoma.
Coronary disease.
Vascular diseases—aortic regurgitation, patent ductus, coarctation of
the aorta.
(b) Lesions of the brain—cause increase in the intracranial pressure.
Meningitis.
Cerebral abscess.
Tumours.
Cerebral haemorrhage.
Cerebro-medullary degeneration. In such cases, Cheyne-Stoke's breath-
ing is the main symptom sometimes.
(c) Poisons and toxins.
Opium, barbiturates, sulphonal, chloral.
Uraemia.
4. FORM OF CHEST
A healthy chest is bilaterally symmetrical. Its contours are
smooth; it has no hollows and at most shows a slight recession
below the clavicles. It is ellipsoidal in shape with the longer

1.8
axis vertical. The ratio between the transverse and antero-
posterior diameter is 7 : 5; the subcostal angle is 70°; the inter-
spaces are broader in front than behind.
Bilateral deformities
1. Indicating proclivity to lung diseases—especially tuberculosis
(a) Alar chest. There is protrusion of the vertebral borders of the
scapulae, drooping of the shoulders, long thorax, long neck and
very acute epigastric angle.
(b) Flat chest. Ribs are placed very obliquely, the subcostal angle
is very acute, the antero-posterior diameter shorter. Generally
associated with "alar-chest".
2. Indicating past diseases
(a) Rachitic chest. There is depression on either side of the sternum;
in children, often associated with "rickety rosary"—bead-like
enlargement at the costochondral junction. Result of old rickets.
(b) Pigeon breast. Sternum unduly prominent; cross section is
triangular. Result of obstruction to the upper air passages in
childhood. Generally associated with rickets.
(c) Harrison's sulcus. This is a transverse groove passing outwards
from xiphisternum as far as mid-axillary line sometimes, occurring
along the line of diaphragmatic attachment. Often associated
with a "pigeon breast" or rachitic chest.
(d) Funnel .chest. A depression found in the lower part of the
sternum. May be congenital, as a result of rickets in childhood,
or an occupational deformity as found in cobblers.
(e) Kyphosis. Commonest cause of chest deformity, not due to
diseases of thoracic viscera, is kyphosis—forward curvature of the
spine with dorsal prominence.
FIG. VI
Cross Section of
Rachitic Chest
Cross Section of
Pigeon Breast

3. Indicating present disease
(a) Barrel-shaped chest. Ribs less oblique; Louis's angle very pro-
minent; subcostal angle wider; anteroposterior diameter increased.
Occurs in emphysema.
(b) Distorted or phthisical chest. Wasting of interspaces; ribs unduly
prominent. Occurs in fibrosis of the lungs, generally tubercular.
Unilateral deformities
(a) Bulging—fluid or air in the pleura, new growths in the lungs,
very big heart, pericardial effusion, tumours, aneurysms, empyema
necessitans, subcutaneous emphysema on one side.
(b) Unilateral depression—fibrosis, atelectasis, pleural adhesions, old
emphysema.
(c) Scoliosis. T h e commonest cause of unilateral chest deformity, not
due to diseases of the thoracic viscera, is scoliosis—lateral curva-
ture of the spine.
5. MOVEMENTS OF T H E CHEST
1. Note carefully for deficiency of movements, bulging or
indrawing of the interspaces.
Ordinarily the chest moves uniformly on either side; hence,
while examining, note carefully whether there is equality of
expansion on the two sides. Note if there is any deficiency of
movements, bulging or indrawing of the interspaces. Note if
the accessory muscles are working. When dyspnoea is present
the accessory muscles are called into play, and hence, one should
carefully observe the movements of the alae nasi and of sterno-
mastoids.
COMMON ABNORMAL MOVEMENTS OF THE CHEST
Causes of unilateral defective movements
(a) Obstruction to a main bronchus by a foreign body or new growths—
there is often indrawing of the intercostal interspaces on the affected
side during inspiration.
(b) Consolidation of the lungs by pneumonia, tuberculosis or new
growths.
(c) Fibrosis of the lungs and pleural adhesions. In early tuberculosis
the apex on the affected side may show a characteristic lagging.
(d) Air and fluid in the pleural cavity.
(e) Massive collapse.

1.8
Causes of bilateral restricted expansion of the chest
(a) Emphysema—in severe cases there may be bulging over the apices
during inspiration.
(b) Fibrosis of both the lungs.
(c) Bilateral consolidation.
(d) Bilateral pleural effusion or pneumothorax.
2. Note if the accessory muscles are working. This occurs in
all conditions that cause embarrassment to respiration. Typically
present in lobar pneumonia.
3. Note the depth of the lung movements.
These may alter as follows:
STERTOROUS BREATHING—paralysis of the soft palate. Occurs in
apoplexy and coma.
STRIDOR—hissing sound occurring in paralysis of the vocal cords or
obstruction in the upper air passages.
WHEEZING—obstruction in bronchi as occurs in bronchial asthma.
HISSING—uraemia.
AIR HUNGER—diabetic coma.
RATTLING—oedema of the lungs.
4. Look for Litten's diaphragmatic sign by standing at the
foot of the bed. The patient has to lie in bed which is placed
towards a well lighted window. The phenomenon takes the
form of a wave motion which begins on both sides at approxi-
mately the height of the sixth intercostal space, travels down-
wards and forwards with maximum inspiration over several
intercostal spaces. It is best seen in thin subjects. It is due to
a pull on the chest-wall by the diaphragm when it descends dur-
ing inspiration. The movements of the diaphragm are dimi-
nished or absent i.e. Litten's sign is absent in pleural effusion,
pneumothorax, pneumonia, subdiaphragmatic abscess, lesions of
the phrenic nerves, or pleural adhesions.
6. PRESENCE OF VEINS
Normally the veins in the chest are hardly visible. If present
in young adults, suspect early tuberculosis (varicose zone of
alarm); if present in elderly people, suspect lung growth or
mediastinal tumours.

II. PALPATION
This confirms the impressions of inspection, especially the
movements of the chest and abnormal appearance of the chest
wall.
While palpating, look for the following:
1. Apex-beat.
2. Tenderness.
3. Fluctuation.
4. Form of the Chest.
5. Movements of the Chest.
6. Vibrations.
1. T H E APEX-BEAT
The apex-beat is normally felt in the 5th interspace half-an-
inch inside the left mid-clavicular line. Its displacement alone
without displacement of the trachea, may be due to enlarge-
ment of the heart or disorders outside the heart like scoliosis.
If both the apex as well as the trachea are shifted it- is a definite
evidence of mediastinal shift.
Z TENDERNESS
Press gently where the patient complains of pain, or where
there is a swelling. Watch the expression of the patient so as
to avoid unnecessary pain.
Tenderness may be due to local injury, myositis, hepatitis,
pleural diseases, heart diseases, etc.
3. FLUCTUATION
This may be present when there is an abscess in the chest wall
or in empyema necessitatis.
4. FORM OF T H E CHEST
(a) Confirm the findings of inspection.
(b) Feel for subcutaneous emphysema. If present, it has a
characteristic spongy feeling.

1.8
5. MOVEMENTS OF CHEST
(a) Measure the chest at full inspiration and expiration just
below the nipples. There should be a difference of at
least two inches normally.
(b) Compare the movements by placing the hands on the
sides of the chest and making the radial borders of the
thumbs meet the mid-line in front of the chest. Note the
distance of departure of the thumbs when the patient
takes a deep breath. For the movements of the apices,
stand behind the patient, place the thumbs near the
vertebrae and fingers over the apices. Note the move-
ments of the fingers. Finally put one hand in front of
the chest and the other over the epigastrium. In health
both the hands are raised on inspiration. In paralysis of
the diaphragm the epigastrium falls during inspiration.
ti. VIBRATIONS
Use the same hand on both sides because the sensitivity of the
two hands differ. Feel with the palms of the hand. Experts
may use both hands symmetrically placed on either side of the
chest and then move them to the various parts of the chest.
Feel for:
(a) Pleural friction—occurs in early pleurisy due to rubbing
of the two pleural surfaces against each other.
(b) Rhonchal fremitus—occurs when there are catarrhal
changes in the bronchi as in bronchitis, asthma, and
pulmonary congestion. The "death rattle" in acute
oedema of the lungs constitutes a striking sample.
(c) Tactile vocal fremitus. Ask the patient to say some
words with a nasal sound e.g. ninety nine, and feel with
the flat of the hand for the vibrations transmitted from
the larynx through the bronchi, lungs and the chest wall.
The high-pitched voices of women and children do not
produce vibrations as good as the lower tones of the male
voice. In children, however, the voice, although higher

in pitch, is fairly well conducted by the smaller lung and,
hence, the vocal fremitus is usually well heard in them.
Over the trachea and bigger bronchi the fremitus is
normally more intense. An unusually thick voice will
tend to diminish vocal fremitus; so also a feeble voice.
III. PERCUSSION
Percussion reveals the character of the lung tissue and the sur-
rounding pleura.
Although percussion of the chest is one of the important parts
of the examination of the respiratory system, the limits of
percussion must clearly be borne in mind. One cannot percuss
deeper than 5 cm. It is not possible to demonstrate any patho-
logic lesion in the lung which is covered by a layer of air more
than 5 cm. thick or fluid 1 cm. thick. A tumour in the chest
lying deeper than 5 cm. from the surface produces hardly any
change in the percussion note. A lesion smaller than 2-3 cms.
in diameter does not cause any change in the percussion note.
Free fluid in the pleural cavity may not be detected by percus-
sion unless it exceeds 200 c.c. in amount.
Percussion mainly determines:
1. The boundaries of the lungs.
2. The resonance of the lungs.
3. The myotatic irritability.
Percuss as follows: ,
Place the middle finger of the left hand against the surface
of the chest allowing the finger to conform to it under light
pressure. With the middle finger of the right hand flexed at a
right angle to the metacarpal bones, tap sharply against the
second or last phalanx of the left middle finger, which acts as a
pleximeter. The stroke should be delivered from the wrist and
not from the elbow. Over the clavicles direct percussion is to
be used.
Percuss from the resonant towards the less resonant area.
Place the longer axis of the pleximeter finger parallel to the
dull border that is being percussed. Areas to be compared
must be identical on both the sides as far as possible.

1.8
METHODS OF PERCUSSION
A. Incorrect, because the pleximeter finger is not making close
contact with the chest.
B. Correct position for pleximeter finger.
C. Correct position of the hand during percussion.

Carefully percuss the front of the chest, compare the corres-
ponding sides, note the dullness in the cardiac and liver areas,
and the hyper-resonance over the stomach area. Next, percuss
the axillae with the patient joining his hands above his head,
and finally the back with the patient sitting up, if possible,
with arms folded and the body slightly bent forward.
Normal percussion note is resonant. This term, is however,
relative as a person with thick chest wall or much subcutaneous
fat will show less resonance than one with a thin, poorly mus-
cled chest-wall.
1. Elicit the boundaries of the lungs.
These coincide with their surface markings. The following
points, while eliciting the borders, must be borne in mind.
(a) The lower border of the right lung is thin and overlaps the liver.
Hence light percussion is necessary.
(b) In older people the borders of the lungs extend beyond by one rib.
In children they are a little above.
(c) The liver may be enlarged upwards and give rise to dullness at the
base of the right lung.
2. Note the resonance and its degree.
Particularly note the state of the lungs so far as their elasti-
city and air content are concerned. Also note the position of
the lungs in relation to the chest wall and whether they are
separated by fluid, air or both, in the pleural cavity.
While listening to the resonance, the following points iritist
be borne in mind: ;
(a) T h e percussion note of the right apex is slightly dull as compared
to the left due to eparterial bronchus underneath.
(b) The area over the liver and heart are dull to percussion.
(c) The area over the stomach is hyper-resonant. This is known as
Traube's space. It is a roughly semilunar area bounded on the right
by the inferior border of the liver, above by the apex, on the left
by the anterior border of the spleen and below by the left costal arch.
Tympanitic resonance can usually be heard over this area as stomach
is situated underneath. This area is obliterated in left pleural
effusion, enlargement of the left lobe of the liver, pericardial effusion
and sometimes in enlargement of the spleen. It is increased when the
stomach is distended with gas.

32 H O W T O EXAMINE A PATIENT
(d) The back of the chest is less resonant due to greater musculature and
requires strong percussion.
(e) Mark the Kronig's isthmus—a band of resonance connecting the
resonant areas on the back and front of the chest and which passes
over the shoulder. This area of about five cm. in width is often
reduced in early apical T.B.
3. Test for myotatic irritability.
In wasting diseases and often in tuberculosis, the muscles in
front of the thorax are unduly irritable and a light tap over
the sternum or over the pectoral muscles produces localized
contractions.
RESONANCE OF LUNGS
1. INCREASED RESONANCE occurs in emphysema, pneumothorax and
over a big cavity in the lungs; also over a normal lung when a
portion of it or the other lung is consolidated.
Special types of increased resonance
SKODAIC RESONANCE—a clear high pitched note occurring above
the level of pleural effusion i.e. over the lung that is relaxed, but
still containing air.
TYMPANITIC—a hollow drum-like sound occurring when air from
the lungs finds its way into the pleural cavity; may also occur in
severe emphysema.
AMPHORIC RESONANCE—a peculiar low pitched metallic sound
occasionally heard while percussing over a pneumothorax or large
cavity.
BELL-SOUND. When one percusses in front of the chest with a
' couple of silver coins, one being used as a plexor and the other
as a pleximeter, a bell-sound may be heard on the back of the
chest when the pleural cavity contains air in a sufficient quantity.
CRACKED-POT SOUND—a hollow note caused by sudden expul-
sion of air through a constricted orifice. Occurs where a cavity
communicates with a bronchus. It is best elicited by asking the
patient to keep his mouth open, while percussing. Occurs in healthy
children while crying. May occur in pneumothorax and above the
level of fluid in pleural effusion.
2. DIMINISHED RESONANCE occurs in pneumonia, thickened pleura,
tuberculosis, fibroid lung, collapse of the lung, atelectasis.
In pleural effusion, the percusion note is stony dull and resistance
is felt by the pleximeter. In tumours, it is dull or often stony dull.

IV. AUSCULTATION
Auscultation of the chest is the most important part of the
examination of the Respiratory System. It clearly gives a pic-
ture of the exact state of the underlying lung and the pleura.
Besides, auscultation is the only method to detect foreign
sounds which are often found in most of the diseased conditions
of the lungs. The vocal fremitus, which is felt by the hand,
may not be a valuable guide to determine the vibrations caused
by the larynx, as the examiner's hand may not be so sensitive.
Vocal resonance is definitely a more reliable method.
Auscultate to determine the following:
1. Character of breath sounds.
2. Presence of foreign sounds.
3. Vocal resonance.
Place the stethoscope firmly over the chest so as to prevent
sounds resulting from its movements.
Learn to discriminate heart sounds while auscultating the
lungs.
Compare identical points on the two sides of the chest.
The following practical points are to be observed while
auscultating the chest.
Hair on the chest produces a crackling noise when it comes in
contact with the stethoscope and may be mistaken for adventi-
tious sounds.
In nervous patients and those feeling cold, shivering will
produce sounds that may be mistaken for adventitious sounds
in the lungs.
1. CHARACTER OF BREATH SOUNDS
While breathing, note the intensity of both inspiratory and
expiratory phases and if there is any pause between the two
phases.
Breath sounds may be divided into two wide groups:—those without a
pause, vesicular breathing and its variants, and those with a pause—
bronchial breathing and its variants.
3

3 4 H O W T O EXAMINE A P A T I E N T
Vesicular breathing and its variants
(i) VESICULAR BREATHING. Normal breathing is known as vesi-
cular. The inspiration is heard thrice the expiration; there is no
pause between the two phases; inspiratory phase is distinct and
rustling in character; the expiratory phase is short, soft and low
pitched.
(ii) BRONCHO-VESICULAR BREATHING. There is a very small
pause between the two phases and the expiration is slightly longer
than normal. Normally it is heard over the second right interspace
because of the eparterial bronchus underneath. In diseased condi-
tion, it is heard in partial consolidation or infiltration of the lungs.
(iii) PUERILE. Sounds are harsher than normal but of normal dura-
tion; heard in children because the elastic tissue of the lungs is not
well developed. Also heard in old people due to loss of elasticity
of the lung tissue.
(iv) HARSH. Expiration is nearly equal to or slightly longer than
inspiration and as clearly heard as inspiration. Indicates loss ol
elasticity of the lung tissue and may be an early evidence of tuber-
culosis of the lungs. May occur normally over the 2nd right inter-
space due to the presence of eparterial bronchus underneath.
(v) PROLONGED EXPIRATION. Expiration is very much longer than
inspiration. Occurs in asthma and chronic emphysema.
(vi) "COG-WHEEL" BREATHING. Jerky interruptions during
inspiration. May occur normally in nervous individuals or may
signify unequal loss of elasticity in the lung lobules. Often heard
in early tuberculosis of the lungs, in neurotics, and in fatigue.
(vii) GRANULAR BREATHING. Finer type of interruptions than those
of "cog-wheel" breathing. If localised, it is an important sign of
early pulmonary infiltration.
(viii) FEEBLE OR ABSENT. The sounds may not be clear in fat indi-
viduals or may indicate defective expansion, as in early pneumonia,
thickened pleura, effusion, pneumothorax, phrenic nerve paralysis
or atelectasis of the lungs.
Bronchial breathing and its variants
In all these there is a distinct pause between inspiration and expiration.
(a) TUBULAR BREATHING. High pitched breathing with a small
but distinct pause and with inspiration equal to expiration. Heard:
in lobar and broncho-pneumonia.
(b) BRONCHIAL BREATHING. Inspiration is equal to expiration; both
phases harsh in character with a distinct pause. May be normally
heard over the trachea. Typically heard in tuberculosis of the lungs
and in broncho-pneumonia. May also be heard in tumours close to a
large bronchus, lung collapse and infarction. In pleural effusion,
distant bronchial breathing may be heard over the fluid. In empyema,
especially in children, bronchial breathing is often present.

(c) CAVERNOUS BREATHING. Botli phases have a peculiar hollow
character. There is a wide pause between the two. Heard over
cavities in the lungs. Normally heard over the larynx especially while
auscultating from the back.
(d) AMPHORIC BREATHING. Intense form of cavernous breathing
having a metallic quality, best imitated by blowing across the mouth:
of a bottle. Occurs over a cavity communicating with a bronchus.
2. FOREIGN SOUNDS
These sounds are normally not heard over the chest. They
occur in the following forms:
(a) Rales—crackling sounds produced in the bronchi or
alveoli by the passage of air through a fluid exudate.
These are of three varieties:
(i) Fine rales or crepitations—heard best at the end of
inspiration in conditions where the alveoli are
blocked as in pneumonia.
(ii) Medium rales—occur in smaller bronchi and are
audible at the end of inspiration and the beginning
of expiration. Often present in phthisis and
broncho-pneumonia. They may also be heard in
ordinary bronchitis, but in such cases they disappear
on coughing.
(iii) Coarse rales—occur in bigger bronchi and are heard
throughout the inspiration and expiration, as in ex-
tensive phthisis. Coarse bubbling rales are also
heard in resolving stages of pneumonia and oedema
of the lungs. Metallic rales are coarse rales of a
high pitch giving the impression of a shower of
drops falling into a metallic vessel; they are asso-
ciated with amphoric breathing, and like it, suggests
a large cavity in the lungs.
(b) Rhonchi. These are dry sounds produced by the pas-
sage of air through thick mucus.
They are of two varieties:
(i) Sibilant—high-pitched sound due to presence of
mucus in the smaller bronchi; heard best during the

3 6 H O W TO EXAMINE A P A T I E N T
latter half of inspiration and beginning of expira-
tion as in bronchitis,
(ii) Sonorous—low-pitched sound heard throughout ins-
piration and expiration due to presence of mucus in
the larger bronchi; typically present in bronchial
asthma.
(c) Friction sounds or pleural rub. These sounds are due to
rubbing of the two surfaces of pleura in early pleurisy.
They occur when the two inflamed surfaces rub against
each other during inspiration as well as during the cor-
responding period of expiration. They are unchanged
on coughing and may be intensified by pressure with
the stethoscope. They are best heard where areas of
pleurisy are more frequent, namely in the axillae and
beneath the nipples.
(d) Metallic tinkle. Over pneumothorax, all transmitted
sounds acquire a tinkling quality, because the air in the
pleural space acts as a resonating chamber. The spoken
and whispered voice, the auscultated cough and rales
acquire a musical and bell-like tinkle and such findings
are pathognomonic of air in the pleural cavity.
(e) Hippocratic succussion. This is a term applied to a
splashing sound heard when a patient, who has fluid and
gas in the pleural cavity, is gently shaken or moves sud-
denly.
,(f) Post-tussive suction. This is a term applied to a sucking
noise heard over a cavity immediately after the patient
has coughed. It is produced by air rushing into the
cavity during inspiration after the cough. When dis-
tinctly heard it is of considerable diagnostic value as it
can only occur when a cavity is present.
3. VOCAL RESONANCE
Just as laryngeal vibrations are palpable on the chest wall as
-vocal fremitus, so also they are audible through the stethoscope,
as vocal resonance. The advantage of the latter over the
former is that even high pitched sounds are appreciated by the
stethoscope which are not easily palpable.

Method. Ask the patient to say some words with a nasal
twang like ninety-nine, while auscultating. Compare identical
points on the two sides. Normally, the vocal resonance is more
distinct in the second right interspace and nearer to the larger
bronchi.
The vocal resonance may be increased, diminished or absent
in diseased conditions of the lungs or pleura. It is diminished
or absent in pleural effusion because the lung underneath is
relaxed and hence, fails to conduct the vibrations, pneumotho-
rax, thickened pleura, emphysema, lung atelectasis, tumours
sometimes, and when a bronchus is blocked by a foreign body.
When exaggerated, it may be heard in the following forms:
(a) Bronchophony. The vocal vibrations are distinctly
heard. Occurs in consolidation of lungs, phthisis,
tumours adjacent to a bronchus, large infarctions, and
in a collapsed lung in intimate contact with a bronchus.
If bronchophony is present, ask the patient to whisper in
order to exclude a cavity, which also gives rise to bronchophony,
as it is surrounded by fibrous tissue.
(b) Pectorioloquy. Articulate voice sounds are clearly
heard; best elicited by asking the patient to whisper.
Characteristic of a cavity.
(c) Aegophony. Sound of a bleating character heard best
near the lower angle of the scapula in pleural effusion
of a moderate size i.e. at the upper limit of a pleural
effusion.
(d) Amphoric resonance. A peculiar metallic resonance
heard in cases of pneumothorax. The metallic resonance
is imparted to the breath sounds also.
E. EXAMINATION OF SPUTUM
Physical Examination
Note the following:
A. Quantity.
Note the amount passed in 24 hours and inquire whether
change of posture produces larger quantity as occurs in bron-

3 8 H O W T O EXAMINE A PATIENT
chiectasis. Measuring the quantity periodically is useful to
determine the progress in tuberculosis of the lungs and sup-
purative lung diseases.
A moderate amount of sputum, about two ounces daily,
usually mucopurulent, is expectorated daily in acute bronchitis;
a little larger amount is passed in chronic bronchitis, resolving
pneumonia and bronchogenic carcinoma. Larger amounts, i.e.
over ten ounces per day are passed in bronchiectasis, lung abscess
or when an empyema ruptures into a bronchus. Copious frothy
sputum is often expectorated in acute pulmonary congestion.
The sudden passing of several ounces of purulent sputum is
almost pathognomonic of a lung abscess, empyema or sub-
phrenic abscess bursting into a bronchus. Rupture of a pul-
monary hydatid cyst is characterised by sudden production of
clear, watery, salt-tasting fluid.
B. Quality and colour.
MUCOID—clear, tough, jelly-like. The amount is generally not great.
Characteristically present in early bronchitis. The sputum is jelly-like
and sticky.
SEROUS—thin, watery, often blood-stained. Indicates oedema of the
Jungs.
FROTHY—copious, frothy, often blood-stained. Also indicates pulmo-
nary oedema.
FIBRINOUS—clear, tough and sticky and may be "rusty" in colour.
Occurs in lobar pneumonia.
PURULENT—contains pus and, hence, offensive in smell. Occurs in
abscess, gangrene, and when an empyema ruptures into the air-passages.
The sputum is thick and yellow—even green—and not sticky.
MUCO-PURULENT—contains lumps of muco-pus, which are heavier
than the other constituents and, hence, sink to the bottom when collected
in a conical glass or settle in "nummular" form when spat on a flat sur-
face. Such sputum is seen in bronchiectasis, abscess, gangrene, putrid
bronchitis and where an empyema ruptures into the air passages.
BLOOD-STAINED. When m excess, it is to be distinguished from blood
coming from the stomach which is darker in appearance and acid in
reaction, whereas blood coming from the lungs is bright red in colour
and alkaline.
RUSTY—occurs in pneumonia.
BRIGHT RED—phthisis, mitral stenosis, leaking aneurysm, bronchiectasis.
PRUNE-JUICE COLOURED—pulmonary oedema, bronchogenic carci-
noma, pneumonia in the aged.
RED-CURRANT JELLY—neoplasm.

ANCHOVY-SAUCE COLOURED—amoebic liver abscess bursting into the
lungs. (An ordinary liver abscess, if ruptured into the lungs, gives a
greenish-yellow colour to the sputum).
BLACK-SPUTUM (not to be mistaken for blood)—common in coal-
miners.
GREEN-SPUTUM—occurs as a result of disintegration of leucocytes when
there is retention of purulent sputum as in bronchiectasis and lung
abscess, when the infected sputum is not easily expectorated.
C. Consistency.
A sample of the sputum should be prepared on a black tray
and examined with the help of two teasing needles for the fol-
lowing:
BRONCHIAL CASTS—these are greyish-white, tree-like casts of bronchi
about half cm. in length, often present in the sputum in chronic
bronchitis.
DITTRICH'S PLUGS—these are yellowish caseous masses, usually about
the size of a pin-head, sometimes a little bigger, characteristic of bron-
chiectasis and foetid bronchitis. When crushed, they emit a foul odour.
They consist of granular debris, fat globules, fatty acid crystals and
bacteria.
CURSCHMAN'S SPIRALS—these are whitish wavy threads, often coiled
into little balls, resembling sago beans. They are better appreciated
under the microscope, where they appear as mucous threads with a bright
colourless central line, around which arc wound many fine fibrils in
spiral form. They are often found in bronchial asthma and nearly always
associated with the presence of Charcot-Leyden crystals.
LUNG-STONES. Pneumoliths, consisting of calcium carbonate or calcium
phosphate may be found in the sputum. They are generally flat and
occasionally have small appendices. Often found in chronic tuberculosis.
LAYER FORMATION. Muco-purulcnt sputum as occurs in bronchiecta-
sis, lung abscess, gangrene, putrid bronchitis and chronic tuberculosis
with profuse expectoration, when collected in a conical glass,
gradually settles into three layers: the lowest yellowish layer con-
taining purulent flecks of pus, blood and shreds of lung tissue; the middle
serous, watery layer of moderate opacity; and the uppermost non-
transparent foamy layer consisting of loose purulent balls mixed with air
and mucus. ,
D. Odour.
In ordinary bronchitis, the sputum has no smell or has a
stale smell. In tuberculosis, the smell of the sputum is un-
pleasant and more so in bronchiectasis. In gangrene and put-
rid bronchitis, the odour of the sputum is very offensive and
may be so in lung abscess as well.

Microscopic Examination.
A. CELLULAR STRUCTURES
PUS CELLS. These are disintegrated leucocytes.
EPITHELIUM. In heart failure, when there is pulmonary congestion,
iron containing pigment may be seen in the alveolar epithelium, the
so-called heart failure cells.
RED CELLS. Presence of a few of these cells have not much significance.
Any violent cough may cause a little bleeding into the alveoli.
EOSINOPHIL CELLS—occur in bronchial asthma and eosinophilic lungs.
B. ELASTIC FIBRES
Their presence indicates destruction of lung tissue as occurs in phthisis,
gangrene or abscess.
C. ORGANISMS:
PARASITES—especially look for hooklets in hydatid disease; so also for
lung flukes and segments of ecchinocci.
TUBERCLE BACILLI. Fix the slide by heat and stain by Ziehl-Neelsen's
method. Cover the smear with carbol-fuchsin and warm the slide until
steam rises from the surface of the stain. Do not boil. Decolourise with
20% sulphuric acid till all the visible colour is washed out. Wash with
distilled water. Countcrstain with dilute methylene blue for about 20
seconds. Wash, dry and examine under oil immersion lens for myco-
bacteria tuberculosis, which are stained red.
COCCI AND BACILLI. Fix the slide by heat and stain by Gram's
method as follows: Stain the smear with oxalated gentian violet for 1
to 3 minutes. Drain off the stain and without washing pour Gram's
iodine on the slide. Keep it for one minute. Wash with water. De-
colourise with rectified spirit, by allowing it to fall drop by drop on a
horizontally held slide and allowing it to flow over the stained area before
falling off the end of the slide. Decolourising agent should not be allowed
to act for more than two minutes. Wash well with water, counterstain
with one per cent saffranin for 20 seconds. Wash with water and dry
before examining for micro-organisms.
D. CURSCHMAN'S SPIRALS—seen as bright colourless central lines
around which are wound tiny fibrils in spiral form. Commonly found in
bronchial asthma.
E. CHARCOT-LEYDEN CRYSTALS—visible under the microscope as
octahedral or spindle-shaped crystals of slightly yellowish tinge. Often
seen in bronchial asthma and parasitic infestation of the lungs.
F. NEOPLASTIC CELLS—may be seen in bronchia] carcinoma.
G. ASBESTOSIS—golden yellow bodies having bulbous enlargement at
the extremities resembling dumbells are characteristically seen in asbestosis.
Bacteriological Examination
Perform cultures, inoculation in guinea-pigs, etc.

PLEURAL FLUIDS
Aspiration of fluid from the pleural cavity may be performed
as a therapeutic measure or for diagnostic purpose. Clinically
fluid can be detected if there is at least ten ounces in the
pleural space. It needs a pint of fluid to cause mediastinal
shift—an important diagnostic feature of pleural effusion.
Let the patient relax on a bed-rest and ask him to raise the hand and
let it rest on the head on the side to be punctured. After aseptic pre-
cautions novocainise the tract and put in a thick-bore needle in the 5th or
6th space in the mid-axillary line or in the 8th space in the back just below
the tip of the scapula. Withdraw the fluid slowly in order to avoid respi-
ratory embarassment. Discontinue aspiration if pain, cough or dyspnoea
develops.
The detailed examination of the fluid is not within the purview of this
book. However, naked eye examination of the fluid invariably helps one
to gauge whether the fluid is exudate, transudate, pus containing or hae-
morrhagic. Blood stained fluid occurs in malignancy, pulmonary infarction
or trauma. In T.B. the fluid is straw-coloured and may 'coagulate on
standing. In empyema the fluid is opaque and is full of pus cells.
The common conditions that produce pleural effusion are inflammations
giving rise to transudates or non-inflammatory conditions giving rise to
exudates.
Differentiation between exudate and transudate.
HOW TO PERFORM PARACENTESIS
HOW TO EXAMINE T H E FLUID
EXUDATE TRANSUDATE
1. There are inflammatory Following disease elsewhere.
changes in the pleura.
2. Brownish-yellow.
3. Sp. gr. above 1015.
4. Protein content 3 to 5%.
5. Clots on standing.
6. Lymphocytes present.
Pale yellow.
Sp. gr. below 1015.
Protein content 0.5 to 1.5%.
Does not clot.
Cells nil, or few endothelial cells.

4 2 H O W T O EXAMINE A P A T I E N T
PLEURALEFFUSIONS
EtiologicalClassification
InflammatoryNon-inflammatoryEmpyemaHaemothoraxChylous
(exudate)(transudate)(pus)(blood)(chyle)
TuberculosisCardiac—congestivePneumoniaMalignancyPressnreonthoracicduct
failure,constrictive
MalignancypericarditisLungabscessTuberculosisFilariasis
PolyserositisRenal—acutenephritis,TuberculosisLunginfarctionTuberculosis
nephrosis(chyliform)
Pneumonia(secondary)NewgrowthsBlooddyscrasias
Liver—cirrhosis.
PulmonaryinfarctionInfectedpneumothoraxHaemorrhagicsmall-pox
Malnutrition
PneumothoraxSecondarytosubphrenic
Severeanaemiasabscess
Sub-diaphragmatic
abscess.Pressurebyglands—Actinomycosis
Hodgkin'smalignancy

MANIFESTATIONS OF COMMON RESPIRATORY
SYMPTOMS
COUGH
Coughing is a defensive reflex which helps to clear the lower
air passages and protect them against the entry of foreign
matter and prevents stagnation of secretion in the passages
themselves. It begins with inspiration—the deeper the inspira-
tion the more air in the lungs and more effective the cough.
The glottis closes, the soft palate is raised, and all the accessory,
in addition to the ordinary muscles are tensed for a forced
expiration. The pressure in the respiratory tract rises as is
shown by congestion in the face and neck. Then the glottis
relaxes and the contents are expelled from the mouth.
Classification of Cough
Cough may be due to infections of the lungs, mechanical
irritation of the air passages and reflex conditions.
A. Infections
COMMON COLD—cough is short and dry at first and later
paroxysmal till the mucus is cleared.
PHARYNGITIS—cough is troublesome, and persistent—generally dry.
LARYNGITIS—cough is noisy, sometimes husky and stridulous.
TRACHEITIS—cough is intensely irritating and may be paroxysmal;
even wheezing may be present.
BRONCHITIS—cough may be free or paroxysmal, but always pro-
ductive.
PNEUMONIA—cough is dry on the first day, followed by passage of
rusty sputum on the next day and frothy later on.
TUBERCULOSIS—cough is frequent, short and sharp and may be
dry in the early stages; later on it is persistent with copious purulent
expectoration.
PLEURISY—solitary, dry, hacking cough, suppressed by the patient
as much as possible to avoid pain.
BRONCHIECTASIS—constant cough with copious expectoration of
unpleasant smell, more marked on waking in the morning or change
of posture.
LUNG ABSCESS AND GANGRENE—the •cough is free, of offensive
sputum and often blood-stained. The expectoration may be affected
by change of posture.

44 H O W T O EXAMINE A PATIENT
PERTUSSIS—there is a long drawn stridulous inspiration, followed
by series of short, sharp, expiratory coughs. The face becomes red,
the veins become prominent, and after the coughing ends, there is a
long drawn-out inspiration. The cough may be accompanied by
vomiting.
B. Mechanical Irritation
ENLARGED UVULA—dry, irritating cough on lying down.
SINUSITIS—irritating cough with little expectoration of mucus; more
common during the first half of the day.
SMOKING—irritating cough with hardly any expectoration; there is
often associated sore throat.
PRESSURE UPON THE TRACHEA (aneurysm, mediastinal glands)—
brassy cough.
ENLARGED HEART—may cause cough, especially on lying down.
C. Reflex conditions
Irritation of peripheral nerves—disordered stomach, thread worms, ear
trouble, teething, pregnancy. The cough is dry and irritating and
repeats at intervals.
Enlarged liver and diaphragmatic disorders—the cough is dry and
often irritating.
Nervousness—single, short, dry and explosive cough.
Hysteria—the cough is loud and barking, often associated with aphonia.
Features of some characteristic coughs
SUDDEN COUGH—respiratory diseases—tracheitis, bronchitis, broncho-
pneumonia.
COUGH WITH PAIN—pneumonia, pleurisy.
COUGH ON LYING DOWN—enlarged uvula, enlarged heart.
COUGH WITH VOMITING—whooping cough.
DRY COUGH—phthisis, laryngitis, neurosis.
LOOSE COUGH—bronchitis, phthisis, bronchiectasis.
SUDDEN PAROXYSM IN A CHILD—suspect foreign body and, if with
fever, laryngeal diphtheria.
SHORT AND SUPPRESSED—dry pleurisy.
IRRITABLE—early phthisis, pharyngitis.
PAROXYSMAL—asthma, bronchitis, pertussis.
EXPLOSIVE—phthisis, laryngitis, neurosis.
"BRASSY"—aneurysm, mediastinal growths.
"BOVINE"—prolonged with wheezing. Occurs in involvement of the
recurrent laryngeal nerve.
HACKING—phthisis, laryngitis, pharyngitis.
STRIDOR—persistent thymus, laryngeal diphtheria.
BARKING—hysteria.

PAIN IN THE CHEST
Lung tissue is insensitive and pain in the chest is always the
result of conditions which affect the surrounding structures. In
common respiratory diseases pain is an uncommon symptom;
when pleura is involved, however, the pain is a prominent fea-
ture, as occurs in pleurisy, lobar pneumonia, (due to associated
dry pleurisy) new growths sometimes, and pneumothorax.
The two commonest conditions that give rise to pain in the
chest are (1) lung and pleural diseases, (2) heart and pericardial
disorders. The pain in the former may be aggravated on
breathing or coughing and in the latter, on exercise.
Common varieties of pain
1. SUPERFICIAL—when cutaneous structures are involved
as by inflammation of the skin, neuralgias, herpes, adiposis
dolorosa.
2. DEEP—bones, muscles, or organs involved. Myalgia,
pressure on bones by growths and aneurysms, pleurisy, pneumo-
thorax, pulmonary embolism, coronary disease, pericarditis or
inflammation of the liver—are common causes of deep pain.
3. VISCERAL. The pain is deep seated and often spasmo-
dic in character due to involvement of hollow organs. Flatul-
ence, stomach ulcers, gall-bladder diseases, hiatus hernia are
common examples.
4. REFERRED. This is a continuous pain, superficial in
character and localised. The pain is projected from a deep
seated point of stimulation to the sensory nerves on the surface
of the body, as occurs in cholecystitis or liver diseases at the.
right shoulder, in pneumonia in children in the abdomen, in
diseases of the spine over the chest, etc.
5. PSYCHOGENIC. Such pains occur in cardiac neurosis,
neurocirculatory asthenia or long after an industrial accident.
PAIN IN THE CHEST MAY BE CENTRAL OR LATERAL.
The common causes of central pain are more often due to
non-respiratory than respiratory disorders. The common causes
are:

46 H O W TO EXAMINE A PATIENT
TRACHEITIS—retrosternal pain which is o£ a sore, scratchy character,
made worse by coughing but not by deep breathing.
ANGINA PECTORIS—retrosternal pain of momentary duration charac-
terised by a sense of impending death.
CORONARY DISEASE—retrosternal pain of severe nature persisting for
hours or days and shooting along the left arm with accompanying collapse.
PERICARDITIS—substernal pain of prolonged duration, aggravated by
breathing, coughing, swallowing or bending. The apex is felt inside the
outermost border of the cardiac dullness; there is often pulsus paradoxus.
STOMACH CONDITIONS—dilated stomach often presses upon the heart
and causes mild retrosternal pain. The patient is generally about 20
years old and too young to have coronary disease. Hiatus hernia may give
rise to central pain and is often mistaken for heart diseases. X-ray of the
stomach is very necessary to arrive at a diagnosis.
MEDIASTINAL CONDITIONS—cause continuous boring pain behind
the sternum and later, pain on the side of the chest.
Causes of pain in the sides of the chest
1. LUNG DISEASES:
PNEUMONIA—the pain is due to associated pleurisy and may be
localised or referred to the abdomen as often occurs in children.
PULMONARY EMBOLISM—sudden pain with haemoptysis and collapse.
CANCER LUNG—pain is not a characteristic feature unless pleura is
involved.
MASSIVE COLLAPSE OF THE LUNGS—distress rather than pain.
2. PLEURAL CONDITIONS:
PLEURISY—pain is sharp and stabbing in character. In diaphragmatic
plcurisv it may be referred to the shoulder.
PNEUMOTHORAX—sudden pain, dyspnoea and collapse.
3. HEART CONDITIONS. In coronary disease, although the pain is
central, is often referred to the side of the chest or along the left arm.
4. MEDIASTINAL CONDITIONS—boring pain felt under the sternum
rather than to the side of the chest.
5. LIVER CONDITIONS. Hepatitis, liver abscess and congestion in the
liver, invariably give rise to pain in the right side of the chest.
EPISTAXIS
Bleeding from the nose may be due to local or general causes.
It often occurs spontaneously without any obvious cause.
A. Local causes
Injury to the nose—blow, fracture, foreign body, violent nose
blowing.

Ulceration—traumatic, syphilis, malignancy, tuberculosis or
leprosy.
New growths—adenoids, polypi, fibromas, angioma.
Varicose veins—hereditary telangiectasis.
Acute infections—severe catarrh, diphtheria, scarlet fever,
influenza, whooping cough.
B. General causes
High blood pressure—hyperpiesia, nephritis, arterio-sclerosis.
High venous pressure as in severe bronchitis, emphysema,
after violent exercise in young.
Venous congestion—mitral stenosis.
Cirrhosis of the liver.
Altered condition of the blood—haemophilia, pernicious
anaemia, purpura, scurvy, leukaemia, obstructive jaundice.
Vitamin deficiency—scurvy.
Severe generalised infections—enteric, scarlet fever, influenza,
small-pox and measles.
Tumours in the thorax.
Altered atmospheric pressure—mountaineering, diving, flying.
C. Of obscure origin. May occur in childhood; and in
young girls as vicarious menstruation.
INVESTIGATION:
1. Inquire if the blood comes from both or one nostril. In
majority of cases if the causes are local, it comes from
one side.
2. Exclude trauma.
3. Examine the nares carefully to seek the bleeding spot,
and exclude ulceration, growths and foreign bodies.
4. Look for naevi on the face, to exclude hereditary
telangiectasis.
5. Take the blood pressure to exclude hyperpiesia.
6. Examine the blood to exclude blood dyscrasias.

4 8 H O W TO EXAMINE A PATIENT
HAEMOPTYSIS
Haemoptysis means bleeding occuring from the lungs and not
from the mouth, nose or pharynx.
Common causes:
A. PULMONARY DISEASES
Tuberculosis—history of cough, low fever, loss of weight and
signs in the chest.
Pneumonia—high fever, cyanosis, rusty sputum, signs of
consolidation in the chest.
Lung abscess—patient passes large quantity of blood-stained
sputum; low fever and localised signs in the chest.
Bronchiectasis—cough, purulent and offensive sputum, club-
bing of the fingers, wasting of the chest.
Bronchial carcinoma—cough with prune juice coloured spu-
tum; patient generally middle-aged; bronchoscopy essential.
Putrid bronchitis—offensive smell of the sputum which is
large in quantity; teeth often septic.
Parasitic diseases—hydatid disease and lung flukes can cause
bleeding. Blood reveals eosinophilia. Sputum examination
essential for diagnosis.
Traumatic—history helpful.
B. CARDIO VASCULAR CONDITIONS
Mitral stenosis—(due to venous congestion in the lungs)—
thrill felt over the apex, presystolic murmur at the mitral area,
accentuation of the second pulmonary sound, congestion in the
liver and lungs.
Pulmonary infarction—sudden, severe pain in the chest with
fever and haemoptysis. May occur in mitral stenosis, conges-
tive failure and in patients immobilised in bed for a long
period.
Aortic aneurysm—may leak or rupture into the lungs, the
latter-being immediately fatal.

Cardiac asthma. The haemoptysis is due to pulmonary
venous congestion. Patient gets paroxysmal attacks of dyspnoea
generally in the nights.
C. BLOOD DISEASES—generally these do not give rise to
haemoptysis; they more often cause epistaxis and bleeding in the
gums. Purpura, scurvy, leukaemia and haemophilia are the
most important.
D. LIVER ABSCESS BURSTING INTO THE LUNGS—
amoebic abscess especially gives rise to anchovy-sauce coloured
sputum.
E. SEVERE HAEMORRHAGIC INFECTIONS—small-pox,
scarlet fever, etc.
F. VICARIOUS MENSTRUATION—may occur in young
girls, although not common.
The commonest cause of haemoptysis is tuberculosis of the
lungs, and next in order, mitral stenosis and bronchogenic car-
cinoma. If an adult coughs blood, one should think of tuber-
culosis first and after forty, of cancer. On the whole the patient
should be regarded as suffering from tuberculosis, until the
contrary is proved. Bronchiectasis also may give rise to haemop-
tysis.
Haemoptysis is often mistaken for haematemesis
The following are the points of differentiation between the
two.
Haemoptysis Haematemesis
1. The blood is coughed up.
2. Preceded by cough; no
The blood is vomited.
Preceded by nausea.
nausea.
3. Colour bright red.
4. Mixed with froth and spu-
Usually dark.
Mixed with food particles.
turn.
5. Alkaline in reaction.
6. History of lung or heart
Acid in reaction.
History of stomach trouble.
diseases.
7. Stools contain no blood, un- Stools may be even tarry.
less blood is swallowed.
8. Episode lasts for days and Episode is usually brief and stops
abruptly.stains sputum for some time.
4

INVESTIGATIONS
1. Exclude blood from the nose, mouth, pharynx, larynx and
stomach.
2. Suspect tuberculosis in every case of haemoptysis until the
contrary is proved.
3. Go carefully into the history of fever, cough, and loss of
weight.
4. Examine the chest for evidence of tuberculosis; heart for
mitral stenosis; and blood for dyscrasias.
5. Examine the sputum for M. Tuberculosis at least six
times, if found negative previously.
6. X-ray the chest, do bronchography, etc.
HOARSENESS OF VOICE
Hoarseness is due to lack of normal movements of the vocal
cords. It may be due to local conditions, which are the com-
monest causes, or due to organic paralysis.
A. LOCAL CAUSES
Over-working of the vocal cords—shouting, singing, etc.
General weakness—debility, convalescence, myasthenia gravis,
myxoedema.
Infections of the larynx—laryngitis.
Constant irritation—alcohol, tobacco.
Ulceration of the larynx—tuberculosis especially.
New growths—papilloma chiefly.
B. ORGANIC PARALYSIS
Paralysis of the vocal cords—aortic aneurysm, mediastinal
growths, bronchial neoplasms.
Lesions at the base of the skull—growths, thrombosis of the
lateral sinus.
Lesions in the bulb—including thrombosis of the posterior
inferior cerebellar artery.

In lesions of the bulb and in lesions of the base of the skull,
other muscles are also affected, e.g., the soft palate, the pharynx
and the tongue.
In every case of chronic hoarseness examine the larynx with
a laryngoscope. Carefully inquire into the past history of
tuberculosis of the lungs and also syphilis. The commonest
cause of transient hoarseness is acute laryngitis and of chronic
sore throat, laryngeal tuberculosis. In hoarseness of long dura-
tion, also bear in mind syphilitic ulceration, tobacco excess,
myxoedema, paralysis of vocal cords, growth of the vocal cords
and myasthenia gravis. Growths of the vocal cords are easily
excluded by laryngoscopic examination, which must be per-
formed in all cases of hoarseness of the voice.
CYANOSIS
By cyanosis is meant blue colouration of the skin and mucous
membranes. It is most noticeable in the lips, nose, cheeks, ears,
hands and feet. It depends upon the amount of reduced
haemoglobin present in the blood and not due to an excess of
C02 as was once thought to be.
The factors that determine the degree of cyanosis are:
1. Insufficient oxygenation in the lungs due to failure of the
blood to reach them as in pulmonary stenosis, or to an alveolar
barrier as in pulmonary oedema, collapse, or consolidation.
2. Increased de-oxygenation in the capillaries due to stasis
from moderate cold, or to increased venous pressure as in heart
failure.
3. The degree of dilatation of the capillaries so as to make
cyanosis visible. The less the oxygen saturation and more dil-
ated the capillaries, the more the cyanosis.
4. The amount of haemoglobin present. If it is excessive as
in polycythaemia, the cyanosis becomes more marked because of
the higher content of the reduced haemoglobin than when there
is less haemoglobin as in anaemia. The minimum amount of
reduced haemoglobin that causes cyanosis is 5 Gm. of Hb. per

100 c.c. of blood; hence, in severe anaemias where Hb. falls
below 5 Gm., cyanosis does not occur.
5. Pathological venous-arterial shunt of over one-third of
the cardiac output as in congenital heart diseases.
CAUSES OF CYANOSIS:
1. Local. Slowing of the blood flow as in cold weather or
vasomotor stimulation. The slowing allows greater dis-
sociation of oxygen. If the cold weather is intense, dis-
sociation of oxygen stops and although the circulation is
very slow the skin is coloured red.
2. Obstruction to the return of blood to the heart:
(a) Right ventricular failure, tricuspid stenosis, pericar-
dial effusion and constrictive pericarditis.
(b) Local obstruction—pressure on the veins by tum-
ours, venous thrombosis, or incompetent venous
valves.
In all the above conditions there is slowing of the current and
more oxygen dissociation plus greater capillary dilatation.
3. Lung Disorders:
(a) Congestion in the lungs. Mitral stenosis and left
ventricular failure cause some blood to pass through
the middle of the dilated capillaries and, hence, out
of contact with the alveolar air. If one-third of such
unoxygenated blood is shunted from the veins to the
arterial system, cyanosis results. Often, in such cases,
there is slowing of the return of blood to the heart
and, hence, two factors contribute to the appearance
of cyanosis.
(b) Diseases of the lungs. These may be acute or chro-
nic. In pneumonia or infarction the blood is shun-
ted back without being oxygenated and more so,
when there is moisture in the alveoli (early pneumo-
nia and severe influenza) than in consolidation. In
lung destruction and emphysema there are enough
alveoli at the surface for oxygenation and, hence,

there is no cyanosis. However, in chronic emphysema
and acute bronchial asthma, the patient may not be
able to breathe enough air, resulting in cyanosis.
In pulmonary endarteritis (Ayerza's disease) there is
no blood reaching the lungs and, hence, cyanosis.
In acute infarction and sudden pneumothorax there
is embarrassment to respiration because of the severe
pain; hence, cyanosis.
4. Shunting of the venous blood directly into the systemic
circulation. In congenital disorders like single ventricle, dextra-
posed aorta, transposition of the great vessels and less commonly
in patent interventricular or interauricular septal defects, patent
ductus, Fallot's tetralogy and pulmonary stenosis, cyanosis can
occur if one-third of the blood is shunted from the veins. In
all such cases there is also capillary dilatation in order to help
the tissues to take up as much oxygen as possible resulting in
more cyanosis.
5. Tracheal or bronchial obstruction. This may reduce the
amount of inspired air to cause oxygenation of blood. Laryngeal
diphtheria, foreign bodies, Ludwig's angina, oedema of glottis,
pressure from mediastinal tumours are common examples.
6. High altitudes. There is oxygen lack and theoretically
cyanosis should occur. Actually it does not do so, but it tends
to exaggerate other types of cyanosis.
7. Blood conditions. Polycythaemia can produce cyanosis
due to higher content of reduced haemoglobin present in the
circulation.
Cyanosis must be differentiated from methaemoglobinaemia
due to poisoning with aniline compounds, potassium chlorate
and coal-tar derivatives; and from sulphaemoglobinaemia
due to sulphonamide poisoning. The cyanosis in these condi-
tions is of a leaden hue. *
DYSPNOEA
Although dyspnoea is a very important symptom of respiratory
and cardio-vascular diseases, alone it must not be taken as an
evidence of diseases of any of the above systems, unless the other

causes of dyspnoea have been excluded. A genuine dyspnoea is
characterised by more rapid and deeper breathing than normal,
and must be distinguished from the sighing and desire for deep
breath so often manifested by neurotic patients.
In cardiac conditions dyspnoea may occur only on effort—an
early indication of cardiac decompensation. To judge the capa-
city of the heart the grade of dyspnoea is a valuable guide. It is
very desirable to know how the patient's breathing responds to
physical tasks to which he has been accustomed then to compare
his response to some special tests with that of a healthy man.
Orthopnoea is a condition where the patient is breathless
continuously and finds it difficult even to lie down in bed. Such
a patient seeks comfort in adopting a semi-sitting posture even
during sleep.
CAUSES OF DYSPNOEA:
1. Mechanical obstruction to the air passages
(a) Obstruction to the upper air passages—nasal conditions,
laryngeal diphtheria, foreign body, aneurysm, persistent thymus
or tumours pressing upon the trachea. All these conditions
cause inspiratory type of dyspnoea, i.e. the inspiration is marked-
ly prolonged.
(b) Obstruction to lower air passages—bronchial asthma,
pleural effusion, pneumothorax, pneumonia, fibrosis, emphy-
sema, pulmonary embolism, increased intra-abdominal pressure
(growths, fluids, etc.) These conditions produce expiratory type
of dyspnoea, i.e. the expiratory phase is markedly prolonged.
2. Cardiac conditions
(a) In left ventricular failure, there is congestion in the lungs,
which becomes more evident when the patient is lying down,
resulting in cardiac asthma.
(b) In right-sided failure, the chief factors that cause dyspnoea
is excess of CO, in the blood and increased B.M.R. in addition to
pulmonary congestion.

3. Upsetting of the acid-base equilibrium of the blood
(a) Nephritis—Uraemia, due to failure of the kidney to ex-
crete non-volatile acids. The patient may even get asthmatic
attacks.
(b) Ingestion of acidifying substances such as ammonium
chloride and methyl alcohol.
(c) Diabetes mellitus—due to incomplete metabolism of fats
resulting in retention of acetone bodies in the circulation.
(d) Congestive cardiac failure and congenital heart diseases
due to excess of C02 in the blood.
4. Oxygen lack
(a) Anaemia.
(b) Co-poisoning, methaemoglobinaemia.
5. Increased basal metabolism
(a) Exophthalmic goitre—the dyspnoea is moderate and
occurs when the patient is doing some work.
(b) Congestive cardiac failure—increased B.M.R. is one addi-
tional factor in the causation of dyspnoea in cases of congestive
heart failure.
6. Nervous hindrance to respiration
(a) Functional.
(b) Paralysis of the diaphragm.
(c) Increased intracranial pressure (Cheyne-Stoke's breathing).
PAROXYSMAL DYSPNOEA
This means that dyspnoea comes in paroxysmal attacks. The
attacks are more common at nights.
Causes:
1. Bronchial asthma. The patient is very severely dysr
pnoeic, the breathing is laboured, the expiration is much longer
than inspiration and cooing rhonchi are heard all over the chest.

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