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| __NOTOC__
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| {{Idiopathic interstitial pneumonia}}
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| {{CMG}}; {{AE}} {{chetan}}
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| ==Overview==
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| For example in [[emphysema]] the patient may appear dyspneic with pursed lips breathing and use of accessory muscles whereas, in [[pulmonary hypertension]] the patients present more with symptoms of right sided heart failure associated with ascites and peripheral edema.
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| ==Physical Examination==
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| The appearance of the patient may give clues as to the etiology of the condition.
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| Physical examination are quite specific and sensitive for severe disease. The signs are usually difficult to detect in cases of mild to moderate diseases.
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| ===General examination===
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| '''If patients has co-existing emphysema then the following signs could be seen.'''
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| * Pursed lips, adopting a tripod position, using accessory muscles.
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| * Thin patient with barrel chest** Barrel chest may cause distant heart sound
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| * '''Pink puffers'''. This is because emphysema sufferers may hyperventilate to maintain adequate blood oxygen levels. Hyperventilation explains why mild emphysema patients do not appear [[Cyanosis|cyanotic]] as chronic [[bronchitis]] (another [[COPD]] disorder) sufferers often do; hence they are "pink puffers" (able to maintain almost normal blood gases through hyperventilation) and not "blue bloaters" ([[cyanosis]]; inadequate oxygen in the blood). However, any severely chronically obstructed (COPD) respiratory disease will result in hypoxia (decreased blood partial pressure of oxygen) and hypercapnia (increased blood partial pressure of Carbon Dioxide)
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| * Signs of right heart failure
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| ** Elevated jugular venous pulse (JVP)
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| ** Peripheral edema can be observed.
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| * Clinical signs on at the fingers include cigarette stains (although actually tar) and asterixis (metabolic flap) at the wrist if they are carbon dioxide retainers (NOTE: Finger clubbing is NOT a general feature of emphysema).
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| * Cyanosis
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| * Tachypnea
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| '''The following signs on general examination could be noticed in cases of pulmonary hypertension'''.
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| ===Pulse===
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| The [[Pulse|pulse]] may be low volume. This usually occurs in more severe disease.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| ===JVP===
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| Assessment of the [[Jugular venous pressure|JVP]] in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial
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| filling) and the height of the JVP column above the sternal angle. Physical findings may include:
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| *'''Prominent 'a' wave''': due to forced atrial contraction
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| *'''Prominent 'v' wave''': later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with right ventricular failure.
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| *'''Elevated JVP''': can be present if right ventricular failure develops
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| *'''Postive [[Kussmaul's sign]]''': JVP elevation during inspiration (the opposite of what normally happens) because of right ventricular failure<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| *'''Positive [[Hepatojugular reflux|Abdominojugular reflux]]''': JVP rises and remains elevated during a period of over 10 seconds whilst abdominal pressure is applied. This may be present if right ventricular failure develops<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| ===Lungs===
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| ====Inspection====
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| * Hyperinflation (barrel chest)
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| * Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)
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| ====Percussion====
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| * Hyperresonance
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| ====Auscultation====
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| * Prolonged expiration; wheezing
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| * Diffusely decreased breath sound
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| * Additional sounds - coarse crackles with inspiration
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| * Examination of the chest reveals increased percussion notes (particularly over the liver) and a difficult to palpate [[apex beat]] (all due to hyperinflation), decreased breath sounds, audible expiratory wheeze. Classically,clinical examination of an emphysematic patient reveals no overt crackles, however, in some patients the fine opening of airway 'popping' (dissimilar to the fine crackles of [[pulmonary fibrosis]] or coarse crackles of [[mucus|mucinous]] or [[edema|oedematous fluid]]) can be [[Auscultation|auscultated]]. This is known as "[[Barclay's sign]]".
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| ===Heart===
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| ===Precordium===
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| An holistic [[precordium|precordial]] assessment of pulmonary hypertension involves [[Palpation of the precordium|palpating the precordium]] for [[Heave|heaves]] and thrills and ausculatating to assess first
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| and second heart sounds, splitting of the second heart sound and determining if there any added [[Heart sounds|heart sounds]] or murmurs. Physical findings may include the
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| following:
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| ====Palpation====
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| *'''Parasternal heave''': due to hyperdynamic right ventricle
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| *'''Palpable P2''': correlates with severe disease<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| ====Ausculation====
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| =====First and second heart sound (S1,S2) assessment=====
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| *'''Loud P2 component of S2''': this is due to forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration. <ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
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| =====Splitting of S2 assessment=====
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| *'''Narrowed splitting of S2''': in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.<ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref>
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| *'''Widened splitting of S2''': widened splitting may occur later if right ventricular failure or bundle branch block develops.<ref name="isbn0-7817-7012-2">{{cite book |author=Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan |title=Textbook of cardiovascular medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2007 |pages= |isbn=0-7817-7012-2 |oclc= |doi= |accessdate=}}</ref>
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| =====Extra heart sounds assessment=====
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| *'''s4''': due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
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| *'''s3''': if right ventricular failure develops. Increased with inspiration.<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| =====Additional sounds assessment=====
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| *'''Systolic pulmonary ejection click''': increased with inspiration
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| =====Murmurs assessment=====
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| *'''Ejection midsystolic pulmonic murmur''': increased with inspiration
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| *'''Diastolic pulmonary regurgitation murmur (Graham-Steele murmur)''': indicates more severe disease
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| *'''Pansystolic tricuspuid regurgitation murmur''': indicates developing right ventricular failure<ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
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| ===Abdomen===
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| Findings in the abdomen include:
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| *'''[[Ascites]]''': indicates right ventricular failure
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| *'''Painful [[hepatomegaly]]''': indicates right ventricular failure
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| *'''Pulsatile liver''': due to tricuspid regurgitation<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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| ===Legs===
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| *'''[[Edema]]''': indicates right ventricular failure<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref>
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