1.

Edema: types, etiology, localization, significance, detection

Definition:
Edema is swelling of body parts (extremities) with an abnormal accumulation of fluid in
interstitium (under the skin or in the cavities of the body)
Types and detection:
a)Pitting - identation appear
b)Non-Pitting Edema- identation not visible
Etiology:

1. increased hydrostatic pressure;

2. reduced oncotic pressure within blood vessels;
3. increased tissue oncotic pressure;
4. increased blood vessel wall permeability e.g. inflammation;
5. obstruction of fluid clearance in the lymphatic system;
6. changes in the water retaining properties of the tissues themselves. Raised hydrostatic
pressure often reflects retention of water and sodium by the kidney.

Localization:
Edema and heart disease (congestive heart failure): When the heart weakens and pumps
blood less effectively, fluid can slowly build up, creating leg edema. If fluid buildup occurs
rapidly, fluid in the lungs (pulmonary edema) can develop. If there is heart failure of the
right side of the heart, oftentimes edema can develop in the abdomen, as well.

Edema and liver disease: Severe liver disease (cirrhosis) results in an increase in fluid
retention. Cirrhosis also leads to low levels of albumin and other proteins in the blood. Fluid
leaks into the abdomen (called ascites), and can also produce leg edema.

Edema and kidney disease: A kidney condition called nephrotic syndrome can result in
severe leg edema, face edema and sometimes whole body edema (anasarca).

Edema and pregnancy: Due to an increase in blood volume during pregnancy and pressure
from the growing womb, mild leg edema is common during pregnancy.

Cerebral edema (brain edema): Swelling in the brain can be caused by head trauma,
low blood sodium (hyponatremia), high altitude, brain tumors, or an obstruction to fluid
drainage (hydrocephalus). Headaches, confusion, and unconsciousness or coma can be
symptoms of cerebral edema.
 Medications and edema: Numerous medications can cause edema, including:

 NSAIDs
 Calcium channel blockers
 Corticosteroids

Symptoms of Edema

 Edema in a small area from an infection or inflammation (mosquito bite) may cause
no symptoms at all. A large local allergic reaction (bee sting) may cause edema
affecting the entire arm. Tense skin, pain, and limited movement can be symptoms of
edema.

 Food allergies may cause tongue or throat edema.

 Leg edema of any cause can cause the legs to feel heavy and interfere with walking.
In edema and heart disease, leg will be heavy. Severe leg edema can interfere with
blood flow, leading to ulcers on the skin.

 Pulmonary edema causes shortness of breath, which can be accompanied by low

oxygen levels in the blood. Some cases rusty sputum.
Detection:
 Extremities edema – Visible of indentation
 Pulmonary edema – X-ray , echocardiography,
 Ascites – Ultrasound

2. Cough: variants, detailing, reasons of appearance, significance

Definition:
A cough is a sudden and often repetitively occurring reflex which helps to clear the large
breathing passages from secretions, irritants, foreign particles and microbes.
-whooping cough, bovine cough (muscle weakness), wheezing cough (COPD)
Classification and causes:
*Acute < 3 weeks
 an upper respiratory tract infection (URTI) that affects the throat, windpipe or sinuses –
examples are a cold, flu, laryngitis, sinusitis or whooping cough
 a lower respiratory tract infection (LRTI) that affects your lungs or lower airways –
examples are acute bronchitis or pneumonia
 an allergy, such as allergic rhinitis or hay fever
 a flare-up of a long-term condition such as asthma, chronic obstructive pulmonary disease
(COPD) or chronic bronchitis
 inhaled dust or smoke

*Chronic > 8 weeks

 a long-term respiratory tract infection, such as chronic bronchitis
 asthma – this also usually causes other symptoms, such as wheezing, chest tightness and
shortness of breath
 an allergy
 smoking – a smoker's cough can also be a symptom of COPD
 bronchiectasis – where the airways of the lungs become abnormally widened
 postnasal drip – mucus dripping down the throat from the back of the nose, caused by a
condition such as rhinitis or sinusitis
 gastro-oesophageal reflux disease (GORD) – where the throat becomes irritated by
leaking stomach acid
 a prescribed medicine, such as an angiotensin-converting enzyme inhibitor (ACE
inhibitor), which is used to treat high blood pressure and cardiovascular disease

*Productive (with sputum)

*Non-productive (dry)
*Nocturnal cough (only night)
Symptoms:
 Infection symptoms include fever, chills
 Heartburn for gastroesophagel reflux (GORD) induced cough.
 Lung cancer or a cancer of the air passages, you may cough up blood.
Diagnosis:
Chest X-ray

3. Sputum production and hemoptysis: types, detailing, reasons of appearance,

significance
Definition:
Sputum is mucus that is coughed up from the lower airways
Phlegm is the mucus produced by the respiratory system that is called sputum after it is
expelled by coughing
Types of sputum
Type Appearance Cause
serous Clear, watery, frothy, pink Acute pulmonary edema
 Alveolar cell carcinoma
mucoid Clear, grey, white, viscid Chronic bronchitis, COPD, asthma
purulent Yellow, green Bronchopulmonary infection:
Pneumonia
Bronchiectasis
Cystic fibrosis
Lung abscess
rusty Rusty,golden yellow Pneumococcal pneumonia

Extras:
 Yellow - live neutrophils, eosinophils
 Green – dead neutrophils
 Purulent – lysed neutrophils, green pigment enzyme verdoperoxidase
 Rusty red – hepatisation stage
 Melanoptysis (black sputum) – coal miners with pneumoconiosis
 Foul / vile (smell) – anaerobic bacterial infection in bronchiectasis, lung abscess,
empyema
 Solid materials might be necrotic tumour, food

Hemoptysis or haemoptysis is the act of coughing up blood or blood-stained mucus from

the bronchi, larynx, trachea, or lungs.
Tumor: malignant and benign Lung cancer, endobronchial metastases,
bronchial carcionoid
Infection Tuberculosis, bronchitis, bronchiectasis, lung
abscess, COPD
Vascular Pulmonary infarction, arteriovenous
malformation, aneurysm, vasculitis
(Wagener’s Syndrome, Goodpasture’s
Syndrome)
Trauma Post intubation, chest trauma
Cardiac Mitral valve disease, acute left ventricular
failure
Haematological Blood dyscrasias, DIC, thrombocytopenia
Parenchymal Sarcoidosis, fibrosis
Pulmonary hypertension Idiopathic, thromboembolic

Diagnosis:
 Imaging examination-chest X-ray, CT scan and or CT virtual bronchoscopy, bronchial
angiography.
 Laboratory tests – blood analysis
4) Chest pain. Increase with coughing but not affected by physical exercise.

Maybe caused by : Acute tracheitis emphysema tumor in mediastinum

Pleuritic pain, increasing during inspiration.

Pathology related to the pleura Pneumonia pneumothorax pulmonary infarction Pleutitis

(pleurisy) Malignant infiltration of the pleura

5) Ischemic cheast pain(angina)

detailing: painful constricting sensation of pressure or weight felt in the centre

of the chest radiate to arms, throat, back and epigastrium.

mechanisms of appearance: provoked by activity that increase heart rate and blood
pressure. Starts while walking and is relieved in few minutes by rest or sublingual glycerol
trinitrate.

significant: ECG- normal at rest, ST segment changes when angina attack.

drug therapy: ACE inhibitors, nitrates, Beta-blocke, Ca blocker.

Unstable angina: when the typical angina becomes more severe and more frequent, occurs
in rest, not relieve by glycerol trinitrate. Patient admitted to hospital for adequate analgesia,
intravenous infusion of nitrate, intravenous heparin and aspirin, bypass surgery

grading: I- ordinary activity no angina. Angina occurs at heavy works.

II- slight limitation of ordinary activity. Angina occurs at heavy works,

walking more than 2blocks.

III- limitation of ordinary activity. Angina at walking 1block

IV- inability to carry on activity without discomfort. Angina at rest

6) Dyspnoea : uncomfortable awareness of breathing Most respiratory pathology has

dyspnoea as a symptom pneumothorax, COPD, asthma etc. Sudden dyspnoea might indicate :
pulmonary embolism, pneumothorax, acute pulmonary edema, exposure to toxic fume, and
hemorrhage blocking the airway Dyspnoea that increase with supine position and relieved
with standing position, indicates heart failure, due edema of the lung as the result of
congestion.
7) Cyanosis

type: Central, Acrocynosis/peripheral, differential cyanosis

reason: blood clots, heart problems(heart failure, congenital heart defects, cardiac arrest),
lung problems(asthma, pulmonary embolism, COPD), arterial obstruction, venous obstruction

mechanisms: excessive concentration of deoxyheamoglobin in blood caused by

deoxygenation, develops when arterial O2 saturation drops ti <85% or <75%(centre).
(peripheral) due to inadequate circulation.

diagnosis value: central cyanosis around the core, lips and tongue

peripheral only in extremities or finger

8)Vesicular sound- vibration/ deflating alveoli, conduction to chest surface of vibration from
turbulence air flow in bifurcation bronchi. Soft, quiet sound

normal
duration: 9(inspiration): 1(expiration)
pitch: low FFFF
intensity: soft
normal location: peripheral lung
abnormal: not applicable
graphic diagram: 9:1

vesicular sound: a) prolong expiration, b) saccaded sound

abnormal
a)prolong expiration
duration: 2:11
pitch: low FFFF
intensity: medium
abnormal: peripheral
graphic diagram
b) saccaded sound
duration: 1:1
pitch: low ff ff ff~ ffff
intensity: medium
abnormal: peripheral lung

9)Bronchial sound-conduction to the chest surface of vibration from turbulence airflow in

larynx(durin inspiration, expiration) laryngotracheal sound

Duration: 1:2
pitch: high HHHHHH
Intensity: loud
normal location: over larynx(thyroid cartilage), trachea
abnormal: in lung
graphic:

10)Dry wheezes: mechanism of appearance, variants, diagnostic value.

wheezes- continuous, coarse, whistling sound produced in the respiratory airways during
breathing. high pitch musical noise that can be demonstrated in patient by increase
intrathoracic pressure and forces the air through voluntarily narrowed upper air passage. In
disease it can be caused by high velocity of expiration through the narrowed , small
airways(asthma and bronchitis)

variants: low frequency: sputum in large bronchial

:high frequency: sputum in small bronchial

special form of wheezes is Stridor : a high-pitched harsh sound heard during inspiration.
Stridor is caused by obstruction of the upper airway. is a harsh, high-pitched, vibrating sound
that is heard in respiratory tract obstruction. Stridor heard solely in the expiratory phase of
respiration usually indicates an upper respiratory tract obstruction, as with aspiration of a
foreign body (such as the fabled pediatric peanut). Stridor in the inspiratory phase is usually
heard with obstruction in the upper airways, such as the trachea, epiglottis, or larynx; because
a block here means that no air may reach either lung, this condition is a medical emergency.
Biphasic stridor (occurring during both the inspiratory and expiratory phases) indicates
narrowing at the level of the glottis or subglottis, the point between the upper and lower
airways.
Wheezes can be differentiated in polyphonic and monophonic wheezes

polyphonic –high pitched sound that can be heard at the end of expiration, consist of clusters
of continuous musical noisy and caused by high velocity of air flowing thru narrowed small
bronchi(asthma bronchitis and emphysema). Normal human can create this sound by end of
forced expiratory as the bronchi are compressed and velocity of air is increased

monophonic-continuous bleating musical noises from individual airway, which is narrowed

due to edema secretion or by extramural compression by a tumor . usually cause by bronchitis
when they are heard tgt with crackles . this unilateral or localised monophonic wheezes are
strong evidence of bronchial obstruction by neoplasm or foreign body

11)Crackles: mechanism of appearance, variants, diagnostic value.

-are caused by fluid in the small airways}.

- Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief.
Crackles may be heard on inspiration or expiration. The popping sounds produced are created
when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus.
Crackles are often associated with inflammation or infection of the small bronchi,
bronchioles, and alveoli. Crackles that don't clear after a cough may indicate pulmonary
edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome
(ARDS). explosive, "popping" sounds that originate within the airways

Crackles are often described as fine and coarse.

a) Fine crackles are soft, high-pitched, and very brief(in the smaller bronchi)

b) Coarse crackles are somewhat louder, lower in pitch, and last longer than fine
crackles(larger bronchi)

crackles: cavity in lung and focal inflammation with consolidation

12)Crepitation: mechanism of appearance, diagnostic value.

-discontinuous sounds; they are intermittent, nonmusical and brief. Crackles may be heard on
inspiration

- sounds produced are created when air is forced through respiratory passages and forced the

alveolus to open
mechanism example: lobar inflammation causes exudation to occur and enter the alveoli and
then washes away the surfactant and then causes the collapse of the alveoli. During inhalation
the alveoli wanted to expand but its hard due to the exudation and at the end of the inspiration
process, the forces and presuure during inspiration forces the alveoli to open therefore
forming a crepitational sound.

diagnostic value= lobar inflammation with consolidation and compressive atelactesis

*extra to differentiate crepi and fine crackles.. call the patient to cough.. if the sound lost after
cough, its crackles and if it doesn’t its it a crepitation

13) Pleural friction rub: mechanism of appearance, diagnostic value.

Its caused by friction between the visceral and the costal pleural producing a scraping, raspy
sound that occurs at the end of inhalation and the beginning of exhalation. Its heard from the
area of pleura inflamed (pulmonary thromboembolism, pneumonia and pulmonary
vasculitis). Coughing will not alter the sound.

On auscultation, High frequency(hear best with diaphragm of stethoscope), a continuous or

intermittent grating,creaking sound.

#Pleural rubs stop when the patient holds her breath. If the rubbing sound continues, its a
pericardial friction rub because the inflamed pericardial layers continue rubbing together with
each heart beat.

14) S1 and S2: basic characteristics, changes in different clinical conditions, diagnostic
value.

• long,soft,low pitched sound

• duration 0.10s – 0.17s

• produced during isometric contraction & earlier part of ejection period

• “ lub” is the first heart sound

• caused by turbulence caused by the closure of mitral and tricuspid valves

• beginning of systole (end of diastole).

• Loudest at the apex and lower left sternal border.

Abnormal S1:

• Loud First Heart Sound: Hyperdynamic (fever, exercise), Mitral stenosis,short AV

intervals like Wolff-Parkinson-White syndrome

• Soft First Sound: Low cardiac output (rest, heart failure),Tachycardia,Severe mitral
reflux (caused by destruction of valve),long PR interval

• Variable Intensity of First Sound: Atrial fibrillation,Complete heart block

S2

• ” dub”

• caused by the closure of aortic and pulmonic valves

• the end of systole

• It is short, sharp and high pitched sound.

• Duration of this sound is 0.10 – 0.14 seconds.

• S2 spliting : Wide, fixed splitting ~> Atrial septal defect

Wide split, varies with inspiration ~> Pulmonary stenosis, RBBb

Paradoxical splitting~> Hypertrophic cardiomyopathy

Abnormal S2:

• Loud Second Heart Sound (aortic): Systemic hypertension,Dilated aortic root

• Soft Second Heart Sound (aortic): Calcified aortic stenosis

• Loud Second Heart Sound (pulmonary): Pulmonary hypertension

# Difference between the S1 & S2 : The S1 lasts longer because the AV valves are less elastic
than the semilunar valves which will enable them to vibrate for longer time. S2 had higher
frequency The great elastic coefficient of the arteries which provides the principle vibrations
of the S2

15)S3 and S4: basic characteristics, changes in different clinical conditions, diagnostic
value.

S3

• It is produced during rapid filling period of the cardiac cycle.

• It is short and low pitched sound.

• Duration of this sound is 0.07 – 0.10 seconds.

• Causes: due to the vibrations which set up in ventricular wall, due to rushing of blood
in to ventricles during rapid filling phase.

• called a protodiastolic gallop, ventricular gallop,

Abnormal : increased atrial pressure leading to increased flow rates, congestive heart failure,
dilated cardiomyopathy with dilated ventricles.

S4

• It is produced during atrial systole and considered as physiologic heart sound.

• It is short and low pitched sound.

• Duration of the sound is 0.02 – 0.04 seconds.

• Causes: due to vibrations which set up in atrial musculature during atrial systole.

• called a presystolic gallop or atrial gallop.

Abnormal : stiffened left ventricles, resulting from conditions such as hypertension, aortic
stenosis, ischemic or hypertrophic cardiomyopathy.

16) Mitral valve opening click (snap) and systolic click: diagnostic value.
-opening snap is an early diastolic ,high-pitched sound,that closely follows S2 by 0.03-0.15s

-an opening snap is produced by opening of mitral valve under high pressure in mitral
stenosis

-in mitral stenosis ,the opening snap is heard half way between lower left sternal border and
cardiac apex and as high as 3rd left intercostal space

-systolic click is high pitched sound that occurs in mid systole,providing by sudden tensing of
chordae tendinae in mitral valve prolapse

17) Murmur in mitral regurgitation (insufficiency): characteristics, diagnostic value.

- backflow of blood from ventricle to atrium during ventricular systole

- mitral regurgitation have a weak S1 (due to incomplete closure of mitral valves )

- holosystolic murmur heard at apex and radiates to axilla

- sometimes there can be systolic click if there is mitral valve prolapse

-intensity usually low

- maybe s2 can be loud or normal

- best heard when patient lies on left side

holoststolic murmur is caused by backflow into the left atrium through an incompetent mitral
valve. When the mitral regurgitation is chronic, and the left atrium can accommodate the
regurgitant flow, the pressures between the left ventricle and left atrium never equalize during
systole, and the murmur isholosystolic.

18) Murmur in mitral stenosis: characteristics, diagnostic value.

-mitral stenosi-the narrowing of the opening of mitral valve ,causing difficulity of blood
passing through to ventricles from atrium during ventricle diastole ,atrium systole

-MS have a diastolic decresendo (gradually becomes low) low pitched

-best heard at cardiac apex

-doesn't radiate anywhere

-MS has opening snap/click sound and then followed by S1 which is loud due to forcefull
closure of the valve

-S2 can be loud or normal

19) Murmur in aortic stenosis: characteristics, diagnostic value

Mid systolic ejection murmur (systolic ejection murmur)
 Produced by forward flow of blood across the ventricular outflow tract
 Begin after S1 and end prior to S2
 Are diamond shaped/rhombus shaped (crescendo-decrescendo)

In aortic stenosis, murmur is caused by turbulence across a narrowed aortic valve orifice.
Murmur is crescendo-decrescendo in shape and may be heard in 2nd right intercostal space, 3rd
left intercostal space and at apex. Murmur may radiate into carotid arteries and frequently
preceded by an ejection sound (ejection click). Aortic stenosis is associated with narrow pulse
pressure and a slow, delayed carotid up stroke. Murmur decreases in intensity with sustained
Valsalva and inspiration.

20) Murmur in aortic regurgitation (insufficiency): characteristics, diagnostic value

Diastolic murmur (early diastolic murmur)
 Begins with s2
 Is decrescendo
 Ends in late diastole
 Heard best in 2nd right intercostal space, 3rd left intercostal space and apex
 It is accentuated by having patient lean forward and hold his breath in forced
exhalation
 Murmur has high pitched, blowing quality
 Murmur increases in intensity with maneuvers that increase peripheral vascular
resistance (handgrip, squatting, exercise)

There may also be an Austin Flint murmur, a soft mid-diastolic/pre-systolic rumble heard at
the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders
partial closure of the anterior mitral leaflet.

21) Epigastric pain: variants, types, detailing, reasons of appearance, diagnostic value

The Epigastrium or Epigastric region is the upper central portion of the abdomen. It is
located between the costal arch (lower edge) of the thorax and the sub-costal plane.
Epigastric pain is subject to certain abnormal reactions that are associated with several
diseases of Epigastrium. Pain occurs regularly when Epigastric region is defective. This
defect can be marked by actions of the diaphragm. The rectus abdominus creates an outward
protruding of the upper wall of the abdomen. The sudden pain produces swift and forceful
breath-exhalation. It brings with it a great sense of ineffectiveness and discomfort. In a
nutshell, this pain can range from mild ache to severe pangs in the abdominal region.

Properties Peritoneal Pain Spastic Pain Distension pain

Localization Local and general Local General
Character Burning Compressive Expanding pain
Intensity Severe Severe Mild
Period Continuous Frequent Continuous
Reasons No specific reason Eating Gas in colon or
excessive eating
Duration Continuous pain 1-2 Some minutes Hours
days
Treatment Morphine Atropine Diet, emptying
contents by
defecation, enema
Radiation - Specific (gall bladder -
to shoulder)
Accompany Tenderness of Nausea, vomiting, Nausea, vomiting,
abdomen, immobile fever fever
abdomen

Causes of Epigastric Pain

There are many causes of the epigastric pain. Many disorders and diseases can lead to the
uncomfortable feeling in this area. Therefore, it becomes difficult to diagnose the exact
condition causing this pain. Here, we have presented all the possible aetiologies behind this
pain.

1. Gastrointestinal reflux disease

2. Heartburn
3. Diseases of the Stomach
4. Gastritis
5. Peptic and Duodenal Ulcer
6. Gastric Carcinoma
7. Gastroenteritis
8. Disorders of Pancreas
9. Pancreatic Cancer
10. Disorders of Gallbladder Causing Pain
11. Liver Problems

There are various other disorders that may lead to pain in the epigastrium such as:

 Chronic cough
 Hiatal hernia
 Abdominal muscle strain
 Perforated Ulcer
 Abdominal aortic aneurysm
22) Peritoneal pain and rebound tenderness sign: detailing, reason of appearance,
diagnostic value
Detailig: Rebound tenderness or Blumberg’s sign is performed during the physical
examination of a patient, usually arriving at the clinic or emergency department with the
complain of abdominal pain.
Reason: The positive blumberg’s sign indicates peritonitis such as appendicitis (inflammation
of appendix) or ulcerative colitis.
Diagnostic value: The abdominal wall is compressed slowly and then rapidly released. A
positive sign is indicated by presence of pain upon removal of pressure on the abdominal wall.
23) Dyspepsia (nausea, vomiting, heartburn, belching): detailing, reasons of appearance,
diagnostic value.
Detailing: Dyspepsia, also known as indigestion or heartburn, is a condition of impaired
digestion and is a term that describes discomfort or pain in the upper abdomen. It is not a
disease. Dyspepsia is a group of symptoms which often include bloating, nausea, vomiting,
heartburn and burping. Most people with indigestion feel pain and discomfort in the stomach
or chest area (heartburn). The sensation generally appears soon after consuming food or drink.
In some cases symptoms may appear some time after a meal. Some people feel full during a
meal, even if they have not eaten much.
Reason: Burped-up stomach juices and gas (regurgitation or reflux) caused by
gastroesophageal reflux disease (GERD) or a hiatal hernia. A disorder that affects movement
of food through the intestines, such as irritable bowel syndrome. Peptic (stomach) ulcer or
duodenal ulcer.An inability to digest milk and dairy products (lactose
intolerance).Gallbladder pain (biliary colic) or inflammation (cholecystitis).Anxiety or
depression.Side effects of caffeine, alcohol, or medicines. Examples of medicines that may
cause dyspepsia are aspirin and similar drugs, antibiotics, steroids, digoxin, and
theophylline.Swallowed air.Stomach cancer.
Diagnostic value: Dyspepsia is frequently caused by gastroesophageal reflux disease (GERD)
or gastritis.[3] In a small minority it may be the first symptom of peptic ulcer disease (an
ulcer of the stomach or duodenum) and occasionally cancer
24) Constipation and diarrhea: reasons of appearance, diagnostic value.
Pain and discomfort related to altered bowel habit are the hallmarks of Irritable bowel
syndrome (IBS).
Basic types of diarrhoea (more explanation can read from green colour book page 84-85): 1)
osmotic diarrhea 2) secretary diarrhea 3) exudative diarrhae 4) malabsorption produces
diarrhea 5) paradoxical diarrhea
Basic types of constipation: 1) faecal impaction 2) acute constipation 3) chronic constipation
Reasons: Diet, drugs, travel abroad, some underlying diseases suchas diabetes mellitus,
malabsorption syndrome, thyrotoxicosis and hypothyroidism may present as change in bowel
habit.
Diagnostic value: Diagnosis of IBS is usually based on negative results for other tests since
no specific test for the disorder exists. Examples of tests that may be performed include stool
sample, blood test and colonoscopy