AUSCULTATORY SIGNS OF PULMONARY DISEASE

It is questionable whether this topic should be included in a differential diagnosis book, but because it is important for the clinician to be able to recall a fairly complete list of possible causes for these signs while he or she is still examining the patient, a discussion is included here. Regardless of what the sign is, it almost invariably may be considered the result of local disease of the lung or heart. Infrequently, a disease of another organ has spread to the lung. Cross-indexing these topics with the mnemonic of etiologies, VINDICATE, will provide a useful list of possibilities.

Lung

V—Vascular diseases include pulmonary embolism, infarction, and Goodpasture disease. I—Inflammatory disease suggests viral, bacterial tuberculosis, parasitic and fungal pneumonia, and lung abscess. Pleurisy must also be considered. N—Neoplasms remind one of carcinoma of the lungs (primary or metastatic) and bronchial adenomas. D—Degenerative disease suggests emphysema and pulmonary fibrosis. I—Intoxication brings to mind the pneumoconioses and changes from drugs such as nitrofurantoin. C—Congenital disorders include cystic fibrosis, α ₁-antitrypsin deficiency, bronchiectasis, alveolar proteinosis, atelectasis, and lung cysts. A—Autoimmune diseases include rheumatoid arthritis, lupus, Wegener granulomatosis, periarteritis nodosa, and scleroderma. The A also stands for allergic diseases, including asthma and Löffler syndrome. T—Trauma should suggest pneumothorax and hemopneumothorax. E—Endocrine disease suggests the bronchoconstriction of the carcinoid syndrome.

Heart

V—Vascular diseases of the heart that cause auscultatory signs include myocardial infarction and hypertension with CHF and the various arrhythmias associated with them. I—Inflammatory diseases of the heart also affect the lungs. Subacute and acute bacterial endocarditis may shed emboli in the lung if the right side of the heart is affected. Myocarditis may cause failure, and pericarditis may cause pleural effusion. N—Neoplasms of the heart rarely affect the lung. D—Degenerative diseases include muscular dystrophy and other cardiomyopathies. I—Intoxication reminds one of alcoholic myocardiopathy with CHF and arrhythmias that may lead to emboli. Digitalis and other cardiac drugs may do the same. Electrolyte disturbances must also be considered here. C—Congenital heart diseases bring to mind a host of diseases that may cause failure. A—Autoimmune diseases, especially lupus erythematosus, scleroderma, and amyloidosis, affect the heart and lung. T—Traumatic hemopericardium or aneurysm of the heart may cause auscultatory changes of the lung. E—Endocrine diseases such as hyperthyroidism, hypothyroidism, acromegaly, and diabetes mellitus affect the heart and may ultimately lead to CHF and edema in the lungs. Endocrine causes of hypertension (aldosteronism and Cushing syndrome) may lead to hypertensive cardiovascular disease (HCVD) and CHF.

Diseases of Other Organs

V—Vascular suggests pulmonary embolism from systemic phlebitis. I—Inflammation includes embolic abscesses or pneumonitis of the lungs and pulmonary tuberculosis, tularemia, plague, Echinococcus, Paragonimus westermani, histoplasmosis, and so forth. Shock lung from septicemia is a possible cause. N—Neoplasms suggest metastatic carcinoma from other organs. Meigs syndrome is also suggested here. D—Degenerative suggests nothing here, although pleural effusion may result from nephrosis and cirrhosis. I—Intoxication may result from ingested turpentine or other products that subsequently affect the lung. Aspiration pneumonitis must be considered in this category. C—Congenital disorders, especially neurologic diseases and esophageal atresia, may lead to recurrent pneumonia. A—Autoimmune diseases have been reviewed above. T—Trauma and burns anywhere may result in pulmonary edema from shock lung. E—Endocrine diseases have been discussed above.

Approach to the Diagnosis

Clinically, the grouping together of signs provides the best way of narrowing the differential diagnosis.

Rales

1. Bilateral crepitant rales, lack of dullness, and normal breath sounds suggest pulmonary edema or pneumonitis.
2. Focal crepitant rales, reduced alveolar breathing, dullness to percussion, and increased tactile and vocal fremitus suggest lobar pneumonia or pulmonary infarction.
3. Bilateral sibilant and sonorous rales without dullness and with increased bronchial breathing suggest asthma, chronic bronchitis and emphysema, acute bronchitis or bronchiolitis, and cardiac asthma.
4. Focal crepitant rales and amphoric breathing with dullness below and hyperresonance above suggest a lung abscess or cavitation.

Hyperresonance

1. Hyperresonance bilaterally with diminished breath sounds bilaterally and sibilant rales suggests pulmonary emphysema or asthma.
2. Focal hyperresonance with diminished or absent breath sounds and no rales suggests pneumothorax.
3. Focal hyperresonance with normal or only diminished breath sounds suggests a large bulla.

Dullness or Flatness

1. Dullness with diminished breath sounds and no rales suggests atelectasis or pleural effusion from empyema, CHF, or pulmonary infarct. In atelectasis, there is no hyperresonance or egophony above the dullness.
2. Dullness with diminished breath sounds and crepitant rales suggests pneumonia or pulmonary infarct. If there is bronchophony as well, there is probably no associated effusion. If there is no bronchophony but hyperresonance and egophony above the dullness, then an associated pleural effusion should be considered.

Laboratory Workup

Crepitant rales should prompt a sputum examination, smear and culture, possibly a tuberculin test, venous pressure and circulation time, chest roentgenogram, and ECG to secure the diagnosis. If the chest x-ray film shows no consolidation and the individual is in no acute distress, a pulmonary function study may help. If it shows a reduced vital capacity with a normal timed vital capacity, CHF is the most likely diagnosis. In acute cases, shock lung or adult respiratory distress syndrome must be considered.

Other Useful Tests

1. CBC (pneumonia)
2. Sedimentation rate (pneumonia)
3. Tuberculin test
4. Sputum smear and culture (pneumonia)
5. Sputum smear and culture for fungi (histoplasmosis, etc.)
6. Sputum cytology (carcinoma of the lung)
7. ANA test (collagen disease)
8. Coccidioidin skin test
9. Histoplasmin skin test
10. Blastomycin skin test
11. Rheumatoid arthritis test (rheumatoid arthritis involving the lung)
12. Kveim test (sarcoidosis)
13. X-ray of the hands (sarcoidosis)
14. Lymph node biopsy (neoplasm, sarcoidosis)
15. Bronchoscopy (neoplasm)
16. CT scan of the lung (neoplasm, bronchiectasis)
17. Echocardiogram (CHF, valvular heart disease)
18. Lung biopsy (neoplasm)
19. HIV antibody titer (acquired immunodeficiency syndrome [AIDS])

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Lung symptoms: Introduction (review 1646 causes)
• Next Book Extract About Lung symptoms: CLUBBING AND PULMONARY OSTEOARTHROPATHY (Differential Diagnosis in Primary Care)
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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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