Clinical Methods in RESPIRATORY MEDICINE

Clinical Methods in RESPIRATORY MEDICINE Jyotirmoy Pal MD (General Medicine) FRCP FICP FACP WHO Fellow

Professor Department of Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India Supriya Sarkar MD (Pulmonary Medicine) FICP

Professor and Head Department of Pulmonary Medicine College of Medicine and Sagore Dutta Hospital Kolkata, West Bengal, India Sekhar Chakraborty MD (Med) MRCP FRCP (Glasgow) FRCP (Ireland) FACP FICP

Consultant Physician North Bengal Medical College and Hospital Siliguri, West Bengal, India Foreword

Rohini Handa

Association of Physicians of India Indian College of Physicians

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2018, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale. Inquiries for bulk sales may be solicited at: [email protected] Clinical Methods in Respiratory Medicine First Edition: 2018 ISBN 978-93-5270-450-7

Printed at Repro India Limited

Dedicated to Prof (Dr) MN Dey Prof (Dr) JC Banerjee and Prof (Dr) Shyamal Sen

Contributors AG Ghoshal MD (Pulmonary Medicine) Ex-Professor Department of Pulmonary Medicine Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital Kolkata, West Bengal, India Director National Allergy Asthma Bronchitis Institute (NAABI) Angira Das Gupta MD DNB (Respiratory Diseases) MRCP (UK)

Consultant Pulmonologist BR Singh Hospital and Centre for Medical Education and Research Kolkata, West Bengal, India Arunabha Datta Chaudhuri MD (Pulmonary Medicine)

Graham Douglas MB ChB MRCP (UK) FRCP (Ed) Professor Department of Medicine Aberdeen Royal Infirmary Scotland, UK Indranil Halder DCH MD (Pulmonary Medicine) Assistant Professor Department of Pulmonary Medicine College of Medicine and JNM Hospital Kalyani, West Bengal, India Jaydip Deb MD (Pulmonary Medicine) Professor Department of Pulmonary Medicine NRS Medical College and Hospital Kolkata, West Bengal, India Jyotirmoy Pal MD (General Medicine) FRCP FICP FACP WHO Fellow

Professor Department of Pulmonary Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Professor Department of Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Atin Dey MD (Pulmonary Medicine) Professor Department of Pulmonary Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Pradip Kumar Chowdhury MD RMO-Cum Clinical Tutor RG Kar Medical College and Hospital Kolkata, West Bengal, India

Colin Robertson MBChB FRCPEd FRCSEd FSAScot

Professor Department of Accident and Energency Medicine University of Edinburgh Edinburgh, UK Dhiman Ganguly MD MRCP FCCP (USA) EX-Professor Department of Medicine Vivekananda Institute of Medical Sciences Kolkata, West Bengal, India

Raja Dhar MD (Respiratory Medicine) MRCP (UK) CCST (UK) FCCP (USA)

Consultant Pulmonologist Department of Pulmonology Fortis Hospital Kolkata, West Bengal, India Director, Research and Training National Allergy Asthma Bronchitis Institute Sekhar Chakraborty MD (Med) MRCP FRCP (Glasgow) FRCP (Ireland) FACP FICP

Consultant Physician North Bengal Medical College and Hospital Siliguri, West Bengal, India

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Clinical Methods in Respiratory Medicine Shubham Sharma DNB Trainee 2nd Year Department of Pulmonology Fortis Hospital Kolkata, West Bengal, India

Sukanta Kumar Dey MD (Pulmonary Medicine) Consultant Pulmonologist DES Research Centre Kolkata, West Bengal, India

Shyam Krishnan DNB (Respiratory Medicine) Senior Resident Department of Pulmonology Fortis Hospital Kolkata, West Bengal, India

Sumit Roy Tapadar MD (Pulmonary Medicine) Associate Professor Department of Pulmonary Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Subhadeep Gupta MBBS Junior Resident Department of Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Supriya Sarkar MD (Pulmonary Medicine) FICP Professor and Head Department of Pulmonary Medicine College of Medicine and Sagore Dutta Hospital Kolkata, West Bengal, India

Subhadip Mukherjee DNB (Internal Medicine) Department of Medicine BR Singh Hospital and Centre for Medical Education and Research Kolkata, West Bengal, India Subhasis Mukherjee MD (Pulmonary Medicine) Assistant Professor Department of Pulmonary Medicine College of Medicine and Sagore Dutta Hospital Kolkata, West Bengal, India Subhra Mitra

Surya Kant MD (Gold Medalist) MNAMS FCCP (USA) FIMSA FNCCP FCAI FIAB FICS FUPDA FIAMS FIACM

Professor and Head Department of Respiratory Medicine King George’s Medical University Lucknow, Uttar Pradesh, India Tanuka Mandal MBBS Junior Resident Department of Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

MD (Pulmonary Medicine) DTCD MRCP (UK)

Professor and Head Department of Pulmonary Medicine Calcutta National Medical College Kolkata, West Bengal, India

Udas Chandra Ghosh MD DTCD FRCP FICP Professor and Head Department of Medicine Murshidabad Medical College and Hospital Berhampore, West Bengal, India

Subir Kumar Dey MBBS DTCD DTM & H MD Professor and Head Deartment of Pulmonary Medicine ICARE Medical College Haldia, West Bengal, India

Uddalok Chakraborty MBBS Junior Resident Department of Medicine RG Kar Medical College and Hospital Kolkata, West Bengal, India

Foreword Respiratory disorders are commonly encountered by all physicians and constitute an important chunk of internal medicine practice. Against this backdrop, a systematic bedside approach to pulmonary diseases is essential. Prof (Dr) Jyotirmoy Pal, Prof (Dr) Supriya Sarkar and Dr Sekhar Chakraborty have got together to produce this book on Clinical Methods in Respiratory Medicine, which indeed is very much the need of the day. The editors have assembled a galaxy of renowned experts. The book covers anatomy, physiology, symptoms, signs, investigations and clinical data analysis in a simple, lucid and easy-to-comprehend fashion. All readers are sure to find this step-by-step approach and data synthesis extremely useful. This work is likely to appeal as much to the experienced clinician as to the fresh postgraduate.

Rohini Handa MD DNB FAMS FICP FRCP (Glasgow)

Senior Consultant Rheumatologist Indraprastha Apollo Hospitals New Delhi, India Dean, Indian College of Physicians (ICP) Honorary Consultant of Rheumatology, Armed Forces Medical Services Quondam Professor of Medicine, All India Institute of Medical Sciences, New Delhi President, Asia Pacific League of Associations for Rheumatology (APLAR) President, Indian Rheumatology Association

Preface We are honored to receive responsibility from Dean, Indian College of Physicians (ICP) to release a monograph on Clinical Methods in Respiratory Medicine. We are thankful to our students Dr Subhodeep Gupta, Dr Tanuka Mondal, Dr Uddalok Chakraborty, and Dr Sayantan Bose, for their effort to make dream fulfilled. In spite of advancement of technology, the art of history taking and clinical examination have immense importance in clinical diagnosis and management. Proper history taking and clinical diagnosis can help us in judicious and costeffective use of diagnostic tools. Again, respiratory problems are possibly most commonly experienced by practising physicians and do also by students in their examination and practising life. From this view point, we tried to highlight clinical anatomy and physiology useful to understand respiratory diseases. We have elaborated common symptoms of respiratory diseases like cough, sputum, hemoptysis, chest pain, dyspnea, etc. General examination is described in details and in a useful manner. Respiratory system examination and interpretation also will be useful to both undergraduate and postgraduate students. Attempts have been made to include important diagnostic tools used in respiratory disease. We hope this book will be useful to all undergraduate and postgraduate students and physicians in both in examination and in practising life. Our sincere thanks to Dr BR Bansode (President, Association of Physicians of India), Dr Rohini Handa (Dean, Association of Physicians of India), Dr YP Munjal (Director, Physicians Research Foundation), Dr BB Thakur (Ex-President, Association of Physicians of India and Ex-Dean, Indian College of Physicians), Dr Siddarth Shah (Ex-President, Association of Physicians of India), Dr A Muruganathan (Ex-President, Association of Physicians of India and Ex-Dean, Indian College of Physicians), Dr KK Parekh (Ex-President, Indian College of Physicians), and Dr GS Wander (Ex-President, Association of Physicians of India), for giving us inspirations to prepare the book. We are thankful to Dr Amal Kumar Banerjee, Dr SB Ganguly, Dr RN Sarkar, and Dr Apurba Mukherjee, for guiding in proper direction. Our thanks should be extended to our API WB Branch office staffs Mr Kaushik Dhar and Mr Dilip Pal, for all out cooperation. We must recognize contribution and guidance which we have received from Prof Dr Colin Robertson author of “Macleod Clinical Examination”. Lastly, we are thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and their staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for taking pains for publishing the book. Jyotirmoy Pal Supriya Sarkar Sekhar Chakraborty

Acknowledgments We are thankful to Prof (Dr) Sukumar Mukherjee, Prof (Dr) Manotosh Panja, Prof (Dr) Amal Kumar Banerjee, Prof (Dr) Apurba Mukherjee, Prof (Dr) SB Ganguly, and Prof (Dr) RN Sarkar towards publication of the monograph.

Contents Chapter 1.

Approach to Respiratory Medicine

1

Graham Douglas, Colin Robertson

Chapter 2.

Clinical Anatomy of Thorax

5

Arunabha Datta Chaudhuri ‰ Basic Anatomy of Thorax 5 ‰ The Anatomy of Airways 7 ‰ Anatomy of Lung, Pleura and Diaphragm 9 ‰ Surface Anatomy 19

Chapter 3.

Basic Science in Pulmonology

23

Dhiman Ganguly ‰ The Blood Gases 23 ‰ The Oxygen Cascade 25 ‰ The Carbon Dioxide Story 28 ‰ Regulation of Respiration 31

Chapter 4.

Clinical Approach and Analysis of Respiratory Symptoms Angira Das Gupta, Subhadip Mukherjee, Surya Kant, Shubham Sharma, Raja Dhar, Supriya Sarkar, Subhasis Mukherjee

A. Clinical Approach to Cough and Expectoration Angira Das Gupta, Subhadip Mukherjee ‰ The Cough Reflex 36 ‰ Causes of Cough 36 ‰ Approach to Chronic Cough 38

B. Clinical Approach to Hemoptysis

45

Surya Kant ‰ Etiology 45 ‰ Approach to Patient 47 ‰ Investigations 48 ‰ Management 50

C. Clinical Approach to Chest Pain

54

Raja Dhar, Shubham Sharma ‰ Etiology 54 ‰ Cardiac Causes of Chest Pain 54 ‰ Pulmonary Causes of Chest Pain 59 ‰ Gastrointestinal Causes of Chest Pain 63 ‰ Musculoskeletal Causes of Chest Pain 63 ‰ Psychiatric Causes of Chest Pain 64 ‰ Other Causes of Chest Pain 64

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