11th January 2024

Examination

Respiratory examination

• Fine late inspiratory crackles at bases are typical of ILDs but may not be present in the early stages and in granulomatous disease, e.g. sarcoidosis. Note the location (i.e. basal/widespread/apical), as it might give a clue towards a diagnosis.
• Wheeze may be present in certain types of ILDs, e.g. HP

Cardiovascular examination

• Usually normal, especially in early disease
• Long -standing ILD may lead to core pulmonale and pulmonary hypertension signs (loud S2, raised JVP, peripheral oedema, occasionally pulmonary valve regurgitation), but this is usually only found in advanced, severe disease. If present early in the course, consider alternative diagnosis.

Systemic features

• Clubbing is a useful feature to note, as it is common in certain ILDs but rare in others (see image below). In particular, it is associated with asbestosis and IPF. It is also strongly linked to many non-ILD diseases, such as cyanotic heart disease, cystic fibrosis, and inflammatory bowel disease (IBD), so should be considered in the context of patient’s history. In ILD, clubbing usually points to advanced fibrosis.
• Examine joints and skin for any evidence of CTD-ILD. Rheumatoid arthritis, dermatomyositis, myositis, SLE, and scleroderma can all present with typical skin or articular signs (see images). Saddle nose deformity might point towards GPA or chronic illicit drug use (see image below).

Image Source: Wikimedia Commons (2013). Clubbing of fingers in IPF, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Clubbing_of_fingers_in_IPF.jpg (Accessed: 24 January 2023).

Image Source: Wikimedia Commons (2010). Dermatomyositis, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Dermatomyositis.jpg (Accessed: 24 January 2023).

Image Source: Wikimedia Commons (2013). Lupusfoto, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Lupusfoto.jpg (Accessed:24 January 2023).

Image Source: Wikimedia Commons (2011). Raynaud’s syndrome, Licensed under a creative commons licence. Available for free at: https://upload.wikimedia.org/wikipedia/commons/4/43/Raynaud-Syndrom.JPG (Accessed: 24 January 2023).

Image Source: Wikimedia Commons (2016). Saddle_nose_38, Licensed under a creative commons licence. Available for free at: https://upload.wikimedia.org/wikipedia/commons/e/ee/Saddle_nose_38.jpg  (Accessed: 24 January 2023).