12 Respiratory Conditions With Physical Signs Beyond Coughing

9. Pulmonary Hypertension - The Elevated Pressure Syndrome

Pulmonary hypertension creates a distinctive pattern of physical signs that primarily reflect right heart adaptation to chronically elevated pulmonary vascular pressures, often developing insidiously over years before becoming clinically apparent. The cardiovascular examination reveals a prominent pulmonary component of the second heart sound (P2) that may be palpable over the pulmonary area, while a right ventricular heave becomes apparent along the left sternal border as right heart hypertrophy develops. Jugular venous pressure elevation with prominent 'a' waves reflects decreased right ventricular compliance, while the development of tricuspid regurgitation creates a holosystolic murmur that increases with inspiration and may be accompanied by hepatic pulsations. As right heart failure progresses, patients develop peripheral edema that typically begins in the ankles and progresses proximally, accompanied by hepatomegaly that may be tender and pulsatile. Ascites may develop in advanced cases, while hepatojugular reflux becomes positive as venous return increases with abdominal compression. The skin often appears dusky or cyanotic, particularly around the lips, fingertips, and nail beds, reflecting chronic hypoxemia and reduced cardiac output. Digital clubbing may develop, particularly in patients with congenital heart disease or chronic hypoxemic conditions causing pulmonary hypertension. Patients frequently exhibit exercise intolerance that seems disproportionate to their apparent respiratory status, with syncope or near-syncope occurring during exertion as cardiac output fails to increase appropriately. The neck veins may show prominent v waves if significant tricuspid regurgitation develops, while the liver may become enlarged and pulsatile. In severe cases, patients may develop signs of low cardiac output including cool extremities, delayed capillary refill, and altered mental status, particularly during exertion or stress when the fixed cardiac output cannot meet metabolic demands.