SN11 SHORT NOTE 5M

Write a short note on the important clinical signs in respiratory disease.

General Medicine · Final Professional

Added Sounds

Sign	Mechanism	Causes
WHEEZE (rhonchi)	Musical continuous sound from turbulent flow through NARROWED intrathoracic airways; typically EXPIRATORY	POLYPHONIC and widespread: ASTHMA, COPD, "cardiac asthma". MONOPHONIC and FIXED: LOCALISED OBSTRUCTION — tumour, foreign body, mucus plug — always warrants investigation
STRIDOR	Harsh, high-pitched, predominantly INSPIRATORY sound from EXTRATHORACIC UPPER AIRWAY obstruction	Foreign body, epiglottitis, croup, ANAPHYLAXIS, vocal cord palsy, laryngeal tumour, tracheal stenosis, retrosternal goitre. ALWAYS AN EMERGENCY
CRACKLES	Discontinuous popping from sudden opening of collapsed airways or air through secretions	FINE, END-INSPIRATORY, "VELCRO", BASAL: FIBROSIS/ILD, pulmonary OEDEMA. COARSE, EARLY-INSPIRATORY, altering with coughing: BRONCHIECTASIS, secretions, pneumonia
PLEURAL RUB	Creaking; INSPIRATORY AND EXPIRATORY; disappears on breath-holding	Pleurisy — pneumonia, pulmonary infarction, TB, connective tissue disease, uraemia
BRONCHIAL BREATHING	Harsh, with a GAP between inspiration and expiration, expiration ≥ inspiration	CONSOLIDATION (classic); above a pleural effusion; over collapse with a patent bronchus; over a large cavity (amphoric)

Voice-conducted Signs

All depend on one principle: solid consolidated lung conducts sound BETTER than air-filled lung; fluid and air in the pleural space conduct WORSE.

Sign	Test	Increased in	Decreased in
VOCAL FREMITUS	Palpate while the patient says "ninety-nine"	Consolidation	Effusion, pneumothorax, collapse with obstructed bronchus, pleural thickening
VOCAL RESONANCE	Auscultate while saying "ninety-nine"	Consolidation	As above
WHISPERING PECTORILOQUY	Auscultate while the patient WHISPERS — whispered sounds become clearly audible	CONSOLIDATION (most sensitive voice sign); above an effusion	—
EGOPHONY ("goat voice")	Patient says "eeee" — heard as a nasal "aaaay" (E-to-A change)	Consolidation, and classically at the UPPER LEVEL of an EFFUSION	—

Other Signs

BARREL CHEST — increased anteroposterior diameter, horizontal ribs, increased subcostal angle, from chronic HYPERINFLATION — COPD/emphysema, chronic severe asthma, cystic fibrosis; with hyperresonance and loss of cardiac and hepatic dullness
TRACHEAL DEVIATION — TOWARDS the lesion: collapse, fibrosis, pneumonectomy (volume loss). AWAY: large effusion, TENSION pneumothorax, large mass. A displaced trachea in a breathless hypotensive patient means tension pneumothorax until proved otherwise
CLUBBING — respiratory causes: bronchogenic carcinoma, mesothelioma, bronchiectasis, lung abscess, empyema, cystic fibrosis, ILD, asbestosis. NOT caused by uncomplicated COPD or asthma — its presence in a COPD patient demands a search for cancer, bronchiectasis or abscess
HOOVER'S SIGN — paradoxical inward movement of the lower ribs on inspiration, from a flattened diaphragm
PULSUS PARADOXUS — inspiratory fall in systolic pressure > 10 mmHg; in respiratory practice indicates acute severe asthma or COPD
ASTERIXIS — CO2 retention (type II respiratory failure)
SUCCUSSION SPLASH — HYDROPNEUMOTHORAX

Putting the Signs Together

Condition	Expansion	Percussion	Breath sounds	Fremitus/resonance	Trachea
CONSOLIDATION	Reduced	DULL	BRONCHIAL	INCREASED	Central
PLEURAL EFFUSION	Reduced	STONY DULL	ABSENT	DECREASED	AWAY (if large)
PNEUMOTHORAX	Reduced	HYPERRESONANT	ABSENT	DECREASED	AWAY (tension)
COLLAPSE	Reduced	Dull	ABSENT	DECREASED	TOWARDS
FIBROSIS	Reduced	Dull or normal	Fine crackles	Increased or normal	TOWARDS (if localised)
COPD	Reduced, symmetrical	HYPERRESONANT	Reduced, prolonged expiration, wheeze	Reduced	Central

CLINICAL PEARL

Percussion and the trachea together separate the four classic unilateral pathologies in seconds. Dull + trachea AWAY = effusion. Dull + trachea TOWARDS = collapse or fibrosis. Hyperresonant + trachea AWAY = tension pneumothorax. Dull with BRONCHIAL breathing and INCREASED fremitus = consolidation. These four combinations account for the great majority of examination cases and of real emergencies, and they require no equipment at all.

All questions in Respiratory System

Every General Medicine chapter →