Lung Auscultation


Low pitched:

  • Vesicular
  • Coarse crackle
  • Rhonchi

High pitched

  • Bronchial
  • Fine crackle
  • Wheeze
  • Stridor




Sepsis Consensus Definitions

From the article



SOFA score: CNS, Cardio, Respi, Liver (Bilirubin), Renal (Creatinine), Coagulation (Platelets)




Reference: SInger et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810


Palpation and percussion of chest

Tactile Fremitus

  • Saying “ninety-nine” while palpating the chest wall
  • More prominent in men due to lower pitched voices.


3 types

  • Comparative
  • Topographical: used to delineate border of heart, liver and diaphragmatic excursions.
  • Auscultatory

Auscultatory percussion

  • Pleural effusion: stethoscope is placed below 12th rib. Percussion is done from posterior chest from apex to base. 
    – At some point, the dull sound will change to a clearer one as it approaches the stethoscope. If this happens above 12th rib, it indicates pleural effusion.
  • Another version is by listening over the back of chest while tapping over the manubrium. 
    – Clinician should hear identical sounds in two sides of chest. A decreased intensity indicates ipsilateral disease on that side

Percussion sounds

  1. Resonance
    – Special types of resonance: Skodaic’s, amphoric
  2. Dullness
  3. Tympanic

Skodaic resonance:

  • Resonance heard above the pleural effusion.
  • Why? Nobody knows

Amphoric resonance

  • Flicking the tense cheek while holding the mouth open mimics the sound
  • Indicates presence of cavities.

Grocco’s triangle

  • A small triangle of dullness at posterior chest contralateral to side of effusion

Kronig isthmus

  • Narrow area of resonance between the dullness of neck and shoulder muscles.
  • If this resonance is lost, it indicates apical lung diseases.


  • Topographic percussion theory
    – The characteristics of the underlying organs determine the type of the sounds heard.
  • Cage resonance theory (the chest wall is the cage, and how it resonates affects the percussion)
    – The type of sounds are also affected by the chest wall and the strength of the stroke.

Cage resonance theory maybe more accurate:

  • External pressure on the chest dampens the percussion notes.
  • Liver span is SMALLER when percussing with stronger stroke.
    – Stronger stroke produces more vibrations and therefore more resonance.
    – If according to topographic percussion theory (stronger strokes lead to deeper penetration), the liver span should have been larger.

Auscultatory percussion

  • Possibly sound transmission circumferentially in chest wall rather than through the lungs
  • Evidences:
    – Heart is not detected. If the sound is transmitted through the lung, some dullness should have been heard in left side of the chest
    – Sounds intensity changes during Valsava maneuver which tenses the chest wall.
    – Sound intensity recorded when the patient breathes room air and a mixture of oxygen and helium is the same (different gases should have different density and this affects the sound intensity).

So what’s good?

  • Only asymmetrical dullness/hyperresonance using comparative percussion maybe ok to detect pulmonary pathologies.
  • Auscultatory percussion is also very specific for detecting pleural effusion.



Evidence Based Physical Diagnosis. Steven McGee.

Thyroid and Its Disorders

Anatomy of thyroid

  • Landmarks: laryngeal prominence (adam’s apple) of thyroid cartilage and cricoid cartilage which lies below it
  • Isthmus of thyroid normally lies just below the cricoid cartilage
  • High vs low lying thyroid
    – If distance between laryngeal prominence and the suprasternal notch is far (eg 10cm), the thyroid gland maybe high lying (pseudogoiter)
    – If laryngeal prominence is close to suprasternal notch (<5cm), the thyroid gland is low lying (and located retrosternally). Palpation maybe impossible.

Inspection of thyroid gland

  • See from the side. The line between cricoid prominence and suprasternal notch (where the thyroid gland is located) is a straight line.
  • If it is bowed, consider goiter



  • An easier way to palpate thyroid gland

What do we palpate?

  • Size
  • Consistency (hard or soft)
  • Nodular
  • Tenderness

The key to know that what we palpate is thyroid gland is

  • It moves during swallowing, and then hesitate a while before returning. As thyroid gland and tracheal is connected by ligaments.
  • If it does not move during sallowing or does not hesitate before returning to its original position, it is likely not thyroid gland.

Cervical goiter

Estimation of size

  • Rule of thumb: lateral lobe is enlarged if it is larger than distal phalanx of the patient’s thumb
  • WHO grading

Retrosternal goiter

  • May cause TOS, SVC syndrome and compression of trachea and esophagus
  • TOS (thoracic outlet syndrome):
    – Compression of brachial plexus: pain in the multiple myotomes in UE
    – Compression of subclavian vein: UE venous thrombosis (Paget-Schroetter syndrome)
  • SVC syndrome:  elevated JVP + plethora + facial & arm edema
  • Compression of trachea and esophagus: dyspnea, stridor, dysphagia

Thyroglossal cyst

  • Cystic swellings of thyroglossal duct , an epithelium lined remnant marking the descent of thyroid tissue from the base of tongue to its final location
  • Midline neck mass
  • Characteristic sign is upward movement when the patient protrudes the tongue

Delphian node

  • Prelaryngeal lymph node
  • Named Delphian because it is the first one exposed during surgery and its appearance often foretells what the surgeon will find in thyroid.
  • Radiologically, it is situated in lymph node level VI
  • If it’s palpable, it is usually enlarged – suspect malignancy or Hashimoto’s thyroidits


  • Classical triad of puffy skin + delayed reflexes + thick & nasal speech
  • Features
    – Skin: dry, cold, puffy skin
    – Achlles reflex: delayed reflex due to prolonged contraction & relaxation
    – Hypothyroid speech: slow, deep and nasal (as if patient has a cold)
  • Billewicz Diagnostic Index for hypothyroidism
    >30 has a high likelihood of hypothyroidism

Graves disease

  • Triad of prominent eyes + goiter + tachycardia
  • Auscultation in thyroid gland can often ellicit bruit (in 70% of patents)
  • Eye findings:
    Lid lag: von Graefe sign
    – ask patient to look down, the upper eyelid “lags” behind

    Lid retraction: Dalrymple’s sign
    – ask patient to look straight, white sclera is seen between the limbus and the lid margin; usually the lid margin rests just below the corneal limbus

    Graves opthalmopathy
    –  NO SPECS
    – Consider if patient with Graves disease complain of gritty sensation in the eyes or diplopia

  • CV findings:
    – Loud S1
    – Tachycardia
    – Means Lerman scratch (systolic rub resembling scratching near the left 2nd ICS)
  • Skin findings:
    – Moist (due to increased sweating) and warm
    – Pretibial myxoedema
  • Neuromuscular findings
    – Fatigue & weakness
    – Fine tremor due to sympathetic overflow
    – Brisk ankle reflexes

** Other ddx of lid retraction

  • Facial palsy: unilateral weakness of orbicularis oculi –> levator palpebrae is no longer being opposed
  • Unilateral ptosis: attempts to elevate the weakened lid causes excessive neural signals which end up elevating another lid
  • Previous eyelid surgeru

More eponyms?

Von Graefe: lid lag (We look down in Grief !)

Darylrmple sign: lid retraction (DaryLRmple)

Joffroy sign: lack of forehead wrinkling (FF resembling wrinkling)

Stellwag sign: staring look (Stellwag for Staring)

Moebius sign: Poor convergence (Merging Of EyeBalls Is UnSuccessful)

Wayne Diagnostic Index for hyperthyroidism >20 points have a high likelihood for hyperthyroidism

Note: BOTH hypo and hyperthyroidism cause amenorrhea !

  • Hypothyroidism: increased TRH causes increased prolactin production which blocks GnRH
  • Hyperthyroidis: multiple mechanisms, but likely linked to high SHBG which leads to high ratio of bound estradiol. Only free estradiol can induce a LH peak.

Mnemonic for THYROID disorders: NEVER FORGET THEM AGAIN !


  • Tremor (in hyper)
  • Heart Rate
  • Yawn (fatigue in both)
  • Reflexes (brisk or delayed)
  • Oligomenorrhea
  • Intolerance to temperature  (heat or cold)
  • Diarrhea (or constipation)
  • Increased or decreased appetitie
  • Skin (cool,dry and puffy or moist and warm skin)
  • Myxoedema (facial puffiness in hypothyroidism, pretibial myxoedema)


Steven McGee. Evidence Based Physical Diagnosis. Pg 250-276

Dengue WATCH OUTS !!


  • Especially poorly controlled hypertensive patients.
  • A “sudden” NORMAL BP could mean compensated shock
  • Even for normal person, do not exclude compensated shock because BP is “normal” !


  • Osmotic diuresis paves the way for dehydration !!

Pregnant women

  • Lower baseline Hct, so Hct in dehydrated pregnant patients maybe magically “normal” !
  • Due to progestogen induced vasodilation, baseline DBP is lower, especially in 2nd trimester. The pulse pressure may not even get narrow to be in shock !

Pharmacology of OADs

This slideshow requires JavaScript.

Note: there is a drug not mentioned in this list


  • Mentioned in NICE 2009 guideline for T2DM but not in 2015.
  • Insulin secretagogue, especially increases its secretion in response to glucose (first phase insulin release).
    – Used in patients with unpredictable meal time. 
    – Good to tackle postprandial hyperglycemia (mild increase in fasting glucose level but disproportionately high A1C)
  • Short duration of action (achieves peak plasma level in 1 hr & producing a rapid insulin-releasing effect that lasts for 3 hrs ) and hepatically excreted (T1/2 = 1 hr)
    – Can be used in renally-impaired patients
    – Lesser hypoglycemia (as it is short acting and increases insulin secretion IN RESPONSE to glucose, unlike sulfonylureas)

Rational of combination therapy

  • NICE suggests metformin + sulfonylurea or pioglitazone or DPP4i
  • Common threshold to initiate combination therapy is when A1C >8%.
  • With time, not only insulin resistance, there is loss of B-cell function as well (to abou 25% in 6 years).
  • Primary objective is to tackle the problems of insulin resistance + deficiency.
    – Metformin: insulin sensitizer
    – Pioglitazone: insulin sensitizer
    – Sulfonylurea: insulin secretagogue
    – DPP4i: GLP-1 based (increases insulin secretion)



Nodular lymphangitis

Nodular lymphangitis is characterized by inflammatory nodules along the lymphatics draining a primary skin infection.

Nodular lymphangitis.png

Reference: DiNubile MJ. Nodular lymphangitis: a distinctive clinical entity with finite etiologies. Curr Infect Dis Rep. 2008 Sep;10(5):404-10




Bottom line:

  • Lateralization in Weber test
    Sensorineural loss: to good ear (= CONTRALATERAL ear is damaged)
    Conductive loss: to bad ear (= IPSILATERAL ear is damaged)
  • Rinne test
    – BC>AC in conductive loss
    – AC>BC in sensorineural loss


Steven McGee. Evidence Based Physical Diagnosis. Pg 242-249