LOOK, LISTEN AND FEEL

Article 9


Look Listen and Feel

(On Signs, Symptoms and Syndromes)


Lim Ju Boo



I am sure all of us are familiar with the first-aid (primary) assessment of the unconscious victim with the golden rule of the thumb “Look, Listen and Feel’ for breathing, and we may also feel the pulse for circulation. We also encounter signs and symptoms in other aspect of first-aid, and also in medicine, whether in the practice of conventional or naturopathic medicine. Occasionally patients and lay people (hopefully not the first-aiders) get confused between signs and symptoms. Although related from a diagnostic point of view, they are two separate entities. Signs, symptoms and syndromes are part of presenting features that aid in a diagnosis. Symptoms are what the patient can feel and tell, such as a headache, itchiness, discomfort and nausea, whereas signs are what a first-aider, doctor, or a naturopath can see, feel, listen, measure or elicit a response. There are several hundreds of examples, but let me illustrate with just a few examples below:

Presentation:

In first aid we recognize that distortion, swelling, and perhaps bruising are signs of a fracture, while the pain associated with them is a symptom. Similarly, a first-aider can recognixe that a bluish discoloration of the skin and mucous membrane called cyanosis is seen in choking and asphyxia. This is due to an increased carbon dioxide (hypercapnia / hypercarbia), and a decreased in oxygen levels in the blood. Low oxygen levels may be caused by both low SaO2 (oxygen saturation in arterial blood), and/or low PaO2 (partial pressure of arterial oxygen). But first-aiders must not think that only choking can cause cyanosis. Cyanosis can also be associated with heart failure, lung diseases, the breathing of oxygen-deficient air, or in congenital heart defect (tardive and congenital cyanosis which may also be associated with clubbing of the fingers).

Auscultation:

Another example of what can be seen is the presence of Koplik’s spots in the inner cheek, which is a sign indicative of common measles, to differentiate it from German measles which a doctor/naturopath can detect. . The sounds of a mid-systolic or pansystolic (holosystolic) murmur may be indicative of a mitral valve prolapse, ASD (atrial sepal defect), or VSD (ventricular septal defect), or Tetralogy of Fallot (a congenital heart defect). Similarly, a physician is able to hear the machinery murmur in PDA (patent ductus arteriosus). PDA is a congenital vascular problem where the communicating vessel between the aorta and the pulmonary vessel remains patent (open) even after birth, when it should be closed. As a result, there is a mixing of oxygenated blood from aorta with the deoxygenated blood going to the lungs for oxygenation when the ventricles contract. The higher pressure from the aorta is shunted into the lower pressure exerted in the pulmonary vessels causing turbulence in the blood flow through the narrow anastomosis (connecting vessel). This is heard as a murmur (machinery, crescendo-decrescendo type). In fact the various types, grades and characteristics, and positioning (areas over the precordium the sounds are best heard) of murmurs heard are the result of some abnormality in the haemodynamics of blood flow which a doctor can recognize for a provisional diagnosis, apart from using 2-D echogram for confirmation. Murmurs are blowing sounds, similar to the rhythmic sounds of flames being blown by a bellow in a furnace, or the purring sounds of a cat’s breathing. The normal ‘lup dup’ (systolic/diastolic or 1st and 2nd) sounds of a heart beat is replaced by regurgitating sounds of mitral / tricuspid or pulmonary/aortic valve incompetence (does not close tightly), or a septal defect (‘hole-in-the-heart’). Of course not all murmurs are pathological. Some are just innocent or physiological murmurs heard in young children, or the haemic bruits heard in severely anaemic persons due to a lower viscosity of blood, and a resultant greater turbulence in the blood flow. These are examples of some kinds of sounds that can be heard, and they are signs, and not symptoms. We will not go further into the pathophysiology how these sounds are generated in health and in disease.

Abnormal sounds:

Similarly, the sounds of crepitation, rales and rhonchi can be heard in certain lung disorders, such as crepitations (soft fine cracking sounds, like fine soap foams bursting) in pneumonia on auscultation. The appearance and the disappearance of the sounds of Korotkoff (named after a Russian physiologist/physician) is used in the measurement of blood pressure, and so are some abdominal sounds heard in peristaltic action of the intestines, aneurysm of abdominal aorta, foetal heart sounds, and vascular sounds from the placenta. Intestinal sounds for example may be absent in paralytic ileus. Not all sounds heard denote a pathological condition. The body emits a lot of sounds, most of which are physiological. The rhythmic ‘lup dup’ are the sounds of a normal heart beat.

So are the soft vesicular sounds of respiration, and the gargling abdominal sounds of peristalsis in the intestines. Likewise, noisy breathing like snoring while asleep does not mean the sleeping person is choking. There are other ways to recognize acute laryngeal or partial airway obstruction other than snoring, such as gurgling noises, crowing, wheezing, cyanosis and laboured breathing, besides displaying the universal signs of choking called the Heimlich sign or the Café Coronary Syndrome. Normal physiological sounds of snoring when a person is asleep, is due to vibration of the soft plate, uvula, pharyngeal walls, or epiglottis when they are relaxed at sleep. It is only when normal physiological sounds deviate from the norm, that there may be an underlying cause or disorder.

Stridor:

In trauma cases, we can also assess the ventilatory status by listening for air entry, abnormality in the breadth sounds, heart sounds and a displaced apical beat. Noisy, harsh and high pitched sounds of breathing (stridor), snoring and gurgling noises are indicative of partial obstructions to the airways, while hoarseness of voice may be diagnostic for laryngeal obstruction. Still on sounds and listening, we can also percuss the chest walls on both sides to listen for resonance, namely for high or low-pitched percussion notes. In severe tension pneumothorax a high resonance is heard on percussion, with reduced or absent breath sounds, in contrast with dullness in the percussion notes with severe haemothorax. This is understandable, since if air enters the pleural spaces of the lungs as in pneumothorax, the percussion notes sounds hollow and empty, but if there is blood, fluid or pus to congest the lungs, the sounds are solid and dull. This is common sense. Percussion is an examination technique whereby an examiner taps the body lightly but firmly to determine the position, size, and consistency of an underlying structure, and the presence of fluid, such as blood or pus in a cavity. These conditions are established by variations in resonance and pitch of the sounds emitted, vibrations elicited and resistance encountered. Another example of signs detected is an assessment manoeuover designed to detect subluxation or dislocation of the hips. The examiner places the infant on the back with hips and knees flexed, at the same time abducting and lifting the femur. A palpable click may be felt as the femur enters the dysplastic joints (Ortolani’s sign). We can also palpate (feel) various parts of the body for any abnormality, say for broken bones. For instance, a physician can feel for hepatomegaly (liver enlargement), by palpating the upper right quadrant of the abdomen (below the border of the rib cage) over the lateral to rectus muscle. He may feel for tenderness, resistance and mass, especially during inspiration when the liver comes down from the diaphragm to meet the finger-tips. Likewise, for spleenomegaly (spleen enlargement) on the left side, and for any kidney enlargement (a bit more difficult, especially if patient is obese) etc, tenderness may be felt.

Signs:

As for measurement as a diagnostic sign, the measurement of blood pressure is a fine example that will provide us information (signs) of blood pressure status and is useful in monitoring the state of shock. We can also measure, (or simply look at it, if a physician is experienced enough) for tale-tale signs of any increase in the CT (cardiothoracic) ratio in cardiomegaly (heart enlargement), say in LVH (left ventricular hypertrophy) as seen on a CXR (chest x-ray). The normal transverse CT ratio is between 0.3 and 0.5. We can also elicit a response, such as the absence of abdominal skin reflex in intestinal inflammation or hemiplegia (Rosenbach’s sign), or signs of inability to maintain balance when the eyes are shut, and the feet close together (Romberg’s sign for ataxia), or elicit triceps reflex to detect spinal tract lesions at the cervical levels of C6, C7 and C8. All first-aiders and paramedics should be familiar with AVPU and the 15 point GCS score in assessing level of consciousness, or the Look, Listen and Feel signs for breathing. All these are diagnostic signs, as opposed to say a symptom of pain in a sprain, cramps, and in bends, or the sensation of giddiness in postural hypotension and low blood pressure in shock and severe anemia, or vertigo and tinnitus (ringing in the ears) due to disturbances in the equilibratory apparatus of the ears.

Syndromes:

A syndrome is a group of related signs and/or symptoms characterizing a particular disorder. In other words, syndromes mean ‘running together’. All the signs and / or symptoms are running together at the same time to form a distinctive clinical picture of a particular disorder. Most of the syndromes have names attached to them after the discoverer who first describe their clinical features associated with a disease. One or two examples are, Fanconi’ syndrome (a renal tubular disorder), and Dubin-Johnson syndrome (a chronic idiopathic jaundice) or Turcot’s syndrome (polyps in the colon and brain tumors, inherited as a recessive traits). Some have no names attached, such as orogenital syndrome (a nutritional deficiency disease), and foetal face syndrome. In trauma, very few examples can be cited. Syndromes generally don’t suddenly appear in trauma cases or in a sudden injury. Syndromes are more generally encountered in medical cases rather than in trauma cases or in injuries. Classical clinical features normally appear one after another during the natural course of a disease. It takes some time for these signs and symptoms to develop until they become the full blown features of the disease. Trauma and injuries like child-birth are not diseases per sec. Nevertheless, certain features do appear as post-trauma (medical) complications.

Acute Respiratory Distress Syndrome:

One example I can think of at the moment is adult or acute respiratory distress syndrome (ARDS) as a result of multiple fractures to the pelvis and long bones in adults. Fat emboli enters the lungs causing alveolar-capillary damage, thus giving rise to increased permeability and plasma leakage, with resultant non-cardiogenic pulmonary oedema. Signs and symptoms are rapid shallow breathing progressing to frank dyspnoea, cough, crepitation and cyanosis. Chest X-ray shows alveolar and interstitial infiltration, similar to pulmonary oedema, except there is no cardiomegaly (heart enlargement). PaO2 (partial oxygen) is less than 60 mm Hg. The profound impairment of oxygenation is largely due to shunting through the non-ventilated lung compartments. Another example is compartment syndrome associated with say an abdominal or a limb injury.

Compartmental syndrome:

Compartmental syndrome is a condition in which increased pressure in a confined anatomical space say in the chest or abdominal cavity adversely affects the circulation and threatens the function and viability of the tissues therein. Compartment syndrome in a limb injury for instance is characterized by an increasing pain, even though the fracture has been immobilized. There may be altered sensation in the dermatome of the nerves passing through that compartment. There is a palpable elevated tension and tenderness of the muscle compartment. There is also pain on passively stretching the muscles within the compartment. Another example is the anterior/central/posterior cord syndromes due to injuries of the spinal cord, each area giving rise to various sensations and pain. One example of a syndrome that I can think of that lies midway between a medical cause, and an effect similar to a shock in trauma, is toxic shock syndrome. The cause is actually due to staphylococcal endotoxic infection in the vagina of menstruating women using superabsorbent tampons. The condition is characterized by high fever, vomiting, diarrhoea, a scarlatinaform rash followed by desquamation. This is followed by decreasing blood pressure and shock, and possible death if not immediately treated.
The first-aid is to treat for shock if necessary even if it is a medical case, and not one due to an injury.

Other features:

There are other more complex definitions of signs, symptoms and syndromes of course, but we shall not go into them. Signs and symptoms in a patient / casualty are commonly encountered in the practice of conventional and naturopathic medicine, and also in first-aid. Patients come to you presented with all these signs, symptoms and syndromes (the 3S), and you just have to identify and sort them out, (differentially diagnose them from certain other conditions or diseases) before treating them. I just casually mention their differences here because I accidentally use the word ‘symptom’ when I started my article on bends, and I know of patients and lay people who were really confused by the usage of these words. So I thought to be on the safe side, I better mention some of their differences here with a few examples.


References:

1. Wenling, J. Normobaric Oxygenation as A First-Aid Measure In Decompression Sickness. Schweiz-Z-Sportmed. (1993 Dec.); 41 (4) : 167-72

2. de-Watteville, G. A Critical Assessment of Trendelenburg’s Position in the Acute Phase after a Diving Accident. Schweiz-Z-Sportmed. (1993 Sept; 41 (3): 123-5.