Good day Mr. Israel. Could you please do a focused respiratory exam on this patient? Good day sir, how are you?
I'm nice. Good good. My name is Israel Shingenge. I'm a fourth year medical student.
I've been asked by a doctor to perform a respiratory exam on you. It will involve me looking at you, touching you and perhaps telling you to do some comments. Is it okay with you? Alright sir, I'm going to ask you to remove your shirt and lie down. Again.
Remember every exam is always good to start from the inside of the bed because you see the patient very symmetrically So you want to notice I'm examining a young male Okay Who's of average build of average build is typically what you call normal weight because remember if the patient appears to be Catechistic you are thinking am I dealing with TB am I dealing with malignancy? Am I dealing with emphysema? Typically those are your catechistic patients as opposed to someone who appears to be obese. You are thinking am I anticipating obstructive sleep apnea am i anticipating your blue blotters in copd okay which we are not seeing then the next thing you want to see how is the patient breathing okay does he appear to be tachypneic remember respiratory rate above 25 is tachypnea which will suggest he's in respiratory distress other features apart from respiratory rate that you can pick up from afar just from the inside of the bed that the patient is dyspneic or is in respiratory distress you can start up and go down look at the nose is the obvious nasal flaring which we cannot see from here look at the mouth COPD patients are known to purse their lips breathing like that which we cannot see from there then you move on to the neck are you seeing any obvious tracheal tug like we see in COPD or other condition we cannot appreciate then you look at your accessory muscle is the patient using accessory muscle especially your seno cladomastoid we cannot see from afar look at the chest is there any obvious intercostal or subcostal recessions that you can see from afar you can't And finally always remember that patients that are especially COPD they typically maintain an abnormal postural or tripod posture which we are not seeing here. So it's useful to pick up from afar signs that will suggest respiratory distress.
Then again you want to look what are you seeing, are you seeing any obvious adjuncts. Patients with respiratory condition may need oxygen so we are thinking is a non-COPD in late stages. Either you see any obvious ammeter dose inhalers that you can see from afar or any IV lines, what the patient is getting.
Those are adjuncts. Another thing that is useful to note is as I was speaking to the patient, I'm noticing their voice. Okay.
Am I hearing obvious stride? Am I hearing obvious wheezing? Am I hearing a hoarse voice which will suggest things like laryngitis or laryngeal. Again, those are all things that you can pick up just from afar. And finally, remember.
This is the only time you see the chest symmetrically from afar. So it is useful to bend down and just see how the chest is moving. Again, I appreciate that the symmetric chest rise. I can't see any obvious precordial deformities.
That's what you do from the inside of the bed. So say I'm going to ask for you to give me your hands. Okay, look at the hands of the patient.
Okay, the first thing I'm going to ask you, sir, you do this. Okay, ideally, if you'd want, you put a paper. to be very much easier to pick up what you call a fine tremor which you typically get in if the patients are using especially beta 2 agonist okay now I'm going to ask you to do this remember here we are looking for negative malclonus or what you call asterexis okay we typically see it if a patient has severe COPD or it typically indicates that you have severe retention of CO2 again we are not seeing that flip that we normally get okay then you come closer to the dorsum aspect of the hands. You want to start here.
Are you seeing any obvious wasting of the small muscles, what we call guttering, which will suggest that you are dealing with things like pen close tumors, which we do not see here. Look at the nail. Are you seeing any obvious signs of clubbing?
Signs of clubbing will indicate loosening of the normal angle that you expect in the nail. Are you seeing any drumstick appearance, which you cannot see any, so there is no clubbing. And it's very useful to know the causes of clubbing in a respiratory station.
remember most conditions that cause a super active condition lung abscess lung empyema bronchogenic carcinoma if you are dealing with bronchiectasis and very important also idiopathic pulmonary fibrosis those are conditions I can give you clubbing then finally start looking in between the fingers for any tear staining okay which we cannot see then you flip the hands over look at the hand how do they feel typically patients that are retaining co2 They typically are warm, they are clammy, which we do not appreciate here. Are you seeing any obvious peripheral synopsis, which we can't? It is useful to note that pulse is not always routinely done in a RESP, but you do expect certain.
For example, if the patient has severe asthma, they may develop tachycardia and also especially pulsus paradoxus. And there are other features that can cause. tachycardia in a resp.
Okay, moving on to the face. Okay, you want to inspect the face Okay, does that face appear to be cushioned? Which will indicate that the patient has been using steroids for a long time.
So chronic steroid usage. Look at the face Are you seeing any obvious plethora? Okay, plethora I seen especially the patient retains co2 or if you have superior vena cava obstruction, which is quite rare Okay, and finally you want to inspect the face. Are you seeing any features in keeping with connective tissue disease? Remember a lot of connective tissue diseases have manifestation on their lungs okay you have lupus valdaris you see in tb you have lupus spenio they're seeing saccharidosis you can have a butterfly rash in keeping with your sre okay either microstonias and other features that may suggest connective tissue disease which we do not see in this patient and the next thing i'm going to say would you please look up okay you want to look for conjunctival pala remember pala and the respiration thinking this patient having chronic illness especially malignancy tuberculosis again those are give away okay and the next thing that you must never miss when you're on the ice is that look for any obvious signs of horner syndrome honor syndrome remember it has a triad that is meiosis which is a small pupil on that affected side you have partial ptosis and then the patient will complain that they they have anhydrosis on that side okay remember horner syndrome if the patient has it it will indicate that you are probably dealing with an apical um an apical tumor or malignancy compressing the sympathetic chain okay sympathetic chain okay which will explain the honor syndrome which we do not see here sir could you please open your mouth okay again you just want to see the overall hygiene are you seeing any broken tooth or rotten tooth that you're seeing that will predispose the patient to develop conditions such as pneumonia and especially land accesses we do not see and finally say would you please put your tongue on your palate let's see again you this way you see best just under the tongue to see for every obvious signs of central cyanosis as the central synopsis gets worse the whole buccal mucosa become very synoptic which would be quite obvious and we cannot pick it up from here okay now we are moving on to examination of the neck remember lymph nodes are best examined from the back okay remember you just warm your hands make sure I let the patient that I'm gonna touch you is it okay okay and then you start with the submental okay you typically can get lymph nodes there then you move down along the mandible for submandibular lymph nodes then you feel for your anterior chain of your cervical lymph nodes you can either slide like that or you can pop it them individually like that then you move on to your posterior chain okay which we do not feel anything post your pre-auricular this is your post regular sorry this is your pre-auricular this is your post-auricular and then finally you can feel for some occipital nodes and you can come down to your supraclavicular and infraclavicular which we cannot appreciate any lymphadenopathy would you please lie down it's very useful to know the causes of cervical lymphadenopathy as we have listed them down on the video the next thing that you want to test for is for Trachea deviation.
Okay. There are many techniques to this one of the techniques you use your two fingers you stabilize The trachea Okay And then use your middle finger to slide through and see where you are deviating to a deviating more to the left We're right to suggest that is deviating that side again We cannot appreciate any obvious trachea deviation another thing that you can do at the neck You can check for trachea attack if you are not so sure you can check for it typically you just want to put your hand at the tracker and please breathe in okay and typically you see it move significantly inferiorly on the inspiration that will suggest track attack remember tracker attack is typically signify that there is a gross over extend over expansion due to airway obstruction which we do not appreciate here another useful thing that you can do is There's what you call a suprasternal to the cricoid distance. Okay.
So you take your three fingers like that. You go suprasternally to your cricoid. Okay.
If this distance is less than three fingers. Okay. You are assuming the distance is less than three fingers.
You are almost sure that the patient is hyperinflated as seen in COPD, which we do not see here. And finally, on the neck, it's very useful. Sir, could you please look here?
You could ideally assess for your. JVP if the patient you are thinking has an element of core pulmonale. so the last thing that you do on the general exam of the rest patient never forget is to assess for edema remember edema you don't need to go all the way and trace where it goes but you want to pick up the base edema okay and typically edema typically accumulates around the media malleola this way to most likely be if you have edema especially if it's little if it's obvious then it will be all over but it's here on your brownie prominence you just push it for a long time then you check there is no obvious edema that marks the end of the general exam of a respiratory station okay remember on closer inspection of the chest you want to always come quickly to the inside of the bed just so you have a symmetric view at the chest then you can even go to the eye level of the patient and notice how the patient is breathing are you seeing symmetric chest rise or you think one side appears to be much more decreased movement as opposed to the So always have your differential if you have asymmetric chest rise think about Fibrosis think about collapse of the lung think about the plural effusion Think about the consolidation and all other things as opposed to a chest that is moving But it's it's globally restricted in chest movement Okay So if chest movement is reduced bilateral to think things like COPD or if you have a diffuse Intestinal lung disease you can also get that picture.
So it's very useful to comment on the chest movement remember when you are checking for scars to look and scan the whole chest okay remember by the way you always do an anterior exam then a posterior exam for a respiration okay look especially on the lateral aspect of the chest okay you typically have patients that get icd so you want to see is the patient having a chest drain near the scar evidence of previous chest drains that were given and remember scars you can have one running in the midline what you call a midline stenotomy. So you are thinking were they doing procedures like cabbage, were they doing a lung transplant okay and as opposed to thoracotomies which can be anterolateral, they can be mid axillary or posterolateral thoracotomies. There you are thinking were they doing pneumonectomies, do they do a lobectomy. So that's a pattern of thinking that you have to use.
So scars are very very important. Okay remember when you're looking at the chest you want to also comment if there are any precordial deformities. Okay, we see that in conditions like muffin and remember muffin has respiratory manifestation So you want to see is an obvious? Pectus escapatum or carinatum that you are picking up Okay Chronic asthma can cause precordial deformities and you can also have vertical Increase in the AP distance as opposed to a lateral distance that we call typically a barrel chest Which is consistent with conditions like COPD. Okay, but also asthma can cause that especially chronic asthma again Those are things that you have to inspect.
Are you seeing any obvious radiation tattoos? Are you seeing any obvious injuration to indicate that the patient has been having some radiation for a certain malignancy? Again, those are all things that you want to pick up from the inspection. At the back, it's always useful to comment if you are seeing any obvious kyphoscoliosis. Again, those conditions are very common in things like Marfan.
So you're thinking, are there any respiratory manifestations? Okay, remember in your palpation if you haven't done your neck exam on the general exam you can check for tracker deviation Okay, however, we already did ours on the general neck exam. So it's okay. We move ahead They need to come from study you can copy there are many techniques to pop it for costal chondritis But this is one of them.
So you just go along the costal chondral margins You look at the patient is a patient feeling to be in any pain, which we cannot appreciate So there's no obvious signs of costal chondritis Then as you come down here, you want to check for chest rise. So remember, it's always useful to put your hand in this groove, okay, facing there as if it's sternum. So you hold tight.
And remember, your hands must be off the chest so that you see them move apart. Because if you hold it like that, you'll struggle to move apart. And remember, the normal one is there has to be about a five centimeter distance in the movement as the patient inhales. Okay. So could you please breathe in?
again again like that and always remember whatever you do in the front you also typically have to do it at the back okay that's the power patient then the next thing that you have it for is what you call tactile parameters okay again there are multiple variations on what you can do it you can do it bilaterally like this I'm showing or some people prefer to do it like that some people prefer to use their palm okay also if i are just trying to elicit tactile parameters but always remember that it's very useful to do tactile parameters because typically one of those tests that you help you differentiate for example a consolidation from a plural effusion okay so what you want to say is say 99 99 99 Okay, when we are moving on to the percussion aspect of the respiratory system, okay, remember always try to Assert in your technique. It's always useful to put only one hand one finger Sorry, and then you hit some people used to some people take one. Remember it's a swinging movement so that you Make a loud noise for the examiner to hear you. Okay, typically we start supra clavicular.
Okay and you Okay Then remember on the clavicle, you typically just want to use your hand. Okay. Then you go.
And remember, the chest is supposed to be resonant. If it's hyper resonant, you are thinking of emphysema. Is it bronchitis?
Am I dealing with a pneumothorax? Okay. If it's dull, you are thinking, am I dealing with a pleural effusion? Okay.
Especially if it's toned up. plural fusion however dullness can be very subjective so the gray zone of stony down to just down is always there but by theoretical means stony down will be an effusion if it's just dahlia i think of a consolidation okay that's the level of thinking that you have to have okay then always make sure that you focus the whole anterior chest okay remember around the heart you will have some level of downness you know especially from your fifth to your sixth intercostal space that's where your liver typically starts so you expect a level of downness okay so it will not be as resonant as the upper chest however if you do find that these areas that you typically should appreciate a level of downness is now hyper resonant and you are thinking is a patient of an inflated scene in conditions like emphysema okay so that's very useful and remember whatever you pick us on the front you have to make sure you pick us on the back Okay, and finally we're at the end aspect of the respiratory system exam So is your auscultation always remember that you use your bell side for your supraclavicular region Otherwise anywhere in the chest we typically use the diaphragm Yeah, so say I'm just gonna ask you to open your mouth and try to breathe in and out deeply as you can Like that then you tend and all okay so remember as i've listened to the patient i had bilateral vesicular breath sounds okay no added sound okay so you want to pick up is there any obvious wheezing is a strider are you hearing transmitted sounds what are you hearing and always always make sure if you are not sure what bronchial breath sounds are always put your stethoscope on the over the track here okay listen how it sounds those are the the the sound that you typically if you are hearing anywhere in the chest that's what you call bronchial breath sounds okay and typically seen in things like consolidation especially loba pneumonia okay so I could not hear any crickles. Nah, he don't want to. You can hear the squeaking near the end.
Sometimes, however, it's not so easy to see or hear. In many kids, it just shows up as a cough at the end of a forceful exhalation, like here. And that marks the end of the... auscultation part of the respiratory system.