good day mr israel could you please do a focused respiratory exam on this patient good day say how are you hi good good my name is washing genga i'm a fourth year medical student i've been asked by 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 all right say i'm gonna ask you to remove your shirt and lie down again remember every exam it's 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 also of average build of average build is typically what you call normal weight because remember if the patient appears to be carcexic you are thinking am i dealing with tb am i dealing with malignancy am i dealing with amphibia typically those are your carcassic patients as opposed to someone who appears to be obese you are thinking am i anticipating obstructive sleep apnea am i anticipating your blue bloaters in copd okay which we are not seeing and then next thing you want to know see how is the patient breathing okay does he appear to be takipnik remember respiratory rate above 25 is tachypnea which will suggest is in raspberry 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 this nick or is in the rest temporary distress you can start up and go down look at the nose is there a obvious nasal flaring which we cannot see from here look at the mouth the copd patients are known to press their lips breathing like that which you cannot see from there then you move on to the neck are you seeing any obvious tracker tag like we see in copd or other condition we cannot appreciate and you look at your accessory muscle is a patient using accessory muscle especially a stenocleidomastery 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 prosthetic or tripoding posture which we are not seeing here so it's useful to pick up form of signs that will suggest responsibility stress okay then again you want to look what are you seeing are you seeing any obvious adjuncts okay patients with respiratory condition may need oxygen so you are thinking is a non-copd in late stages either you see any obvious emitter dose inhalers that you can see from the floor or any iv lines what the patient getting those are adjuncts another thing that is useful to note is as i speaking to the patient i'm noticing the voice okay am i hearing obvious stride i'm hearing obvious wheezing am i hearing a horse voice which will suggest things like laryngitis 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 asymmetric 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 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 we 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 uh especially beta-2 agonist okay and i'm not going to ask you to do this remember here we are we're looking for negative mycolon as what you call asterixis 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 okay you want to start here are you seeing any obvious wasting of the small muscles what we call guttering which will suggest that you're dealing with things like pancreas tumors which we do not see here look at the nail are you seeing any obvious signs of clapping signs of clubbing will indicate loosening of the normal angle that you expect in the nail i seeing any drumstick appearance which you cannot see any so there's no clubbing and it's very useful to know the causes of clubbing in a respiratory station okay remember most conditions that cause a superactive condition lung absence lung empirement bronchogenic carcinoma if you are dealing with bronchiectasis and very important also idiopathic pulmonary fibrosis those are conditions that can give you clubbing then finally you start looking in between the fingers for any 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 you they typically are warm they are clammy which we do not appreciate here are you seeing any obvious peripheral cyanosis which we can't okay it is useful to note that pulse is not always routinely done in a rest okay but you do expect certain for example if the patient has severe asthma they may develop tachycardia and also especially pulses paradoxes okay and there are other features that can cause tachycardia in a response okay moving on to the face okay you want to inspect the face okay does that face appear to be pushing white which will indicate that the patient has been using steroid for a long time so chronic steroid usage look at the face are you seeing any obvious plethora okay plethora is seen especially if the patient retains co2 or if your 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 about that as you see in tb you have lupus peniosing sarcoidosis you can have a butterfly ratio in keeping with your sre okay other 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 answer would you please look up okay you want to look for conjunctival polar remember polar and the respiration you're thinking this patient having chronic illness especially malignancy tuberculosis again those are give away okay then 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 is a triad that is meiosis which is a small purple on that affected side you have partial ptosis and then the patient will complain that they they have anhydrosis on that side okay remember honest syndrome if the patient has it you do indicate that you are probably dealing with an applica uh an apical tumor or malignancy compressing the sympathetic brain okay it's the pathetic chain okay which will explain the honest syndrome which we do not see here so could you please open your mouth okay again you just want to see the overall hygiene i see any broken tooth or rotten tooth that you're seeing that will predispose the patient to develop conditions such as pneumonia and especially lung abscesses we do not see and finally say could you please put your tongue on your palate let's see again this way you see best just under the tongue to see for every obvious signs of central cyanosis as the central synopsis guess west the whole become the course has become very cyanotic 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 palpate them individually like that and then you move on to your posterior chain okay which we do not feel anything your pulse your pre-auricular this your posterior class sorry vco pre-auricular this is your post-auricula 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 tracheal deviation okay there are many techniques to this one of the techniques you use your two fingers you stabilize the tracker okay and then you use your middle finger to slide through and see where you are deviating to are you deviating more to the left to the right to suggest that it's deviating that side again we cannot appreciate any obvious tracker deviation another thing that you can do with the net you can check for track your attack if you are not so sure you can check for it typically you just want to put your hand at the track here you place breathe in okay and typically you see it move significantly inferiorly on inspiration that will suggest track your attack remember tragedy typically signify that there is a gross overextend 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 suprastena 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 if 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 so could you please look here you could ideally assess for your jvp if the patient you are thinking as an element of core permanently 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 this edema okay and typically edema typically accumulates around the medial malleolus this way it will most likely be if you have edema especially if it's little okay if it's obvious then it will be all over but you see on your brownie permanent 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 and 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 a much more decreased movement as opposed to the other one so always have your differential if you have asymmetric chest rise think about fibrosis think about collapse of the lung think about the pleural 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 it's chest movement is reduced bilateral to think things like copd or if you have a diffuse interstitial 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 they have a scar of evidence of previous chest strains that were given and remember scars you can have one running in the midline what you going a midline stenotomy so i thinking where they're doing procedures like cabbage where they're doing a lung transplant okay and as opposed to thoracotomies which can be anterolateral they can be mid-axillary or posterior lateral thoracotomies they are thinking when they're doing your moneta means do i 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 excavatum or carinatum that you are picking up okay chronic asthma can cause precordial deformities and you can also have what you call increasing 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 okay are you seeing any obvious radiation tattoos are you seeing any obvious induration 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 break is always useful to comment if you're seeing any of the sky for scoliosis again those conditions are very common things like muffin so you're thinking are there any respiratory manifestation 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 hours on the general neck exam so it's okay we move ahead they used to come from stead you can probably there are many techniques to pop it for costochondritis but this is one of them so you just go along the costochondral margins you look at the patient is the patient feeling to be in any pain which you cannot appreciate so there is no obvious signs of costochondritis okay 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 is if you sternum so 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 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 sir 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 palpation then the next thing that you participate to do it like that some people prefer to use their palm okay however you 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 sir could you please say 99 99 99 99 99 99 99 99 99 99 99 okay so we can appreciate that vector film it does appear to be normal and symmetric on both sides okay remember if it's increased on one side as opposed to the other one you're thinking it's a consolidation if it's reduced i think is it a plural fusion of course there are other more differential we are done with the population okay then we are moving on to the percussion aspect of the respiratory system okay remember always try to ascertain your technique it's always useful to put only one hand one finger sorry and then you hit some people use two some people take one remember it's a swinging movement so that you make as loud noise for the examiner to hear you typically we start supraclavicular 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 we are thinking of emphysema is it bronchitis am i dealing with a pneumothorax okay if it's down you are thinking am i dealing with a plural effusion okay especially if it's tony the plural effusion however downness can be very subjective so the gray zone of stone it out to just the it's always there but by theoretical means stone it down will be an effusion if it's just value i think of a consolidation okay that's the level of thinking that you have to have okay then always make sure that you percuss the whole anterior chest okay remember around the heart you will have some level of downwards you know especially from your fifth to your sixth intercostal space that's where your liver typically starts so you expect a level of dullness okay so it will not be as resonant as the upper chest however if you do find that these areas that you typically appre should appreciate a level of dullness is now hyper resonant and you are thinking as a patient of an inflated scene in conditions like emphysema okay so that's very useful and remember whatever you percuss 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 it's your auscultation always remember that you use your bell side for your supraclavicular region otherwise anywhere on the chest we typically use the diaphragm okay so say i'm just going to ask you to open your mouth and try to breathe in and out deeply as you can like that okay bring your tent and knob okay so remember as i've listened to the patient i had bilateral vesicular breast sounds okay no added sound okay so you want to pick up is there any obvious wheezing is a strider you're 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 anyway in the chest that's what you call bronchial breath sounds okay and typically seen in things like consolidation especially low by pneumonia okay so i could not hear any crackles [Music] foreign now he don't 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