Ace Your Respiratory Examination OSCE - With This Clinical Skills Master Class - Dr Gill

[Music] foreign clinical skills video today we're going to be focusing on the respiratory exam both demonstrating the exam and going through each bit and highlighting what it is we're looking for and how we're doing the examination so with that in mind we'll get started in order to start off our examination obviously we want to make sure gelder happens and we introduce ourselves to patients hello my name is Dr Gill I've been asked to do an examination of your chest today so specifically your your lungs that's come to involved with having a look at using either getting to take your shirt off checking your blood pressure having looking over your hands your face putting my hands on your chest and listening with a stethoscope is that okay so before we go any further could please confirm your name and date of birth it's obvious I'll be 2nd of January 2000. super and do you have any problems with your chest at the moment and any problems with your breathing no brilliant so we're just going to start off um and as I'm looking at the patient in that initial step I'm just making sure the T seems calm at rest and I'm looking around the bed so I can't see any sputum pots nebulizers anything might suggest that there's any respiratory um issues going on underneath and similarly as the patient's lying there and looking at the rise and fall of his chest making sure that I can see that he doesn't appear to be in any obvious respiratory distress and I check that at this stage could you just take a nice deep breath in for me and out any issues with that super so what we're going to do I'm going to take uh sort out your blood pressure and things so I forget you take your shirt off please so it's very important that we're going to be able to use the manual blood pressure cuff but we're also going to as well as taking his pulse manually we will want to use a pulse oximeter to make sure that we can determine his oxygen saturations I.E how much oxygen is going from his mouth all the way to his fingertips so just have a finger to start off please we'll just put that and relax that down there and these normally take a couple of seconds to work if somebody has a cold fingers for example maybe reynards or they've been outside before coming to Clinic we may have a problem and here we're showing us an oxygen saturation of 98 so we know that's absolutely fine then we need to have a look at his hands so if you put your hands out for me and we're looking to see if there's any evidence of a fine Tremor that we might associate with salbutamol use thankfully there's no evidence here so what we're going to do is we're going to take a piece of paper I'm going to put that over the fingers and again we can see no Tremor being exacerbated with the paper so we know we don't have a fine Tremor and if you just your wrist back please and we can see no evidence of a a flap here that we might associate with CO2 retention so having a good look over the fingertips we can't see any Colony that might indicate iron deficiency anemia we can't see any evidence of yellow nails and that doesn't appear to be any signs of clubbing any blue tinge to the fingertips which might indicate cyanosis and similarly if there's any tasks staying that might indicate a patient's smokes if you could turn your hands over please and we're going to press over the fingertip looking at the capillary refill and it should ideally be less than two seconds if we had issues with reynards that could be one of the reasons that would slow the capillary refill there we're also going to look on the Palmer creases to make sure there's no evidence of anemia a nice and pink and healthy so again no signs of anemia and I'm making sure there's no wasting of the small muscles of the hand that might relate to potentially a pankos tumor pressing on the nerves there now if you could turn your hands back over and put your fingers together like so so they didn't appear to be any signs of a clubbing but we're looking and we can see shamroth's window so we now know there's no signs of clubbing relax down for me so having got our vitals in place if there was a a concern we may also do a temperature at this stage but we're not going to worry about that now I can use the 62 beats per minute that we've got on there but we also want to be able to take a manual pulse so we're going to press over the radial border of the arm and I'm just checking I'm feeling that pulse there again in an Oscar situation I'd count for 15 seconds and multiply it by four the other benefit of checking here is that I can confirm the Rhythm as well as the rate and I'm going to move up a little bit higher onto the arm to press over medial to the bicep tendon to feel the character of the pulse so it's thin and thready or is it full and bounding so with no obvious issues there we're going to check the patient's blood pressure so any issues with that arm at all one of the things that you can encounter sometimes one will we ask about blood pressures maybe somebody has had for example breast cancer and they've had an auxiliary clearance so problems on that are similar a patient may have had a a renal fistula footing so we'd want to protect that arm but there's no issues here so we're going to go forward and to check the index of the arm make sure it's covering the right size so we've got the right size cuff and then bring things up and round and the first time obviously we're going to make sure that I'm checking his pulse and feeling for it to disappear okay so the pulse is gone and then letting the pressure out and that's returning at about 90 systolic so that's interesting so I'm going to do the same again but this time listening with the stethoscope and I'm going to increase the pressure by 30 millimeters to make sure I've got the right location and I'm going to be listening for the pulse to disappear and then reappear so tightening up okay so full pressure the pulse has disappeared and coming back down okay and the pulse is ripped at 102. okay and we've got silence again at 70. so 102 over 70 that's a a nice healthy pulse now having now having completed our vitals uh we can again have a look at the patient without um his shirt on and we can't see any abnormal signs of respiration so there's no obvious um asymmetrous to the chest there's no clear scars we must make sure that we also look at the patient's back because if for example you've had a lobe removed then we'd see the scar at the back rather than the front I like to do my examinations up in a straight line and down because I'm a bear a very small brain and if I'm following a simple line I can't have forgotten something so again all the way up to the top of the head and if you could take your glasses off please and if you just pull your eyelids down and I'm having a look to see and I can't see any signs of anemia relax now some texts will suggest that you should also pull the eyelids up to have a look at the white of the eye to see if there's any evidence of jaundice now to my thinking jaundice is mainly a an abdominal system sign however there's no such thing in medicine as never so we can theorize ways that we could be wanting to check for jaundice in a respiratory patient for example there was a hemolytic anemia where the blood cells were being broken down that high turnover of blood could result in a raised bilirubin level in the system which could give rise to anemia and thus the patient being short of breath due to sufficient blood to carry the oxygen around so that could be one rationale for doing it we're then going to have a look down at the patient's mouth so if we can have a look at your tongue please so we've got good hydration status and it's not large and smooth suggesting a B12 deficiency nor is it pale and anemic put your tongue to the roof of your mouth please and here I'm having a look at the base thank you and there's no signs of central cyanosis similarly I can't see any bluedness around the lips so I'm very confident that there's no sinuses here cyanosis is a particular sign you're only going to have that when you've got 10 deciliters per mL of deoxygenated hemoglobin so we can get the peripheral cyanosis where we may have blue fingertips if we've got raynards if we've got you know exposure to cold and we're at altitude because literally the blood supply is stopped to the fingers so the tissues there have pulled the oxygen from the uh the blood causing an increased level of deoxygenated hemoglobin however if we've got a respiratory or potentially cardiac issue then we're going to get at the central cyanosis if there are issues with oxygenation if for example you've got a ventilation perfusion mismatch that you might see with a pulmonary embolism where the blood vessels in the lungs have been blocked so although the lung seems to be working I.E you can breathe into it that that part of the lung is not being able to transmit the oxygen to the blood so you end up getting some deoxygenated blood coming back into the system hence it builds up and we get that blue appearance one of the other things we need to pay attention for when we're doing a respiratory exam and looking at the face is evidence of Horner syndrome which may occur due to a pankos tumor so in the apices of the lung pressing on the thoracic chain so with that we're having a look in the eyes themselves to make sure that we haven't got meiosis a small pupil there's no sign of ptosis so his eyelids are equal the same and there's no evidence of something called anhidrosis the lack of sweating on one side the affected side of the face now the first two the ptosis and meiosis are very easy to assess the anhydrosis is lesser however the patient may mention that in their history taken beforehand carry on down the body we then need to have a look at the trachea so to start off with we need to find out if the trachea is Central so after we've had a look over the face we need to prep put a small amount of pressure on the neck but before we do that we need to make sure there's no problems do you have any pain at all around your neck so it's important we check that with regards to things like thyroiditis and recent surgery and things so we're going to feel down the cernicular muscle muscles between the head of the clavicles with a tiny bit of pressure and I should be able to feel the pressure between my fingers showing the true care is Central if we had a pneumothorax it would push the trickier one way and conversely if there was a collapse it would pull the trachea toward it now did that hurt at all or to cause you any discomfort so it's very important about the pressure that we're applying there you can try this on yourself at home if you get two fingers and just shove it at the base of your neck it's not a particularly Pleasant thing to do so a it can be beneficial if you're new to this warn the patient what you're about to do and how that they might perceive it but also by practicing on yourself you can modulate the pressure that you're going to need to be able to apply so that you can determine you've got the right pressure to get the information you need but not hurting the patient so we then need to check around your neck for any lumps and bumps because they get you to sit up and swing your legs around we're going to examine the lymph nodes from behind so that's going to be putting my hands on your neck is that okay this is something I'm particularly keen on making sure the patient is aware of and is comfortable with because otherwise you go to examine the lymph nodes and suddenly hands appear from behind which can be startling and potentially unpleasant for many patients so we're going to start off under the chin checking the submental lymph nodes and then along the angle of the jaw the submandibular to the base of the the angle of the jaw to checking the tonsilla and slightly above that the parotid lymph nodes we're going to do all the head and neck lymph nodes so checking for the preauricular and the postericular and at the back of the head checking for any occipital nodes we want to press down the neck checking for the deep and superficial cervical chains sometimes referred to as the anterior and posterior cervical chains we also want to check along the clavicle and for a respiratory examination get the patient to shrug their shoulders up and forwards that lets me push down on the left side in the supracurricular fossa here to make sure there's no evidence of a pankos tumor that's suggesting that we've got an apical lung tumor here so if you relax back for me okay so in terms of having a look at the jvp we get the patient to lie back and if you could turn all the way to the left for me and just relax so waiting for the sternicular mass times to go completely relaxed and we're having a look to see if we can see the jvp and there's a pulsation here but we can also see a slight pulsation here so I'm going to press over here and I can feel that suggesting that's the Carotid and over here I can't feel this pulsation so we know we've got the jvp in order to confirm that this is a jvp we're going to do the herpatter jugular reflux so I'm going to press down on the abdomen so do you have any pain over your stomach okay so I'm going to look over here okay so one two three up and in depressing deeply one two three and we saw that rise occurring there so we know that what we're looking at is the jvp and we're in the right location we'll also confirm the height of the jvp because we're going to measure an imaginary ruler up four centimeters three to four centimeters here and then pull across and as long as this is below that three to four centimeters we know that everything is healthy we may get to jvp that's risen so far up we can't actually see it in which case it's gone up inside the skull but we may expect that in somebody with hyperinflation for example COPD now we've already had him do one deep inspiration and observed no obvious issues but we're going to do that same again now so if you take a deep breath in for me and out the movement again appears normal and I can't see any obvious changes to the chest here so we might be looking for things like Pectus excavator where you've got deep sulcus between the ribs that will be a congenital deformity conversely we may have a Pectus caronatum where the ribs are pointing forward which could have issues in terms of pressing on internal structures now whilst the movement of the chest appeared to be normal I want to double check that and I'm going to do that by putting my hands on the chest we're resting our palms on the chest a deep breath in and out and I can see my thumbs moving apart we then need to do the same low down as well deep breath in so I'm looking at the movement of my hands because it's going to be different potentially for different individuals and things such as a barrel chest that you may see with COPD where the chest is hyperinflated you may get a different level of movement compared to somebody like a father here who doesn't have any respiratory problems so what you're looking for is to make sure the movement is equal on both sides so having checked um for a chest expansion we then need to assess where his Apex speed is so that's the area of the heart uh most lateral and where often you can see uh and certainly in thin people the apex of the heart hitting against the chest wall obviously we can't see that here so we need to prove where the apex beat is so we're going to define the maneuverable sonal angle which is in line with the second causal space and then we're going to count down third fourth Fifth and we're going to measure around so we're in the mid-cavicular line and I can feel the apex beat just about here now if we had someone we couldn't feel it we get the patient to roll over onto their right and keep holding there and come backwards for me if we've got a patient for it perhaps with COPD and when we've got hyperinflated lungs we may not be able to feel the Apex beak due to that lung expansion particularly with the lobe over the heart there conversely we may have a patient that has heart failure and they've got a left ventricular hypertrophy as a result this can result again in movement of the Apex speed and perhaps a diffuse or tapping Apex speed another area where cardiovascular is going to cross over with respiratory we need to feel for a heave so sometimes there's a debate as to whether or not we assess for both heaves and thrills I would argue that the heave is the important part in a respiratory examination because that is feeling for a left ventricular hypertrophy conversely The Thrill is a palpable murmur so I would argue as firmly in the cardiovascular side of things but with regard to a heave we're going to place our hand over the left side of the chest and lock out our arm if we did have a left ventricular hypertrophy we'd feel the whole of our arm pushing off the chest so having palpated across the chest we then need to percuss the chest so we're going to start off by placing a hand flat over above the clavicle and I'm going to percuss on the distal endopharyngeal joint in terms of percussion we're going to percuss over the Apex and then also over the clavicle we're going to continue down after covering the anterior of the chest we must also go around to percuss over the auxiliary and any changes in that percussion note we're going to highlight because we're going to need to focus on that area when we get our stethoscope out when it comes to percussion we may get hyper resonance so sounding like we're beating a drum practically if we're looking at a pneumothorax whether or not that's a tension pneumothorax or merely a collapsed lung we wouldn't be able to tell from the percussion note but we would have other information that would suggest one or the other attention pneumothorax may result in an imbalance in the chest expansion when breathing and similarly may push the trachea away from the side that is affected if we had a collapsed lung then we'd find a decreased percussion note over the area of collapse similarly consolidation from an infection or pneumonia or potentially pleural plaques if been exposed to asbestos would also potentially have a decreased percussion note we then want to take our stethoscope and we're going to listen over to all the areas that we've just precasted we're going to ask the patient to take a deep breath in and out through the mouth as we do so so deep breath in and out in and out in and out in and out in and out in and out and out in and out in and out and and out so apart from Over the clavicle where we do percuss but we're doing an auscultate we're going to listen over to those same locations and with that I got normal vesicular breath sounds throughout when it comes to breath sounds there are three major sounds that we need to pay attention to so bronchial breathing which you can listen to at home by listening directly over your trachea so that's a very Hollow washing noise that if heard lower down in the lungs we would associate with a potential of infections or consolidation would also want to be paying attention for wheezing this is a whistling sound heard on exploration and it's associated with the small Airway narrowings often seen in asthma but again can be seen in infections there is a counter to a wheeze which is a stridor now stridor is a medical emergency was a wheeze is an inspiratory sound due to narrowing of the small Airways a stridor is an expiratory sound due to narrowing of the large Airways so that could be potentially due to a tumor blocking the bronchus or pressing on the trachea potentially the case for child having swallowed a foreign body if you remember nothing else from this video that is the key take home a wheeze we need to address but a stridor is an emergency the other sound that we can listen to or listen for perhaps is a plural rub this is often described slightly conflictingly either as this crunching noise that you get when standing on Fresh snow with that little squeak as well or sometimes like the squeak of rubbing sandpaper together but I assure you once you've heard a plural rub yourself you'll never be able to walk on Fresh snow again without stopping and hearing that as you step on that fresh snow so having completed the examination in the front we then need to get the patient to sit up and this gives us an opportunity to assess the chest from behind so again there's no signs of scars and no obvious scoliosis or deformity now with regard to scars if you recall previously we highlighted that any um sort of pneumonectomy any removal lobes the scar is visible on the back rather than the front we also then want to do chest expansion at the top deep breath in and out and then again right at the bottom and out so we've got good chest expansion there we then need to put cuffs over the chest and we're going to get the patient across their arms over the chest please and this opens up a lovely area between the spine and the scapula and I'm going to percuss down between the spine and the scapula which are down just moved apart so we've got normal percussion throughout and then we're going to auscultate and we're going to do the same as we did on the front and this and auscultate over the areas we've just precussed so if you breathe in and out through the mouth please and out and in and out and out in in and out but then you'd press over the sacral region make sure there's no signs of fluid there and during the auscultation we also take all the way down to below the 12th rib where I would lose the normal breath sounds now before we put the stethoscope down we also need to listen for vocal resonance so what we're doing here is we're listening for the transmission of sound through the lung parenchyma if we think about whales they were jumping around suddenly but whales can have their well-song travel for miles and miles under the water because water is a very good conductive medium um however their sound obviously doesn't travel above their water because air is a um an insulator it's the same reason why if you put your hand in water at 50 60 degrees it's going to scold you but there's no problem with putting your hands into an oven at 100 degrees in order to put something into the oven that you're going to cook so what we're going to do we're going to get the patient to say one one one and we're going to listen for the sound transmission now the individual who came up with vocal resins was German and thereupon he asked his subjects to say 99 well actually he didn't he asked him to say which is a diphthong so the reason why that's important is a diphthong has a different sound wave so travels through fluid and tissue differently to 99 which is not so we need to use another depth on ourselves whereupon we're going to get the patient to say one one one and if we're listening over normal lung we should find a muffled sound coming through conversely if there was consolidation for example a collapse if there was a pleural effusion or if there was an infection and consolidation we get a very clear transmission of the sound so listening over the chest so if we could say one one one one one [Music] and again and again and again final two one one and again okay that's fine so we've got normal vocal resonance there if you could sit backwards so we can listen over fewer areas with vocal resonance because the nature of sound transmission given that it's coming from the voice box so the last bit of our examination will be to have a look at the patient's legs okay so find the media malleolus and going up we're pressing with 10 millimeters of mercury so our fingertips go white and waiting for 10 seconds that and then running a finger over to make sure we can't feel any indents of Edema if um the there was edema it would have been forced out and we would have been able to feel it we must make sure that we're pressing over both sides making sure the same again getting our fingers White and then we're going to work for 10 seconds and then again running back over to confirm there's no problems so we've got a normal examination that we haven't found any issues do you have any questions for myself no super we can get your um shared thank you complete our respiratory examination would also assess for any sputum uh cultures that have been sent to the lab would want to review any chest x-rays perhaps do spirometry or Peak flow meter and also look at any arterial blood gases that may or may not have already been done so that completes our overview and in-depth rundown about how we do the respiratory examination I hope this has been useful for yourself please put down in the comments what other systems you'd like us to do a breakdown like this for if I could ask a favor of yourselves if you could like the video it tells YouTube we're here and if you click the Subscribe button it lets you get involved with us on the community community tab so you can help us guide where the videos are going next with that in mind thank you very much and we'll see in the next one sure yeah thank you [Music]