Respiratory Examination Explained - Clinical Skills Deep Dive - Medical School Revision - Dr Gill

hello and welcome to this video on explaining um how we do the respiratory examination thank you very hairy examination the intention for this one is to build upon that and is to provide students with an understanding not only of what they're doing when examining a patient but why they're doing it and what no particular signs that come forward might indicate however before we get onto that in the respiratory video we mentioned that you have a chance to win this the copy of McLeod's essentials of examinations and don't want it we haven't forgotten about that so we've done a random draw from everybody who commented on the previous video and we'll give you the name of the lucky winner of that at the end of the video so stay tuned okay with that out of the way let's start are discussing the respira examination so your examination actually starts well before you get your patient sat down in your clinic or in your examination room my examinations that patient start and they're walking toward me down the corridor after I've called them into the room the reason for this being is I get an opportunity to see how the patient is behaving how they're walking and what their breathing is like before they actually get into an environment where they're expecting to be examined if you try it with a relative or friend at home just say I want to count your breathing rate and then watch and see what happens as soon as you say oh you know I'm focusing on you the person's approach changes they become very aware of their body as a result that brief few seconds where the patient's coming down the corridor towards me I get an unvarnished glimpse of how well they are or the case maybe once the patient has come into the room we get them sit down uncomfortable again I want to assess the person as a whole so in terms of that short distance into the room it was a difficult walk for them to do are they now short of breath after having sat down in my examination chair have they brought in an oxygen cylinder with them mean are they requiring supplementary oxygen order to help them breathe as I look at them can I see any evidence of tar staining at all to their fingertips and are they sitting upright engaging me in conversation or are they in a posture such as try potting where they haven't embraced themselves on their legs in order to engage their accessory muscles in order to help them breathe with that in mind it's going to give us a suggestion as to what we may find when we combine the information the patient gives us in the history from the information we begin to find during our examination and I suppose that is a effective point for us to begin talking about the examination so we've discussed broadly the end of bed examination but we then need to focus to the hands now the hands were a wonderful window into a patient and their biological processes there are so many signs that we can pick up here that may give us hints and clues to what might come later to start off with we get the patient to put my hands out stretch and we're going to have a look over the back of the hands and see what we can identify so beginning with the nails we may see : e Kia so spoon shaping the nails indicating a patient with iron deficiency anemia now that's obviously going to be important in a respira Tory patient but if a patient doesn't have enough blood going around the body they're not going to be able to carry enough oxygen and that's going to impact on them as a whole we want to see if there's any signs of you yellow nails now this is particularly rare but I highlight it as a potential finding of lymphoma and some connective tissue diseases and possibly lung cancer because it's different from the tar staining that we might see with a cigarette smoker although they do look similar the yellow nail will be focused purely on the nail whereas tar staining will affect the skin around the fingers where the cigarette is held as well and I think it's important to highlight that we are dealing with Tarver or we get that a yellow staining from cigarettes not nicotine because nicotine is a clear colorless substance and that's a common error where students tend to drop marks in written exams we're going to want to have a look to see what the patient's capillary refill is so pressing on that fingertip and seeing how quickly it takes the blood to return anything about two seconds will be normal and at this point we might notice a little bit of power to the fingers so paleness and color if there's also any evidence of anemia but there is a several better ways to assess anaemia on a patient which we'll come to in a minute before we get to turn the patients hands over get them to stretch them out in front of us see if there's a tremor now there are two types of tremors we may find with respiratory patients the first a fine tremor which we could exacerbate or make clearer by placing a piece of paper on their hands that would exacerbate any tremor that's there the other is a coarse tremor certain asterixis where the hand is rhythmically beating when cocked back the differentiation between these two signs is what caused them so fine tremor is normally due to medication use particularly the beta agonists sound beautiful blue inhaler that most asthmatics are familiar with or theophylline another respira medication in terms of the asterixis that course tremor that's a bad sign for a respiratory patient because it normally indicates co2 retention and that they've got such a buildup of carbon dioxide in the blood vessels that it is affecting the brain specifically those are involved in movement turning our hands over we may see pale palmar creases which again is going to provide us with more suggestion that there may be problems with anemia here we'd also want to check to see if there's any evidence of clubbing to the finger tips in terms of checking for clubbing we'd want to get the patient to put their finger tips together like so to see if there's evidence of sham roth's window if we've got shamless window present then we know that a patient doesn't have clubbing whereas if it's absent and it suggests that they have lost the connection between the nail bed and the actual skin over it causing this sort of spoon shaping to the end of the finger tips now there are many different course of clubbing and it's definitely worthwhile remembering those or learning those for the Cardinal systems they were spiritually kardea abdominal and a little bit of endocrine systems as well because they're very common questions for both written and practical examinations having examine the hands we need to move upwards to have a look at the patient's polis now personally I'd like to show you both pulses at the same time because it doubles my chance of finding the radio world pulse which is quite an important thing when you're in the stress of an examination but also it allows me to find another potential cardiovascular sign with that of a radial radial delay in a healthy patient we should expect the pulse to come to the wrist at the same time on both arms but if there's a coarctation of the aorta then we may get an irregularity between the two beats coming down the arm when we're checking the pulse here we want to check for rate and rhythm so simply how quickly is the pulse going now this is to a regular pulse and a regular pulse are there any gaps or changes in the pulse we have to check for the character at a large-bore artery is the brachial or the carotid because we need at that large volume in order to be able to determine is it thin pulse is it a thready pulse is it a bounding pulse and if we got any other variations in character such as pulsus paradoxus moving on up at this point it would be a useful to check a patient's basic observations so do their blood pressure and also check their box from saturations which can be particularly useful in our respiratory patient now normally a saturation of 92 percent is considered to be normal however I personally get a bit anxious when I have a patient with a saturation less than 95 I want to know why their saturation is lower than I'd expect it to be similarly once a patient's saturations are down to 92% it's vitally important we work out what going on because that patient may need admission to hospital unless they have an existing respiratory condition such as COPD where we change our boundaries for concern so a patient with COPD would be happy to have their SATs down as low as 88 percent before getting seriously concerned now when I do my examinations I like to strive and stay in a straight line so I'll go up the arm to the top of the head down the neck and down the body from there so after having assessed for the blood pressure I want to move up to have a look at the face to start off around the eyes I'm going to be looking for any signs of anemia which we'll find by pulling the lower lids down and looking at the conjunctiva there so so far in terms of anemia we've been able to look for : EQ the spoon-shaped nails we've been able to check for poorer creases and now we've also been able to have a look at the conjunctiva of the eye now there is a significant sign that we can see on the face Horner's syndrome which has three cardinal features there's ptosis so the eyelid drooping down along with an ophthalmoscope eyeball will have meiosis so a shrunken pupil on the affective side and similarly anhidrosis an inability to sweat on the side of the body where the problem is in terms of that problem it's off it's due to compression of the sympathetic nerves in the neck often due to a cancer preventing the normal functioning on their face having locked over the eyes we need to have a look at the face around the mouth we may see peripheral cyanosis so blue tinge into the lips now such as with Raynard there are potential external factors such as cold which may cause blue tinge lips however blue tinge lips and central cyanosis so the changing underside of the tongue to a blue color will be highly concerning about a patient's oxygenation now we've spoken previously about levels of acceptable options saturations if a patient has got central cyanosis and we know this is normally associated with an 85 to 95 percent oxygen saturation level to put it in another phrase a patient must have between three and five deciliters of deoxygenated hemoglobin there so what we mean by that is when oxygen is binding to the hemoglobin molecule in the blood the to bind together to provide a red coloration when the option dissociates though from the hemoglobin molecule it takes on a cyanotic color instead and that's partially why we have the classic colors for arteries and veins with the artery carrying the option negative blood looking bright red and in textbooks the vein carry the deoxygenated blood blue because of the lack of option binding to the heme molecule changing the color one of the key features to look at in the neck of both there were spiritual passions and the cardiovascular patient is the jugular venous pressure the jvp in order to assess this we must have the patient lying back at 45 degrees with their head relaxed on the bed behind the reason being is the jvp from the internal jugular vein runs underneath the sternocleidomastoid muscles which help us turn the head if a patient is holding their own head and that will keep the sternocleidomastoid muscles engaged I don't mean that we will not be able to see the jvp waveform with the patient relaxed and lying back we can have them turn their head to the left to examine the neck in a healthy person the jvp may be not visible visible just above the clavicle up to three centimeters in height and we're measuring that three centimeters in height from the Renewable sternal angle up to where we're seeing the actual jvp itself if there are reasons for a patient to have increased blood pressure or hypertension then we'll see the jvp pulsation move up the neck so things which might cause this would be pulmonary hypertension COPD and on the cardiovascular side of things perhaps cardiac tamponade which can be seen from respiratory courses such as a tension pneumothorax the reason why these changes in blood pressure affect the jvp is but because the jvp sits directly above the right atrium as a result the jvp can considered as a manometer of the atrial pressure there so what this means is anything affecting the atrial pressure will cause the jvp to increase so for example if a patient has an atrial myxoma so a tumor in the heart then that will cause the pressure to move upwards the patient has COPD with a hyperinflation chest compressing the heart that will push the jvp up but what happens if you have a patient for whom you would expect to have a raise jvp but can't see it that may be because the jvp has risen so high it's gone up inside the skull and can't be seen but in that situation how do you determine whether the jbp is not visible because it's gone up versus not visible because actually the patient doesn't have a hyper dynamic circulation we can conform the hepatic jugular reflux well we press on the patient's right upper quadrant pushing blood up the venous system into the heart and moving the jvp up in a health individual if they're jvp has not been visible because clavicular head don't have to have circular reflux well then move the jvp up and have it visible in a patient for whom we didn't think that jvp was visible because it has gone too high we will not see a change in the position when we do her pattern jugular reflux but there is always a way to work these things out in medicine and if the jvp has gone so high up it's within the skull we may see the earlobe Weidling with each pulse indicating where it is now we've mentioned that the jvp lies underneath the sternocleidomastoid heads but we need to separate that pulse from carotid pulse and that's very easily done because the carotid pulse will be palpable whereas the jvp will be visible but won't place our fingers over it we won't be able to feel it having checked patients jvp we want to assess them for any lymph nodes so for that we need to stand behind the patient and then put our hands on the patient's neck from behind so it's very important to tell the patient what it is you're about to do and gain their consent to do so even though you've gained that consent already for your examination the reason why we need to do this is otherwise you get the patient to sit up you walk around the back of the patient and suddenly hands come from behind around their neck which could be quite startling and certainly not something we want while placing your hands on the neck we need to check for submental submandibular cervical pre and post auricular and also the lymph nodes at the back of the skull the occipital nodes to complete we get the patient just shrug their shoulders up and then press our fingers and deep into the suprachoroidal ER fossa to see if we can feel any lymph nodes there a lymph node on the Left supraclavicular fossa may be verk house node now this is commonly seen in stomach cancers but may rarely be associated with the lung cancer - in terms of checking the super Vicki laughs ah sir it's actually easier than you may think shrug your shoulders forward now and just see how far you can push behind your own clavicle it doesn't hurt and you can actually press much further down than you may think and that's the depth that we need to go to when assessing our patients now our standard Examination approach is inspection palpation percussion and auscultation and so far we've kind of been inspecting and then a little bit of palpation we need to go further on the palpation now by checking for the position of the trachea normally we should find that assisting equally between the heads of the clavicle but there are various respiratory issues which could result in the clavicle being pushed away from a problem or conversely pulled toward it so as an example if we get a tension pneumothorax where the lung collapses but actually with every breath we get air leaking into the pleural cavity causing that to expand with every breath we're going to get increased pressure on the affected side pushing the trachea away if we have something such as a lung cancer then that may both push and pull the trachea a fibrotic lung disease that can cause the pulling of the trachea and similarly in pneumothorax which doesn't go to a tension pneumothorax that collapse will cause such a care to be pulled toward the effective side in terms of assessing the trachea we want to pull those fingers either side of the trachea just by the clavicular heads and we should be able to fill in the equal pressure on both fingers be careful with this because it can be a little bit uncomfortable again try this on yourself when you'll feel that it's not the nicest thing to feel in the world if there is a deviation of the trachea and we're likely to feel increased pressure one or the other fingertips as we examine on that with the trachea being cleared we then need to move on to examining before examining the patient's chest so we're getting to unstrap at this point taking off their shirt so we can have a look at their chest and I like to perform an end of the bed examination again looking for any structural abnormalities on the chest wall so we may see hyperinflation we may see pectus carinatum where we get at a very prominent sternum we may get a pectus excavatum where we seem to have a central sulcus to the chest in terms of these deformities but many people aren't too concerned about the a hyper of latent chest however people can be very self-conscious when it comes to a pectus carinatum or pectus excavatum I know a friend who's particularly concerned about theirs and as a result they're never happy to take that t-shirt off when even out in public with friends so go into the pool and things like that it's something to be cautious of during our examination to make sure that you don't make the patient feel self-conscious we may see dilation of blood vessels in the chest if we've got a tumor obstructing the superior vena cava impacting on blood supply coming down from the chest at this point I'd like to get the patient to take a deep breath in and out so I can watch for the movements of their chest wall and see whether or not we have equal movement assuming everything is equal I'm not too worried that I'm going to be finding a unilateral Geshe however if we go to the things we've already discussed previously if we have a tension or a straightforward pneumothorax that's going to affect one side of the chest moving less than the other we similarly may see a reduction in movement if we have an empyema on one side or any evidence of fibrotic lung disease which is impacting on movement of the chess wall when the patient does their deep inspiration it's worth or paying attention to their face as well to see if there's any evidence of discomfort if we have caustic and Rytas so inflammation at the chest wall then that can be uncomfortable for a patient similarly the presence of pulmonary embolism causing pleuritic chest pain would result in the patient expressing pain on that deep inspiration so even these simple tests were more assessing the patient can reveal a very useful information I like to formally assess the movement of the chest by placing my hands around the base of the patient's chest and ask him to breathe in once more when checking the patient's chest expansion we should expect our thumbs to move apart by at least 5 centimeters during the inhalation and then back again during the exhalation and there I'm assessing is the movement from the thumbs equal on both hands so not only have I visually assess the movement of the chest but I formerly confirmed we've got equilateral movement on both sides once we've established that the patient has a normal chest wall movement then we can go on to check for the apex beat the apex beat is the position of the heart which is most inferiorly and where the heart is impacting on the chest wall it's normally found in the midclavicular line fifth intercostal space and we'd normally put our hand just below the nipple on the left in order to be able to feel it in thin people such as myself I can actually see my apex beat where the heart is impacting on the chest wall if we've had hyperinflation of the lungs if we've had cardiomegaly or left ventricular hypertrophy and all of these things will result in the heart moving further down and round so the shift in the apex beat having assessed the chest wall we now need to put cuffs over the chest this is one of the areas that many students find very difficult at the start of medical school to perk us we're going to take our index finger or middle finger and we're going to strike over the middle phalanx of our middle finger one we're positioning the hand we want to place it between the ribs to transmit the force from our finger through so we will get the sound reflected back to us there is how about one place during the examination where you can per cusp directly on to the patient and that is over the clavicle if we've got a consolidation I collapse or a infusion then when we put cuffs over this area of the chest will hear a reduced so sound coming through this may be described as a dullness conversely over normal lung spaces we'd expect a resonant sound one percussing and finally over a pneumothorax would expect to find a hyper resonant sound one percuss in the chest there are two additional conditions a hemothorax and the pleural effusion which can cause a specific finding called stoney dullness both of these are where there's a liquid in the pleural cavity and as a result for cussing directly over that will result in very little sound coming back I've got an example here for you and see what you think if you want to practice or simulate some signs you may get fruit percussion of the chest get yourself a bottle of Pop make sure drink at least half of it when you've got the empty space at the top if you book us here you have a resonant sound which is what you get over any in the thorax conversely if you book us over the bottom where there's still the fluid then you have a dull sound which is what you might see over an air of consolidation such as an infection or the collapsed lung of a pneumothorax we're doing percussion as well as tapping rectly over the clavicles we need to make sure that our percussion lines are either side of the sternum and cross the exilic as well will perk us over the same areas as well when examining the back but we'll need to make sure the patient crosses their arms over their chest to move the scapula away so we have clear fields of lung to perk us having Pro custo over the patient we finally get to get our stethoscopes out and do that auscultation at all points trying on auscultation we want the patient to breathe in and breathe out through the mouth giving us a good airflow to listen to it it's actually the turbulent flow through the large Airways that gives us our breath sounds a non normal breathing is considered to be vesicular if we have issues with the consolidation so for example a patient with pneumonia there we're going to hear a different type of breath sound specifically bronchial breathing you can simulate bronchial breathing at home by listening over your trachea when you breathe in that hollow blowing sound is one of the features that you'd hear over an infection as well as this hallowed nose we may get crackles over any air of infection as the small Airways open and closed during the inspiratory efforts there are however other crackles present in the chest if a patient has pulmonary fibrosis or a pulmonary edema then we'll get fine crackles the difference here being with pulmonary fibrosis those fine crackles can be heard across the chest worse with pulmonary edema those fine crackles are seen on the basis alone other chest sounds that we may come across our wheezes which we associate with normally with asthmatics and patients with COPD this is you two narrowing of the small Airways giving a polyphonic breath set there is another breath sound some to that called a stride or which we're going to significantly worry about a stride or is due to narrowing of a large-bore airway and should be considered a medical emergency until proven otherwise as a result a Strider is an inspiratory warping noise or whistling which may be associated with a lung cancer affecting the large Airways or conversely a foreign body this is often seen in children who may have been held a small toy for example unfortunately I'm going to spoil snow for you now one of the other features that we can come across on the auscultation is what's called a pleural rub if a patient has pleurisy so information the pleural membranes or potentially a pulmonary embolism we get a creaking or rubbing sound so it's considered to be the same as the noise you get when stepping on fresh know that as you crunch the snow for that first time now I didn't really buy into that as a sound when I was first told about it however after hearing my first pleural rub I'm now no longer able to think about anything else when I'm walking on snow for the first time so when we talk about fine crackles in the same way that you can simulate bronchial breathing by listening over your trachea we can also simulate fine crackles by rubbing your hair between your fingers that faint noise is the sound you'll hear with fine crackles to complete our respiratory examination in terms of auscultation of the chest would want to do the vocal resonance at this one area I'm particularly passionate about because it speaks to the history of medicine the gentleman who first came up with this finding was a German and what vocal resonance is it's listening to the voice of the patient transmitted through the lung tissue so over normal Airways a normal lung tissue you'll get a slight muffling of the patients words convert if you have a pleural effusion or you have consolidation then you're going to get an improved transmission of the sounds through that tissue in Germany they use the phrase ninety nine well in German it's actually knowing unknowns ik and this is where an error has crept into classic respiratory teaching in the UK with previously had patients saying ninety nine however that is a different sound it is not a diphthong as the word annoying when noisy is in Germany the gentleman found when he got his patients to say a specific word 99 you'll be able to hear the vocal resonance however classic teaching has had students getting patients to say 99 this is a problem because it is not the same as the original discovery in German 99 is annoying annoying sick and hopefully you can hear the changes in tone they're annoying or noise ik is a diphthong it has both high and low notes whereas 99 does not thus having students in English use the phrase 99 doesn't provide the same diagnostic information as the correct knowing when noise it does however it will be slightly strange if in an English setting you start asking your patients to say the German words as a result we can find another diphthong in English that I think want to want to if your English or German is not your native language I'd advise you to find the diphthongs in your language which you feel happy to get your patient to say to you when doing vocal resonance and if anyone asks why you deviate from classical teaching of getting the patient to say 99 you now know to complete our respiratory examination we'd want to check for any evidence of sacral edema that the patient at the base of the patient's spine we'd want to check for peripheral edema at the inside of both legs on the border of the tibia and also review any existing x-rays sputum cultures and if possible check the patient's peak experience which would do by getting to breathe into a peak flow meter right well I hope that this has been a useful review of the respiratory examination few cells and I hope that you've been able to learn something I think we've got a giveaway haven't we yes so here's our McLeod's essentials of clinical examination and the chap who's won this name should appear hopefully here so if that's you drop me a line on twitter at dr. james gill and we'll organize a code for you so you can get one of these sent out yourself i really hope that this has been a useful video for yourself if you'd agree i personally be really grateful if you could give the video a like and consider subscribing to the channel doing that both tells me I'm not just shouting into the empty space but also allows you to know when we've got the next video published so given that we've pretty much completed the respiratory examination now you've got the demonstration we've done the understanding the history and we don't understand the examination which would you prefer to focus on now we've got the cardiovascular demonstration and the thyroid examination videos up would you prefer to focus to the cardiac or the Faridah examination forced to look at understanding the examination next okay I'll put a poll up here hopefully and I you know if in doubt drop me a comment than the down below and we'll see what you do to help you guys out well have a good evening and thank you for watching take care you