0:00 [Music] welcome back to the emergency medical Channel I am Divya rajin a fourth year medical student and this is Vu who has volunteered to be our patient today for our respiratory system examination so firstly we have to start with the history a generalized history and after finding out that the pathology is in the respiratory system we will take the consent of the patient if he's comfortable with the respiratory examination normally the examination should be done uh without any clothes on but due to the patients Comfort we are keeping the clothes on okay now starting with the general examin okay okay starting with the general examination uh usually in general examination the
0:46 things that will be positive are cyanosis at the tip of the tongue at the tip of the fingers so you have to see the hands and tongue to see whether the patient is CTIC or not okay and you can also see clubbing clubbing fingertips you have to see whether it is bulged or not yes and cervical ly mostly cervical and aary we have to see because cervical it drains all lungs and axel drains the fla okay yes after that we can start with the respiratory examination there are four components of the respiratory examination is inspection palpation percussion and osculation so first starting with inspection first we have to inspect if the trachea is Central or not so you can see the tra it's Central or not so TR is C you can see the stoc
1:32 mid now we will check if this chest is bilaterally symmetrical yes next we have to check for chest movements whether there's equal chest movements on both sides okay then we could overall inspect if there's any skeletal deformities or scars okay then we have to inspect the appical impulse that will usually be in the left fifth inter Coastal space at the midclavicular L so all these things are done like whether the movement or appical impulse all these things are done to see whether the media is shifted to one side or if Suppose there is a leion on the right side in the L so movement can be naturally reduced okay that's why we are checking all these things and next we will turn the patient towards the back P
2:17 light back P light okay and now we should check inspect if there's any drooping of shoulders there or not there next again in the front and check if there is like inter Coast any hollowing in the spaces in the deace so any interal indro is there or not normally in asthma cop when the patient is breathing tightly you can see intercostal inro happens or there are some condition L volume loss condition there also you can see one-sided intercostal inro okay but normally what clinical practice what you see is the accessory muscles that is intercostal muscles are highly active so you can see visibly see the intercost drawing okay
3:03 next we will inspect the sternum and the spine sternum if it is hollow then it is Pectus excavator and if it is bulged out it's Pectus car so these things are very important because when there is anus excavator lens lenss can be slightly displaced to one side or backwards okay so these things may slightly alter your examination finding so you can explain all these things or there are some other conditions bone lesions or bone diseases where you get a Pectus carinatum okay then we'll check the spine okay if there's any skyphos or scoliosis present so during the examination of spine normally what in mbbs what we don't learn is to check for the pain pain in that uh pain or tenderness in the
3:49 sternum or spine or ribs that is very important because there are some conditions like malignance you get rib pains so due to that patient will get breathlessness or pain during breathing okay so that also during examination you can just uh see and Skip okay yes then uh next we can go to palpation in palpation first we have to check with the dorsing of the hand any local rise of temperature in any region of the chest then check for any tenderness if it is present any bony tenderness bony tenderness now for then we have to check for Respiratory movements in palpation okay now first initially so before that you have to check your whatever you have seen this tra you have to confirm your so we have to put our hands at the stno clavicular joint and then run our middle finger down to check if the TR and press
4:37 on the both sides of tracha and see whether tracha is deviated to one side or not okay uh next for Respiratory movements if we turn the patient around uh we can see uh totally done uh here when I take a deep breath okay here her hands should move up and my thumbs should move L so there are two important movements here you are keeping on the shoulder so one is up and down okay up and down you can see other one is expansion expansion ideally you have to check here here there will not be expansion here only up and down okay and here yeah here you can check expansion so keep it like this so you can see that so you can see now it is expanding okay so that finding Suppose there is
5:24 leion on right side that side movement will be reduced anteriorly how we check anter an we keep our hands like this okay and then we have to here so it is it is called as bucket handle movement handle will move upwards on the top and anly it moves like this posteriorly it moves like this so that is called as bucket handle movement what we learn in physiology okay so all sides should be equally moving that's that's what we are expecting in a normal patient okay yes now if the pathology is usually in the the front of the chest then it's usually the upper L okay if it's in the back it's the lower L and predominantly back side is lower L okay what we think normally is it there also
6:11 upper l Middle L lower L but it is not like that posteriorly everything is lower L and early it is predominantly upper L and axel can be any of the okay any three Lopes can be on right side any two Lopes can be on the left side okay now we will check the diameters Okay so for the diameters first we'll check the entire circumference of the chest okay for this we have to keep it at the level of the nipples in the front Okay some books does not allow that some books says that you have to go for a bony prominence in the chest but for practical purpose in male patient nipple is okay nipples in the front and t7 at the back okay okay t7 at the back okay so why some
6:56 books does not some guideline does not allow some patient can have gyom so it will be droing so they ask for a fourth intercostal rib or fourth rib or something in the anterior okay now we tell him to take a deep breath patient is taking a deep breath and then the expansion should be minimum of 2 C so if there is a there is no major L leion expansion will be good Suppose there is a severely restricted Len okay even externally like a thick skin can also reduce the movement okay anyway you have to document the total movement and Horax Horax Horax is at the midpoint of the anterior the middle of the anterior part
7:42 and the middle of the posterior chest wall and again we'll for both the sides we have to check yes you have to check the opposite side opposite correct now we'll check the uh AP and transverse [Music] diameter here and here okay so two book are kept or two pads are kept like this and you have to take the measurement so this is I have to check that this is the trans diameter around 20 okay and then other we keep the like this and check the anal posterior D okay now normally the transverse should be greater than the uh uh transverse is more than the AP which condition you get reverse like reverse means transverse
8:28 diameter will be more or equal to AP that is in Barrel shape just like COPD okay AP diameter will be slightly more than the normal okay it will become a become like a barrel it is classical finding of asema or M it is a classical finding of cop but remember in Pectus excav also you can get something like this so that's why I told initially there are some physiological variants can alter your clinical diagnosis okay now next we can go to percussion okay per cussion now the we have to first percuss the anterior chest wall now here first the areas are the supraclavicular clavicular infra cicular mamory and infr mamory yes correct now in mamory and infr mamory there is first second third
9:14 fourth and fifth and sixth some books does not say memory and infr memory they just say infra clavicular and memory so but to avoid that confusion you can just tell second space third space fourth space like that also possible we just want to know where is the leion that's all okay you can percus in the Supra clavicular area so Supra clavicular you put our so you to use the middle finger and use our wrist so only wrist should be moving like this not the hand okay then for clavicle we have to stretch the skin okay and in at the medial 1/3 and lateral 2 the jum we have to perus okay similarly like that we have to perus till we go to the sixth space okay and we reach the sixth space there's a dullness there okay that is liver dness
10:00 then you ask the patient to take a deep breath so that it will go down suppose that is not going down so you are getting liver dullness and you ask the patient to take a deep breath it is not going down patient is having fever chills rers what will you suspect uh we'll suspect if it's shifting dullness then it will s below the below the diaph if it is not shifting then it is mostly above the diaphrag it can be tumor it can be pneumonia it can be even plural efficient also okay so that is the importance of liver dullness then opposite opposite side next opposite side also we have to do so ideally always remember like this you are puring Su sua Claver notch in the right side immediately you go to the left side then clavicular right clavicular left not like this okay ideal method is compare
10:46 both sides okay uh next we can go to the axil here what is the difference between uh here on the left side there will be cardiac D so you don't get any resonant node there only in the second space you get resonance suppose in a patient with hypertension that can be slightly DED okay so that is anterior percussion then now axila how do you percuss AXA we will tell the patient to keep the hand okay so that is ideal position yes okay and then axillary and then infra a okay axillary and infra axillary so like that axillary perus here then aary on the opposite side infra on that side infra on this side then posterior okay turn yeah back so how do you per in the
11:33 posterior part posterior part now we'll do for super before that what should be first we have to keep the patient hands so that is very important so you get a space here okay then Supra scapular on this side and on this side okay then inter scapular okay on both the sides okay and then infra scapular okay okay okay so you know now how like what is a method to percuss what are the various types of percussion nodes so normally when I'm percussing on the right side I get a Noe percussion note what is that resonant it is resonant because length contains air that's why it is resonant when I perus on the heart what is what note you get D it is D because it is water that's why
12:20 it is D suppose you perus on the table what type of node you'll get it is almost resonant to D mildly D but if you per on the wall what you get it will be Stony D plural efficients are always Stony D but whereas a pneumonia consolidation or a tumor that will be impaired okay so you should understand the difference between resonant impaired and D resonant is it contains air it is replaced by solid but it is not water then you get a impaired like something like you perus on the table okay but when you are percussing on the water that is plural efficient it will be ston dness okay so that is that is about dullness sorry percussion not okay then now next is next we'll go to oscal ult
13:06 osculation initially now we have to use our set where initially we have to first check the trachea so you taking you seeing the tracha for bronchial so you just wanted to know what is actual bronchial breath sound so whenever you are osculating in a tracha in a normal person what you're hearing is a bronal breath sound bronal breath sound is a high pitched high quality sound and there will be some Gap in between inspiration and expiration expiration also prolonged okay so that is bronchial bread sound so that is high pitched gap between inspiration and expiration expiration is prolonged that is a bronal b sound what you oscal it here next is here we hear vesicular vesicular so what is the difference between this and this the pitch has come down from that high pitch it has come down to a normal pitch
13:52 or low pit but what will happen to the middle part middle part is atten okay the last part of the expiration is filtered off this is called as filtration and atation effect of the your lung okay so osculate all the areas no same areas which we percussed okay the Supra clavicular okay clavicular okay infra clavicular normally we cannot oscal it you get only scratching sound so we can just avoid it but all other areas you are to osculate okay normally you get a vesicular breath sound okay but there are some conditions like uh pneumonia consolidation what what changes can happen on osculation on osculation in pneumonia instead of getting vesicular breath sounds here you
14:38 will get bronchial so you have a t you have a consolidation consolidation means L tissues replaced by a uh solid structure okay so always you should understand that solid structures are good conductors of sound so whatever produced in your Bron like in tracha that is bronal bread sound when it is going to your tracha and your brus it going to a pneumonia consolidation here when you're osculating here whatever you are hearing you can hear also okay that is because the solids are good conductors of sound whereas suppose you get a plural efficient what will happen plural efficient what will happen plural Fusion you won't get same vascular bre sound you get vesicular bre sound but it is completely reduced so plural Fusion can Mass the sound it can reduce the
15:25 sound fluids are not good conductors of sound so you can get secular BL sound but it is very very minimal whereas in a fibrotic band lot of fibros is there what sound you get you get citation crepitation so in pneumonia later phase of pneumonia fibrosis or any uh like fibrothorax everywhere you get crepitation whereas in plural effici you get reduced breath sound consolidation you get bronal breath sound tumor you you can get again bronal breath sound but what you should understand is whether it is a tumor or consolidation your main bronos is blocked then there you get absent blath sounds so that is normal vesicular breath sound now what are the other things you have to check in oscilation then we have to check for vocal fius so what is that vocal fius what have take vocal fius and vocal
16:13 resonance here we should use our alar bottle okay and check for and first using alar B because of the for the frequency okay so that actually comes under inspection but uh when you're examining in routine case vocal fromet vocal resonance come together but in a examination like practical examination this has to go in inspection side and with stethoscope it has to come in osculation side okay but both are same so how do you check it here you ask the patient to say one one again you just keep your hand here hand in the TR and ask him to tell one one so what is the feeling you can feel like increased okay now you keep it here
16:59 so what is that it is reduced so this is a high pitch sound that's why you are getting more so same like that suppose you have a major large cavity or large pneumonia consolidation again whatever sound you are getting here that same sound will be heard over there also like that you can use your stethoscope also use your stethoscope that is for vocal resonance okay vocal resonance we'll check tell him to say one one so you're feeling that sound now oscal it here so it is less here it is more it's okay so in tra you're getting bronal breath sound you you getting vocal resonance and vocal uh what is it from
17:48 from both are increased okay so suppose you have a pneumonia here same things happen there also okay so that is a difference okay next is what next after oscal findings after we've confirm that whether it is sometimes vocal resonance will increase or decrease as you said in case of consolidation it will increase and plural if decreas based on that we can uh diagnose what is the respiration okay so some few scenarios I'll just tell you you have a asthma case you have a COPD case how do you differentiate all these things in asthma case first of all about the risk factors and when it will okay allergy risk factors family history are very important where is in cop in cop it will be smoking smoking history
18:33 is very important age it is Asma is younger age group COPD is older older age group history of smoking is more in m m or COPD then uh major thing is uh the progression of the disease asthma it is intermittent intermittent sometime patient will have symptoms sometimes he'll be absolutely normal whereas COPD continues is throughout the year he La of breathlessness and in between you get acute exacerbation then if you do a PF pulmonary function test what will be there it will improve in Asthma as it after nebulization you can see 15% Improvement in the Fe fev1 whereas in COPD that much improvement cannot be there okay so that is Asma and COPD what are the clinical findings of plural
19:19 Fusion plural Fusion on percussion will be ston first you see that that side of the chest will be tra also will be deviated to the opposite side tra will be pushed to opposite side then then chest movements will be reduced reduced on that side then then there will be the diameter also can sometimes increase significant plal efficient can increase then on percussion Stoney D Stone dness osculation osculation the vocal ferment and resonance will decrease everything will reduce whereas in neumotorax neumotorax again the tracha again will be deviated to opposite side tra deviated to opposite side uh the chest Ms again reduced on just Ms are reduced uh percussion percussion it will be hyper is hyper resonant then and then a
20:05 vocal resonance and vocal FES will uh will it's a air is not a good conductor like your water air is also not a good conductor so everything will come down all your respiratory sounds will come down only thing what a clinical like mbbs student should know is once you diagnose pneumo or once you get a feeling of pneumo you not examine in detail the patient if the patient is in distress you have to treat it fast or it just take an x-ray if possible percussion all these things can sometimes aggravate the problem okay suppose you have a tumor on the right side tumor what findings you can get tumor or consolidation uh the consolidation is different tumor tumor there will be uh when you're doing osculation findings tumor normally a
20:52 tumor drags the tracha towards it or drags the media channel towards it so TR will be Med to the same side then osculation what do you get osculation for the the vascular sound instead of vesicular you will hear bronch so you can get a bronchial birth sound because it's a tumor it's a solid structure only thing suppose the major bronchus is obstructed by lymph nodes or something you can get absent bre sounds fibrosis fibrosis cavity and all cavity and all also they will be will be deviated to the same side and on osculation again inste you can get lot of crepitation times you get bronal breath sound or sometimes you can get cavness breath sound okay cavness is a type of bronal breath sound but it is still higher pitch nowadays we don't see all these
21:37 things because the amount of tuberculosis coming down okay but that also you can get okay so these are the common scenarios mbbs student should know okay so we have discussed most of the thing Wu thank you welcome okay [Music]
