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Yes. Hi, guys. This meeting is being recorded. So, my guys, welcome to today's session. Today's pop two off Risperdal, the respiratory Oscar station. Um, yesterday we went through part one run through sort of focus history. Taking differential diagnosis coming with investigations. Management plans for common respiratory conditions today will go through the respiratory examination just before we start. We have this study that we are collaborating with its study. But you see how it's the attained study we really appreciate if you guys can take one or two minutes to fill out, fill out the form that in the chart on. But when I ask for who when it says who referred you to the study, just press other type in our ski. See, we appreciate that. Yeah, please take a minute or two to fill out the form. Uh, just a big responses. So you just heard from, um, Medical Protection Society? Help with your medical indemnity problems? Questions. In a major amazing question, bank offer a lot of support for these medals. Amazing software that helps provide us with the feedback forms and helps generate a tendency certificates. Big shot of the Quest mint. Um, so way have osteo see 20% discount coat. So if you type in Oscar the 20 you can get 20% off your question subscription plan. I also have a Facebook groups of the osteo see community. So if you guys check out Facebook, move. If you guys have any questions and general with medicines, research integration, feel free to put on the group chat, and we can aim to try it on to you. Also always with these sessions. If you share us and tigers on Instagram story, you can receive a three Aussies examinations revision guys eso just any time during the session. Just take a pic, make sure the Tigers on, But we'll send you guys a Oscar, the examination revision guy that will just acid do. If you have a private account, just screen shot your story and just a message us with that and we'll still send it to you. Uh, so I just said, This is the second part of our respect to your school session. My name's necessary in case a, um, family with me. Eso I said it's part, too, covering the respect your examination. Okay, so if you turn into last week we did the physical examination for the cardiovascular examination. Okay, today is gonna be a sort of similar format. Okay, so we'll be covering physical findings that you're looking for with the respect your examination. Okay. And I've got a bunch of videos, images. There's gonna be a whole lot of spot diagnosis on day. I've also got actually sounds off breath sounds as well up normal breath sounds. That's something that people often struggle with the respiratory examination, like knowing what they're actually listening. Problem. They also states I will talk to all the sort of relevant clinical knowledge as well. Ah, a session hopefully lost less than two hours, but no promises. I'll try my best to be as quickly as efficient as I can. So that's getting to us a first station toe do stationary. We've been asked to see Ms Romanoff's, a 44 year old female who presents with shortness of breath, and you've been asked to do a focus examination of the Risperdal system. And at seven minutes the examiner will stop you and ask you to present your findings. So let's get into it so generally so. I just want to follow up with some general tips for all physical examination's. We did this last week with the cardio last time. So there's general tips for approaching physical examinations. And osteo is I always thought, with your general inspection, Okay. Always take a good few moments to just look okay at the old station. Okay? Look what's happening in the station. Look at the patient's look around. The bad for any general car for data. Okay, Just show to the examination that you spent a good few moments just doing your general inspection When you if you are talking during the examination, okay? Always say that there's no evidence off the physical finding rather than just saying I'm looking for this physical finding. Okay, So say there is no evidence of digital clubbing rather than saying I'm looking for digital coping. Okay, Just look small, clean, the more formal. Always perform white, but the start okay, and we'll go through our you introduce yourself in a bit, examine from the patient's right downside. Okay, so this is just part of your general bedside manner and put on a show. Okay, so this is an osprey. Okay. This is Ah, examination off. How much you guys know and how competent. And I'll select. You guys are gonna look so put on a show for the Examiner at. As as I like to always say, with these examinations, you should feel like you just want the one. The Oscar. Yeah, it's just about putting on a show. Blessing your knowledge. That's what doing physical examinations and osteo is all about. So you're talking about the physical talking about the research examination, and, as always, with the Oscar sessions, we start with some spot diagnosis on. Good. So we have a suit of clinical vignettes with different examination findings, which relates to the respiratory examination. So that's sort of the first one. So on examination, a patient has fine, and it's inspired crackles. There is reduced chest expansion bilaterally, a swan neck deformity seen on examination. The patient has a dry cough. What do you think? So you got one on seven, So Yeah, that's right. So probably fibrosis. Okay, this is a classic description of call me or fibrosis. And you also mentioned the rheumatoid arthritis. So this examination, last examination, findings of pollen, your fibrosis. Okay, fine. And inspiratory crackles and we'll talk about what crackles sound like they grow up later on. Reduce taxes. Function bilaterally. Okay, guys, typically both lungs are gonna be infected with a policy. Fibrosis. Dry cough is a very classical symptoms and problem. Fibrosis is often a complication off most systemic diseases. For example, rheumatoid arthritis and a swan neck deformity is a classic hand sign for rheumatoid arthritis, and we'll go through some of the signs off rheumatoid arthritis as well. Next one. On examination, a patient has caused crackles in both lung bases that also, when coughing, there's a sputum pot and a long acting anti muscarinic at the bedside. There is evidence off. It starts throbbing, slightly tricky. One. What do you think we'll figure out in the chat? Do you guys think the likely diagnosis is Ah, makes getting a mix of, uh, COPD um, bronchi access? I said. This is more of a case of bronchi, it says, but I think I would. It's COPD is reasonable. It's well, it's ineffective exacerbation of COPD. But actually no, it's not still pretty. Why is it not COPD? Actually think about it. What? What makes this not COPD? Okay, this coming. Okay, Right. This is right. I remember this COPD doesn't cause clubbing again. We'll emphasize this later on. Okay, COPD is not a cause of visual rubbing. Okay, so that's why I bronchiectases the most likely diagnosis is so why bronchiectasis of bronchi access condition where you're getting sort of airway validation and information again, classically, patients are getting very productive Sputum. Okay, that's one of the main predominant symptoms with bronchiectasis to get loads of sputum. Okay, so on examination, patients were classically have a sputum. Got a spot, a pot on da a Lamisil often used for bronchiectasis for treatment and course crackles as well. We'll talk about what course crackles represents. Okay, But again, it's sign it's often seen in bronchiectasis. And good way to differentiate course crackles from fine Rackers is to see if it changed in a coffin. Okay, so again, this is just signifying that the these are course crackles, abscess, bronchi access next one on examination. Patient has bronchial breathing. There's increased vocal residents and dollars to get to percussion. What do you think? Eso rather than pneumonia. How would you describe it? Yes. Oh, consolidation. Okay, so I describe this as long consolidation. Okay, so Why consolidation? So bronchial breathing is We'll talk about what your uncle breathing represents where it is. Very representative off a consolidated lung. Okay. Increased vocal residents and dullness to percussion again. We'll talk about these this stuff later. Okay, But again, these are features off lung consolidation. Um, next one on examination, patient has reduced errand tree decrease vocal residents and stony dullness to percussion. What do you think? Here. Good. So the key difference. Here's the vocal residence. Okay, so this is a significant thing, a likely pleural effusion. Okay, so the consolidated lung local residents will typically be increased, but total effusions book presents will typically decrease this. And also the way you describe the dullness to percussion with a pleural effusion is it's typically described as a stony dog percussion. Okay, so that's, uh, bone infusions. Next one on examination. Patient has a point for a queasy type of residents to percussion and reduce crackers. Stand distance is the fine tremor and is evidence of taught staining. Uh, what do you think? Yeah, COPD. Very good is that we've got some classical examination finding for a COPD patient s a polyphonic. We's very suggestive of obstructive lung disease. Hyper evidence to percussion. So a sign of a sort of hyperinflated lung have reduced crackers, total distance or COPD. Classically patients get this barrel chest. Okay. And that can cause a reduced quite a little distance. What's the significance of the fine tremor and this patient? Likely? Yes, You to retention Likely. Okay. So potential type to respect your failure potentially, um, toss staining. So what? What's toss dating a sign up? Yes. Smoking. Okay, good. Okay, so remember So it it's the tar that causes staining. Okay, not nicotine. Okay. Remember that. Uh, next one on examination, a patient has course crackles evidence of a third heart sound personal. Dema and ascites. There's also a raised JVP. What do you think? Yeah, heart failure. Okay, this classical examination findings for heart failure. Okay, so these all spot signs off Sort of decompensated heart failure. Okay, sort of fluid. Overloading course crackles in this contact is indicating pulmonary edema. Third heart son is indicating a volume overloaded ventricle. Perfect demon ascites sign of congestive heart failure. Okay, you're getting back pressure and also raise your baby's sign of sort of a congestive heart failure picture. Okay? And you're doing back pressure. Last one on examination. Patient has reduced breath sounds on the right side of his back. There's a scanned his exhilarate drink the strength of the vision deviation to the right side and reduce chest expansion. What do you think this is an interesting one? Uh, some people saying collapsed lung. But why would the role of the scar indicate? So this is likely a You met me. Okay, this is some people. So you said no back to me. So it is. I can see why you say low back to me. So it's likely a pneumonectomy because that that's called brachial deviation. Okay, You wouldn't expect trickle deviation with just a lobectomy. So when you met a pneumonectomy So, um, you may actually so you're, ah, removal of an entire lung. Eso This patient has reduced breath sounds over the right side. Okay, um, again, because there's no longer scar under is exactly what kind of surgical scar would you expect with a pneumonectomy? What? What kind of stuff? Do you expect that? Yeah. Lateral to record today. Okay. We'll talk about the surgical starts a swell later. Trickle deviation to the right side so we'll talk about trachea deviation as well, but with tracheal deviation in either deviates away from a side off, increased volume in it's in the chest or it will deviate towards the side where there is a loss of body. So with a pneumonectomy, there's clearly there's a loss of volume on one side of the chest. So that trick trick is going to deviate towards it on deduced chest expansion, because there's only one luck. Okay, so there is some, uh, classical examination findings or a human excellent patient. So let's get into the main stuff. So introduction for the respiratory examination, I've just included some lines. If you it's pretty similar stuff to the cardiovascular station examination, introduction. Okay, Just always make sure you're getting your consent. Ask of the patients in, has any pain and always do your safety. Nothing if there's any. If you experience any pain during the examination, please let me know and we can start the examination. Okay. So just learn. Learn your lines for introducing yourself. Okay? We're going to start off with some general inspection spot diagnosis. Okay? You guys are gonna tell me stuff. I'm going to show you some signs and you guys are gonna tell me what it's indicating. So what is this device? It? Yeah. Peak flow meter. Okay, way. We briefly went through a peak flow. How to explain peak flow tech technique yesterday. Okay, but this is what they beat flow meter. Looks like. Okay, so look for it at the bedside. Likely indicates an asthma asthmatic patients. Um, next one. What about this picture? What? We talked about this last because what what is this picture? Likely it? Yeah, pillows. Okay. It's a number of closes. Very important, even in a respiratory examination. Always thinking about heart failure patients, and we'll stop here, Okay? It's always important to look at the number of pillows patients are using. Or even if if the patient just sitting upright. Okay, there and no, actually able to lie down. Okay. Just important to pick up on science like that. What about this one? This is Ah, my seem a bit harder. Yeah, Stupid. Um, parts are sputum cup where whatever you want to say, it's just ah, thing that patients are gonna be carrying to collect their sputum. Okay. So again, it could be indicative of a number of conditions, namely, We think about things like COPD bronchiectasis. Okay, uh, what about this one? This is hopefully should be pretty obvious, But again, I'm just thinking I'm just picking up stuff that you need to just be your to recognize and take it upon. Yes, it's a pack of cigarettes. Right. Okay, So it's a cigarette pack again. It's a sign. It's just the osteo station is designed to try and help you come up with the diagnosis. Okay, So if they putting things like a smoking pack of the bedside, they want you to think of certain differentials. Okay. For example, COPD namely in a respiratory station. Next one. Um, what do you think about this? Do? Yeah, you know this This. Okay, so you might see some tissue paper which are blood stained on the side. Okay, so this is indicative off hemoptysis. Okay, last one. Uh, what do you think about this? It's a bit more interesting. What is that? What is this medication? Yes, it is given your name. So I'm trying to get you want to look for medications in your Oscar station generally. Okay, But with this one in particular, So this is prevented own. And somebody said it's used. It's a new drug that's used for probably fibrosis. Okay, I just thought I'd include it because, uh, I thought it was a particular drug you should be able to recognize in your osteo and for probably five doses patients. Yeah. This is before any done at the type of anti fibrotic agents, which is, uh, quite recently, relatively recently, Been licensed for Call me fibrosis management. Uh, next one, Uh, what about? Okay, we're gonna talk about auction delivery diaper devices that because this is pretty high yields for your osteo. So you guys are gonna tell me what the oxygen delivery device is? Uh, what? What is the's device? Yep. Nasal cannula. Get Okay. So you got You can see the problems here. Okay. Is pretty much the the lowest level of auction delivery. Okay. You know, you can You're not gonna be able to get much, you know, you don't give you can't get too much auction with nasal cannula gave you. Typically, if you give anything more than four liters, run is a kind of that's going to come back area uncomfortable for patients. But this is just be sort of Louis level of auction delivery. Okay? Yeah. Thinking about needing to describe oxygen. Uh, what about this one? Yeah. This is just a simple face mask. Okay, so it's a bit of a level above the days of kinda. Okay, You can give sort of 6 to 10 liters, typically with a simple base must. Ah. What about this one? Good. Okay, it's a venturi mask. Okay. If someone's in ventura mask and your osteo you be thinking about Yeah, definitely. Definitely. Think about COPD. Okay, that's why is this eventually muscle? The key thing is this little reservoir. Okay, this colored to about the end of the mask. Okay, This is the thing that makes adventuring mask function. Okay, Because keeping the venturing masses that helps give you a controlled amount of inspired oxygen. Okay, It's it has because these, um uh, these reservoirs, they have a fixed space. The actual apertures. They have a fixed space of the only allow certain amount of inspired auction to enter the musk. Okay, so if you see these sort of colored reservoirs at the end of the few, that's indicative of venturing mask again. There's different colors which allow different sort of f i o two's okay, depending on the flow rates. But that's eventually must. What about this one? This is Ah, probably use something. You were more from anywhere. Yeah. Uh, no. Yeah. This unknown. Really? The mask. Okay, so you see this reservoir, This reservoir by guess is very this is ah, non rebreather mask. Okay. This reservoir by this has a one way flap. Eso creates a one way system, too. Basically, it's gonna is used for the acute, Ian. Well, patient, right. So it gives you it's able to give a lot off flow. Okay. You continually need to give 10 to 15 liters. If you give anything less than 10 liters with the laundry, be the bag, the bags might deflates. Okay, but that is a known. We breathing Muskoka. Make sure you're able to recognize it. Uh, what about this one? Yeah. What do you think? Yes, it's a nebulizer. Okay. Specifically is a nebulizer mouthpiece. Okay. Often used in hospitals. He has a nebulizer mouthpiece. Ah, about this one. Yeah. So this is still a nebulizer. Okay, but this is a nebulizer face mask. Okay. So you can give nebulizers either using a mouthpiece or using a baseball score get depending on, uh, patient preference And, uh, what the patient situation is? Um, but yeah, those, ah different ways. Nebulizers can be used, uh, again. Still think about auction. What? What is this called this little bit that the auction too will be connected to What do you think this is a auction top? Okay, technique. I think it's you might You might call it atopic Doc. I got oxygen flow meter. Okay, so the thing is, if someone is on oxygen, okay, you'll be connected to this flow meter. Okay, So if someone's on oxygen, just look at the flow meter and see how many liters of auction they're on again. Make a note of it. I'm comin. It commented to the examiner. Okay, but that's the auction flow meter. Last one. Um, it's probably you're probably not going to see this in your osteo, but what is this device again? I don't You can't really tell if it's cpap a bipap just space. And it's like I'd say this is from the image you say this morning basis ventilation. Okay, so it's got a complete face covering okay connected to this ventilator. Okay, so this is example of noninvasive ventilation. Okay. Either CPAP or BIPAP. Um, but yeah, those are some different types of auction. Delivery device is Make sure you're able to recognize them. Know they're sort of common indications. And try and remember the sort of typical of volumes and flow rates you can give with each type of device. Uh, still on some spot diagnosis. Now we're gonna move on to some inhalers. What is this inhaler? We went through this last week. It's just our beautiful. Very good, eh? So this is your reliever therapy. Okay? Which will put your patients will use if they get symptoms. Uh, this is your brown one. So this is your, uh, steroid. Okay. Beclomethasone typically. And your preventer. Um, again, Make sure you were able to recognize this spacing these basic inhalers. What do you call these type of inhalers? What's the general term for these inhalers where you're pressing on the canister to give delivery medication? Yes. Meter dose inhaler. Okay, so these are both examples of meter dose inhalers, but there's also other types of inhalers. What are these inhalers? Court. What types of inhalers of these. Very good, sir. These are dry powder inhalers. Okay, the so they're different to the meat of those inhalers. You have dry powder inhalers. Um, if you want to know the this is a turbo heyler. This is an Accupril. And this is a Ellipta inhaler if you want to know the brand names, but right, powder inhaler. Is that different to the meter dose inhalers? Typically, these drugs drive other inhalers. They're breath actuated. Okay, so with the meter dose inhalers, you you need to press on the canister in order to deliver the medication with the dry powder with the breath actuated inhalers. Um, patients need to sort of breathing a lot deeper. Okay, but they don't need to be. The inhalers don't need to be primed, okay? You don't need to press anything. You just need to breathe in a lot more forcefully to get the medication. Um, can anyone say only one would do one with patients be given a dry powder inhaler over a meter dose inhaler? What might When might you consider using one of the dry powder over the metered dose inhaler? What's the problem with the meter dose inhaler? Yeah, Someone doesn't have the dexterity for it. Okay, so to do the meter dose inhaler, as I showed you with the inhaler technique yesterday, you need to be able to press on the canister on inhale at the same time. But a lot of patients might struggle with the dexterity of that and might not have the coordination. Okay. Oh, if they have things like rheumatoid arthritis, they have difficulty. Um, just doing at the same time, they might not be unlikely to be suitable for a need to dose inhalers. Okay, so you might try these dry powder inhalers instead. Um, what's the problem with the dry powder inhaler? So when would you avoid giving a dry powder inhaler? Yeah, people, if people have difficulty breathing in very deeply, Okay. So, you know, if they're very elderly, have very severe COPD respect your failure, you definitely probably avoid giving a dry powder inhaler. Okay. So, again, this is all sort of patients considering the patient circumstances, patient preference in general. Okay. But that's the sort of factors were thinking about. What is this device? This baby is using it. Yes. This is a spacer device. Okay, so, um if you are in your very young young kids using inhalers, Ideally, they should be using a spacer device. Okay, so spacer devices are helped with delivery of medication. Okay, Um, but yeah, this is an example of a spacer device. What about this one is ah, newer type of inhaler. Yeah. This is an example of a soft mist inhaler. Okay. Ah, relatively new inhaler. They just released the vaporizer, Gus. Similar to the meter dose inhalers, but they have a newer type. Um, what about the last one had What is this device said? A lot of patients will be given this, uh, they can use our home. Yeah, it's that this is a nebulizer. Okay, So, nebulizer the way the nebulizers workers, they're gonna vaporizer medication, okay? And then pick patients come in, he'll it, um So they can either be given in hospital. They can either be given with oxygen driven in with oxygen or without auction. Okay, depending on if the patient's hypoc sick. Generally. Yeah, that's ah, Nebulizer. Uh, Still got a question for you guys. So we're gonna move on to talk about home auction therapies, But before we do that, I want you guys to tell me one of the indications for long term auction therapy and COPD. We talked about this last week. Sorry. You talk about this yesterday. When do you give home? Ox went in Patients be given long term auction therapy. Yeah, I have to be a non smoker. Okay. And what about the numbers? What? What? What appeared to Can they be given it? Eso Yeah, less than 7.3. Okay, that was in the number. So the two main things we think about the after a a non smoker. Okay, that's very important. If you're gonna be giving a long term option Therapy smoking, uh, explosive hazard on either if they have a pa Oh, to less than 7.3 on two separate occasions, which are three weeks apart. Oh, if that Pa oh two is between 7.3 and eight and they have one of these features. So either secondary polycythemia peripheral edema or pulmonary hypertension? That's not That would also be another indication. Okay, but yeah, those are some of the main indications for long term auction therapy in COPD. So we still got some spot diagnosis to you guys. What do you? What is this type of device? Schools? This is a talk about home auction therapy. Now which patients might bring it to the Oscars? You guys know very good. It's oxygen concentrator. Okay. And we'll talk about this after next one. So what? What do you guys, If this is an auction concentrator. What type of devices? This action condense it. So this is an auction cylinder. Okay, so this auction cylinder Okay, so these are both of these are both types of portable oxygen therapies that can be used. Okay. Home auction therapies, I should say. Um, so what's that? Okay, let's talk through what each one is. So auction concentrators. So this is a way of giving home auction, but any speak connected to electricity? Okay, auction cylinders. They don't need to be connected to electricity. Okay, but what's the disadvantages of using an auction concentrator? When would you prefer to give portable auctions? Auction cylinders over oxygen concentrator? What's the problem with auction concentrators? Yeah, but you can't. You can't go. You don't really go outside with, um auction concert. It doesn't like I said, because they connect, they need to be connected to electricity. uh, if there's if they have a house risk of power cuts and things, you know, it's not going to be suitable for them. Okay, so that's what a disadvantage of concentrators. Also with the concentrators, Um, the oxygen that comes with the concentrated. It's not that you're compared to auction cylinder. Okay, cause it's based on the environment in which these cylinders placed in. Okay. With the, um, still with the cylinder, you always get proper pure 100 sent auction with the cylinder. Okay? The problem of the cylinder is you need to You need to be replaced once it's finished. Okay, but the concentrator, it doesn't need to be replaced, but yeah, those are sort of key factors to be thinking about with the home oxygen, their base. Uh, still on the topic of oxygen. What? What is this called? This is definitely something you're not going to see in your osteo. But what is this things? Hyperbaric oxygen chamber. Okay, not something You're seeing your osteo, but I'm just trying cover everything you want to be picking up on general inspection off in a respiratory examination. Uh, I put one of the hyperbaric oxygen chamber useful. What Which condition's gonna be used to treat? Yep. Decompression sickness is a big one. Okay. Uh, what else? Gas gangrene is good. One year. Carbon monoxide, part closing as well as a big one. Okay, um, but yeah, that's this is an example of a hyperbaric oxygen chamber. Ah, cool. So we covered most of the doxidan stuff therapies to be aware of. Okay, to be able to recognize, uh, now we're gonna move on to the patient's, uh what type of breathing is this patient doing here? Yeah. Per slip. Breathing her. Get her there. Okay, So there is this personal it breathing, Um, typically seen in COPD patients because there trying to increase that. Um yeah. And exploit your pressure. Teo, prevent alveola collapse. Okay, Abby, that's so that's personal. It breathing. I've got a video for you guys. This is another type of breathing pattern that might be seen as have a watch of the video. Okay. What do you think? What type of breathing pattern was that? So it was initially they were very hyper. Um, there's top tachypnea at the start. Okay, Then slowly, their breathing patterns slow down until they were almost up. Nick Do you know what? What that type of breathing is called? Yeah, it's changed. Tokes reading. Okay, Um, so, yeah, that was the example of change. Stokes breathing. Okay. Often seen in things like severe heart failure or some of the central apnea and things be a lesson example of a chain Stokes breathing pattern. Ah, cool. Um, have a look at this video spoke Sing on the patients, Have a look at the neck and trying. Pick up on what? The physical finding us. Have a look at the trachea. Have a look at the muscles on the side. Yeah, so that was definitely, uh, accessory muscles use. Okay, Definitely. This patient's using the accessory muscles. What about the trachea? What was happening with the trachea? Yeah, there was trying to recall tugging. Okay, the trick. Your music was moving forward, doing it forward and back during inspiration. Okay. Um, so it was trick. You'll tugging. Okay, So this patient had, um but signs of trickle tugging and accessory muscles used. Okay, so these are both features off respiratory distress. Okay. Ah, I got another image of respiratory distress for you guys. What is this image trying to indicate Yeah. Tripoding. Okay, so tripoding so that leaning forward, extending the neck. Okay, this is Ah, the tripod Costa. Okay, So this is a position that patients who are in severe respiratory arrest they might adopt this posture to try and eight with. Ah, the passage of bed. Okay, it's ah. This posture allows increased passage of there. Okay. And improves that work of breathing. Generally about if someone is try burning. That's a sign of severe respiratory distress. Okay, but particularly in babies, if you see it. That's a very worrying sign in general on. So we still got some more signs of it. This is a sign we talked about during our pediatric session, but I thought I'd included again for this Oscar station. So trying pick up on the physical finding? Yeah. Good. Yeah. You guys got it. So there's definitely stuff costs or recessions. But if you look closely at the nose, what else was happening with the nose focus on the nostrils? Yeah. Nasal flaring bigots. Okay, so this way this baby had evidence off. Um, nasal flaring and subcostal recessions. Okay, both beaches off the spirits you distress. Okay. Um but yeah, just important to pick up on all of these physical findings. I recommend you watch the pediatrics for final session. I did a couple months ago when we talk about loads the different signs of respiratory distress in infants. Okay, but these are some important wants to be able to pick up on. Um So can you just tell me some other respiratory signs of respiratory distress in babies? In case this is a pediatric salsa gestation, you might get us the US This It's a very important, and this is very important bit of knowledge to have in General sinosis recessions in general. Grunting nasal time. We talk about what else had bobbing? Um Yep. Good. Okay, so these are all the different signs off. Especially distress in infants. Okay, this is a list that absolutely recommend you memorized. Just learn all of them. Okay, Stridors another important one to pick up on. Okay, sign of Operalia obstruction, and we'll listen to Strider later on. But these are all important features off respect you distress in pediatric patients to the thinking about. Okay, so we just talked about all this different stuff. We want to be picking up on general inspection of the patients, so let's quickly review it. So, in general inspection for the respiratory examination, we want to be looking at both the patients and at the bedside. We've talked through these different things you want to be looking at with the patients on. Be talked to a lot of this stuff. We want to look at the bedside. Okay, So, general powerful paraphernalia or respiratory disease? Okay, so let's now move on to talk about the hands and arms on. So again, some spot diagnosis. What is this image indicating here? Clubbing. Very good. Okay, so remember when you're checking for clubbing in your osteo, always get the patient to put their fingernails together and look for that gap. Okay? Between the fingernail beds. Okay. To be honest, if patients actually have clubbing, um, you can usually pick it up on general inspection. Okay, but in your skin, just make sure you ask oscillation to do to do that. Uh, next one cost any very good. Okay, so don't say nicotine staining, okay? It's always it's taught. It's the taught that causes the discoloration. Okay, so this is tossing sign off smoking. Uh, what about this one? Look at that finger tips? Yes, it is. Evidence of peripheral sinosis. Okay, important to pick up on that. So it's a bluish discoloration of the fingertips. Uh, what about this one? This is an interesting one. There's a difference in the right on. There's a difference in this hand. Combat the best on. Yeah, very good. You guys got a bean? A muscle atrophy, uh, you know, muscle wasting like you said. Um, well, this this be a sign up in a respiratory osteo station. Where did you guys be thinking about? If someone had, you know, muscle atrophy, why would they have wasting of these muscles here? Lung cancer, go to ball type of lung cancer. What might cause, uh ah. Damage? What? What kind of lung cancer might need to, you know, most electrically. Yeah, man. Co streamer. Okay, We'll talk about pankos tumors in a bit, but if someone has a pankos tumors or tumor at the apex of the lungs, have that tumor compresses on the break up plexus. That might need to sort of, um, there's damage to make a break up access that can lead to impaired innovation to the dean. Um, a group okay. Eh? So you get motor deficits century deficits there, and you can get muscle wasting. Okay, so that could be a sign off pankos tumor and a respiratory station. We'll talk about a lot of these hand signs in much more detail during our hand examination station. I get doing on SK station in a few weeks. Okay. Ah, let's keep moving on. What about this sign? So that's a primary? Yeah. Yes. You guys got it So that Palmer and people get so this is kind of Palmer erythema. Ah, in your risperidone Riascos station. What would you guys be thinking up with? Palmer erythema? Yeah, so definitely be, um so Palmer erythema would typically thinking about chronic liver disease. Okay. Typically, Palmer erythema were thinking about as one of the part of the stick models chronic liver disease. But in your respiratory Oscar station, if someone has palmer erythema, I be thinking about, um COPD. Typically because with COPD, patients can get, um, secondary polycythemia. Okay, so then get polycythemia because off, uh, chronic hypoxia. And because of the polycythemia, they can get Palmer erythema. Okay, but yeah, that's another hand signed to pick up on on your respiratory examination. And so I got a question for you guys. What are the respiratory causes off? Rubbing. One of the difference risperidone causes off clubbing. If someone says COPD, I will not be very happy with you. Okay, Say anything but COPD. So we got a bunch of on says interstitial lung disease bronchiectasis, cystic fibrosis, TV, cancer goods. There is a bunch of them. Okay. I mean, I like to use the new Monica A B C D E f um, So, in terms of the different signs so we can go using your Monica A B C d e f So a for obsessive be for bronchiectasis. See for cancer room D for rheumatoid disease. Okay. Oh, you can say D for don't say COPD, okay? It's up to you. Which one? But the rheumatoid can cause clubbing Or And remember, COPD does not cause clubbing if a empyema and f for pulmonary fibrosis. Okay, these are all these sort of important causes off Risperdal causes of clubbing on. Can you tell me if a COPD patients developed it truly developed clubbing? What would that What That indicates if a COPD patients actually had clubbing. Yeah, So have a seat, buddy. Patient developed clubbing. I definitely be worried about cancer. Okay, if they've developed a bronchogenic carcinoma. Okay, so remember, COPD on its own doesn't cause plumbing. Okay, if they've developed clubbing, I'd be would definitely be worried about cancer. Yeah, those are the respiratory causes off coming. That's why you keep going on. What is this hand sign here? Yeah, it is a one next 40. Okay, so we're talking about moving on to talk about the signs off matured arthritis. Okay, the hand signs for rheumatoid arthritis. So this isn't a sign off a swan neck deformity. So we're getting extension at the PIB joints. Okay, Piper, extension that the proximal interphalangeal joints, but we're getting flexion at the distal interphalangeal joints. Okay, so this is a sample of based one neck deformity. Uh, what about this one? Okay. Yeah. This is an example. Off a boot on year deformity. Okay, so it's basically the opposite off this one. Next year, you get in flexion at the pee I pee joints and hyper extension of the VIP joints. Last one here. What about what is this one? We got two signs in this patient's one of the two signs here. Yeah, so definitely there's all no deviation. Okay, Um, And what? What about the thumb? Yeah, there's Ah, the thumb is the deformity. Okay, so there's all no deviation. Okay, so there's a deviation at the all my joints, and there's also sub locks Asian at the level of the MCP joints. Okay, so there's sub locks a shin at the MCP joint level, and there's also a Z deformity. So there's hyperextension at the interval and your joint of the thumb, but flexion at the MCP joints. Okay, so that's a Z a Z thumb. Okay, again, these are all signs off rheumatoid arthritis. If a patient with rheumatoid arthritis you see a patient rheumatoid arthritis in your respiratory station, What do you think the we're likely respiratory diagnosis is if they give you a rheumatoid arthritis patient? Yeah, opponent fibrosis would be what I would be thinking about. Okay. If I see if you can pick up that the patient has rheumatoid arthritis and you're in a respiratory. So if you're in the respect your station definitely be thinking that the likely diagnosis is a form of fibrosis. Ah, let's get going on. Um, What is this? Chest X ray showing here. What is the abnormality hit? What is this bit of space? A pacification happening at the right upper lobe. Yeah. So this exam, this is the pankos tumor, which I was talking about. Okay, so, uh, tumor at the apex off the lungs. Okay, um, a lot of complications associative it because it has very close proximity to the break of plexus. Okay. And again, diet that in your risk progestation you might see evidence off on a muscle atrophy with your pancreas tumor. Uh, good. Uh, what about Okay, we just done your general inspection. Now we're gonna ask the patient to put our hands out like this. Uh, these are actually my own hands. Okay? I couldn't find any copyright through the images, but this is the one of my looking at with when I'm asking the patient to put my hands out like this. Yeah. Fine. Drummer. Okay. Sign of of you to attention Flat. Very good. Um, sorry. No, no, no. Seriously. Retention from a beat agonist is for myself. Salbutamol lab therapy year. But when I asked a patient too. Okay, So have a look at the this video. So what is this video indicating? Yeah, so this is likely, uh, asterixis. Okay, um, so a steel to retention. Okay. And your respiratory station, If you see Astor excess, you be thinking about, oh, to retention. Uh, if you're doing your you're doing abdominal examination and you see and asterixis what would you be thinking about? Yeah, they think about hepatic and careful. Opti, get by in your respiratory station, to be see asterixis. Think about oh, two retention. Uh, good. Okay, Now we're gonna move on to the pulse. Okay? So again, with your special examination, help it the pulse using three fingers, Not your thumb. Okay. Uh, what? Three things to be comment on in the past with the risk with any examination? Yeah. Great rhythm volume. Okay, those are the three things to comment on. Okay, so rates rhythm volume. So let's talk about some pulse abnormalities that you might see in your respiratory station. So you have a watch of this video, have someone that's in very quickly. You might remember this video from the cardiovascular. Same nations. Well, what is this? Uh, indicated? Yeah. Bounding pulse. Very good in your Risperdal station would a bounding pulse indicates? Yeah. Yeah. Someone has a pounding pulse in a respiratory station. We thinking about Oh, two retention. Very good. Um, let's keep going on. Have a watch of this video. This is very interesting. So we got a BP monitor on DA Have a look at follow the BP monitor as the patient inspires. Do you guys think I was Ah is interest. It's an interesting physical finding. What was happening? That. So the BP was dropping as the patient kept increasing as the patient kept inspiring. So what is that physical finding cold? Yeah. You guys got a pulse is paradox is very good. Okay, so, um, so is that this video is trying to demonstrate pulses paradoxus a post paradox says a drop in systolic BP during inspiration. Okay, of typically more than 10 millimeters per mercury. Um, so in your respiratory station, you might notice this in the pulse. Okay. You might notice that the pulse becomes you can palpate the pulse during, um, inspiration. Okay, Because that becomes there's a drop in the BP, but yeah, possible Doc, sis and your respiratory station. You might be thinking about things like, um, severe COPD or severe asthma. Although typically with pastas, paradoxes with thinking about things like cardiac tamponade are constricted pericard. I just But they're all they're all system respiratory causes such a COPD and asthma. So remember, in your special station, always offer too much measure. BP in both arms. Okay, so measure BP does. You don't actually have to measure BP. Okay, But you should for it to the Examiner. So offer to measure BP in both arms. Just go to tell the EXAMINA. Uh, this stage in the examination, I would like to measure the patient's BP in, is right on and his left arm and compare. Okay, so just offer a little statement like that. Okay, so we just talked to the hands and the arms. Okay, so let's review what we just talked about. So, in terms of the hands we inspected again, look for different signs. Make sure to check your temperature as well, because they just check the temperature bilaterally in the hands. Check the capillary refill thymus. Well, and this is important while you're operating the patient's radio Close. Uh, check their respiratory rate as well. Okay, so company the pulse and at the same time, just have a look at that breathing as well, just to do the Book of ST both at the same time, cause in reality, it's a bit awkward to just look at the patient breathing and try and calculates response rate. Okay, so you're gonna get a more accurate value if you I just have a look at the response rate while palpating the pulse while the patients just breathing normally. Okay, check for a fine tremor and check the the flapping tremor. Okay, so we talked about both the Stein's and remember to offer to check BP in both arms. Okay, Now we're going to move on to the neck. Okay, so we're gonna talk about some neck findings, and then we'll take a break. Uh, let's talk. Stop. Start with a face and then move onto the next. What is this finding here? Central Sinuses regards. Um, so we've got blue ish discoloration or lips. Uh, what is this sign? This is very interesting one. Okay. Yes, about the sort of purple discoloration off the nose. Ah, telangiectasia. This would think about a respectful station. What kind of risperidone condition can lead Teo skin manifestations such as? Ah, that effect that can affect the nose. Someone's got a cutaneous sarcoidosis. See, this is this is what's known as Lupus Pernia. Okay, Uh, it's the major pathognomonic, Um, cutaneous manifestation of sarcoidosis. Okay, Um, so this is Lupus pain, you know? Okay, I recommend just having a look at different images of it. Okay, But this if you see this, this is proper pneumonic for sarcoidosis on How about this one? Yeah. I think about this. Sign here. Get, like, this is a quite a severe case of, uh, counted Isis. Okay. Or old candid Isis. Uh, what? Why would you What? What? What could cause this And the respiratory station? Yeah. Steroids. Okay, Someone is, uh, taking steroid inhaler the brown one over a long period of time. Again, they're not doing things like rinsing the mouth after after the use it. Okay? They have a much higher risk of getting things like kind of diet. Cysts. Get thrush. Yeah, that's kind of isis. What about this one? This is again is interesting One. What do you guys think about this time Yeah, you got you got It s So this is this is trying to indicate plethora. Okay. Facial plata. Um, what is this indicating? Yes. Someone said, um superior vena cave obstruction. So if you see this, um, this is ah, pretty indicative off someone having a structure in the superior vena cava. Okay. For example, if you have a lung cancer which is obstructing the superior vena cava, they could get this sort of, uh, facial plethora. Okay, on DA. Uh, this is a specific and sign this is actually it's called when they left their arms up and they get this plethora. It's known as a pen button sign. Okay, but yeah, the key thing you want to be looking at is a facial plata. Ah, last one. In terms of the face. Uh, what do you think this is? Ah, quite a difficult one. So we're looking at the mouth and you see these? All right? Just ah spots. Patikieye. Hear what you guys think Red particular One of these particular indicating. Ah, these uncoupling spots. This isn't the measles. And you know what? Respiratory different choking cause petechia in the mouth up thinking most are ent stuff the NT strong. So this is what we call this is a pa little Tiki. I okay, this is a particular on the palate. And, like, Yes, someone said it's strep throat. Okay, definitely. There, this is. Ah, very indicative of strep throat. Okay. Streptococcus found itis. Um, but yeah, this is just a, um just some particularly see in the mouth. Good. These are sort of the different things you wanna be inspecting on the face and in the mouth. Okay. Um, so let's keep going on. We're gonna move on to the, uh, neck now. Okay. Well, actually, we're not going to be moving sticking with the I guess. What? What do you think about this? These patients, Uh, what do you think about this patient's, uh, can you guys be as specific as possible as But as when you describe the diagnosis. Okay, so So says Okay, So this is this is whole nose syndrome. Okay, Pacific Lee, it's a This is the left side of your nose syndrome. Okay, so why so one of the key symptoms I need a bunch of you have set it, set it, withhold a syndrome with think about three classical examination findings. Okay, we're thinking about this triad off my OSIs. Okay, so you see this pupillary constriction here, Uh, partial Tosis. Okay. So drooping off the island. Okay. But it's only partial. You don't get the same kind of toast issue, get with something like a ocular motor nerve palsy. Okay, It's only a partial Tosis and also have, um, hydro sis. Okay. Typically, you can get an eye drops. Is, But these are the key examination findings for Horner's syndrome. Um, in the context off a respectful station. What would what can cause Honus syndrome? Yeah. Good. So pankos tumor. Okay, so, like we talked about the pancreas tumor is very, uh, problematic. Okay. Can compress different things. So back assume is that can compress the sympathetic chain and lead to a whole A syndrome. Okay. On the same side. Um, so that's where we would be worried about in a respiratory Oscar station. But I am going to be a bit mean. And, uh, So you guys one of the the different causes Akona syndrome. Not just thinking about the respect your station one of the generally would really be thinking about for the causes of phone. A syndrome? Yeah, I think one of the different causes of a wholeness syndrome. If if someone has I selected, hold a syndrome. What is the main emergency you're worried about? Yeah, You had a carotid. You definitely worried about. Carotid artery dissection is very good. Some some people said stroke. What type of stroke can cause on a syndrome? What type of stroke typically can cause on the syndrome brain stem stroke? Can you be more specific than that? What? Which stroke syndrome can cause bone A syndrome eso It's a lateral medullary stroke. Okay, so not not medium middle. Recent. Ah, lateral medullary syndrome. Um, also known as Wallenberg syndrome s. So if someone gets infection off the, uh, Pekka okay, posterior inferior cerebellar artery, that might be too lateral medullary syndrome, which you need to on syndrome. Okay, so there's a whole bunch of causes. Um, I'm gonna try and explain Horner's syndrome quickly, So I made this little diagram explaining the Oculus sympathetic pathway. So the way sympathetic activity reaches the I, um, so, you know, I think about the different causes. Our phone A syndrome. We want to be thinking about B and not to me off the parkway, Um, so we can divide the pathway into three different points. Okay, We have the first order in your oncoming from the brain. Okay. Up to the level off the about tea, too. Then we have the second order neurons. Okay. Coming from the spinal cord to the sympathetic chain ganglia. Okay, so these are your second order neurons and then from your sympathetic ganglia, Okay. Specifically your superior cervical ganglia. Then you have your third order neurons. Okay, so your third order neurons, which go to your eye. Okay. So you have your third older, sympathetic neurons, which will go to your, um, iris dilator muscles as well as your level to palpably superiorize. Okay, so you have three different neurons, which is forming the pathway, eh? So we're gonna go through what can damage this part for now. So if you get damage to the first order neuron, that's going to lead to a Horner's syndrome because your disrupting the sympathetic pathway to the eye. Um, like we discussed the main problems you can get with you first. Start on, you're on. Is brain some strokes? Okay. It's particularly a lateral medullary syndrome. and there's some other causes as well. In terms of second order in your own problems were thinking particularly about things like you think it's particularly about a pankos tumor. Okay, so this is what the risperidone A differential list. So if someone has a pankos tumor that can compress thesis in order neurons and lead to a corner syndrome and his other causes as well. And finally, that made the big one you would be worried about for wholeness syndrome. If someone has hold a syndrome that you need to rule out if you can't explain it is disorder off the third and you're on. So I've showed you had that. The third order, your own runs very close to the carotid artery. And that's very clinically significant, because if someone has a carotid artery dissection that can lead to a Horner's syndrome, Okay, So if someone has an acute home owner syndrome on and you can't explain it, you need to rule out a carotid artery dissection. Okay, because the third order neuron runs very close to the internal carotid artery. Okay, but yeah, those are your closes off on syndrome. Okay, so I recommended an examiner Ask you this Just divide it into the different bits of anatomy. Okay? But I hope that was useful. Let's move on to the neck. Okay, so I got some images videos off the JVP so I quickly just highlight the JVP Make sure you examine the patient JVP um so you see the patients JVP here Um so if you show it again uh we're looking for that double pulsation and then neck Okay which is different to the carotid artery Classically with the GOP looking for that double pulsation and it moves in would okay classically with JVP If you see it, it's moving in wood And if this is very evident with this video So this is again a video off a JVP so have a look so you can see the JVP very beautifully here. Uh so you could see the jugular Venous put pulse is moving in words Okay Whereas this one what was that? If you notice quickly, I'll show it again There is another position in So this was the carotid artery. Okay, so you can really see the difference in the, uh JVP and the across adultery The JVP is moving in words but the rotted Autry, it's moving outwards. Okay, beautiful video. Hope you guys can appreciate. The difference is now, um so let's keep going on. Okay, then. So once you examined the JVP, okay, then you wanted to do a bunch of things with the neck. Okay, so check for trick. Your deviation. Okay? And the way to do it is to put your index finger and your ring finger on the sort of political heads. And then, um, tell the patients it's going to be a bit uncomfortable, and then just check if the trachea is central. Okay, so that's the technique to do it. Okay, Just make sure you're putting your fingers either side of the, um on the clavicular heads and then pop palpate the trickier with your middle finger. Um, so let's quickly, I've got some chest X rays to you guys for in terms of trick your deviation and you guys are going to tell me what the cause of the trickle deviation ist. So what is the cause of trickle deviation? And this patients? Yeah, tension pneumothorax. Okay, so we got tracheal deviation to the left again. We got no lung marking says so This is a right side. Attention. Pneumothorax to remember a tricky about deviates away from attention, you know, thorax. Okay, because there's an increase in lung volume in this side. Okay, how about this one? Okay. Yeah. So the trick is not significant. Deviated, but it's slightly deviated. So you got? Yeah, You got it. This is a huge pill. A fused. Um, Okay, so the trachea deviates away from the pleural effusion. Okay, so it's the right sided pleural effusion. Uh, last one. What about this one? Those of you who lit game yesterday will hopefully be very familiar with this one. Yeah. So this is a trickle deviation towards a lung collapse. Okay, so, um, you see that is like the even be. Typically, even though it's a little a fusion head, the tricky has deviated towards ER, which indicates that there's a loss off volume. Okay, so remember trachea either deviates away from an increase in volume or it will deviate towards a decide of the chest which has lost volume, so the tricky is deviated. To decide it in it indicates that there's some kind of loss of volume, so I'd like to indicates that there's a lung collapse. Okay, so those are the different ways to think about trickle deviation. Okay, so just get these different concepts really clear in your mind. Okay. Well, once you've checked for trick your deviation, then check for CRI coastal distance. Okay? So just stick your fingers above the sternal notch, okay? And you should be able to fit three fingers, um, above the sternal notch and below the cartilage below the cracker Senecot cartilage. Okay, um, so you should be able to fit three fingers. If you can fit three fingers in that space, that suggests that be critical. Sternal distance is reduced on. Particularly be thinking about, um, hyperinflation of the chest. You to COPD on. But yeah, that's how you check the crackles total distance on. But once you've checked, it crackles total distance. The next thing I like to do with the examination is to move to palpating lymph nodes, and I'll explain why I move on to it. A lot of people then move on to their chest. Okay, But I recommend once you've done your crackers little distance, I'd recommend moving onto palpating lymph nodes. So remember, with your lymph node in about examination doing systematically. Okay. And remember, when your palpating lymph nodes you're not palpating it like it's a piano. Just palpate all the different nodes systematically. Okay. And when you stop moving down the neck, Okay. Remember, avoid palpating both sides of the neck at the same time. Okay? Because you don't wanna, um, palpate both car carotid arteries at the same time. So I recommend just going down the neck one at the time when your palpating um can you tell me which note do you have to palpate in the respiratory examination? Which lymph node do you really need to check for in the Risperdal examination? Yeah. Birkavs note. Okay, so the left supraclavicular node on, so I'll show you an image now. So remember, with your lymph node examination, you really need to make sure that you palpate the left supraclavicular node. Okay. At the hospital, specifically the it's called the workouts. No. Um, so you can see an example of an enlarged because note here, uh, can you tell me, what would you be worried about if someone has an enlarged but cars node in a hospice station in a respiratory station? Yeah. Cancer. Okay. It can sense that there's a lot of physical findings you need to be wearing off for lung cancer. Okay? And enlarged because note is very concerning for Milligan. See? So you just remember to palpate vocals Note? Okay, well, we're gonna take a break up now so quickly we'll just review what we did with the neck. So with the neck and face, we inspected the eyes looking for wholeness syndrome. And you can also look for pallor as well. When I inspect the face in the mouth looking for different things which we talked about make sure you examine the JVP. Okay, So make sure you're ostentation to look to the left and examine the JVP properly check for trick, you'll deviation. We talked through how you check pro trickle deviation, then check like a sternal distance. Okay, we talked through that and then after you check the cracker cell distance, move on to palpating live notes, Okay. And the reason I say move onto palpating lymph nodes is because when you pick when you help a lymph node, you want the patient sitting upright, okay? So you can palpate the lymph nodes from the back. And because because you've got the patient sitting upright. Once you palpated the lymph nodes, I can then move on to the back. Okay, So the key thing that people often struggle with the respiratory examination is that they often don't have enough time to examine the patients back. Okay? And then the respiratory examination, the most important bit is to examine the patient back. Okay, cause that's where all the auscultation percussion findings are gonna be. Okay, so that's why I recommend palpating lymph nodes. And then because you've already got the patient sitting upright, you can then move on to examine the back. Okay, so that's just going to save you time again. And it's gonna make you look slickers well, doing the examination. Um, so, yeah, that's my big recommendation for doing our experience. Same nation. Examine the back before you examine the chest. Okay, So well, think of break. We'll take a break for five minutes. I will come back at 8. 22 back. Okay, so we're gonna move on to the back, okay? We're gonna talk about things you want to be inspecting with the back. Okay, So remember, uh, he said after you do your lymph node examination because you've already got the patient sitting upright doing. Then move on to just examine the back. Okay? And once you examine the back and understood your findings, you can then quickly do the same thing on the chest. Okay, so let's talk about the back where you're inspecting. So, what do you think about this patient, but yeah. So something pneumonectomy start typically pneumonectomy It could be low back to you as well, but yeah. So I'd say when you see any scars, describe what the scar is. Okay. What type of incision is is before you describe what the indication for it is. Okay, so this is an example off a poster lateral. Forgotten the scar. Okay. And typically it's done for a pneumonectomy. Okay, so this is a very common station that can come up in a hospice. Okay, you can get patients about a pneumonectomy. And this is by far the most important examination finding to be able to pick up on for a pneumonectomy. Okay, so make sure you have a good luck at the back again. Have a look under the axilla to see how far it goes. Okay, Um, very important Scott to be able to pick up on still looking at the back. What do you think about this patient? Ah, yes, this's scoliosis. Okay, so, scoliosis. We can see the sort of s shaped curve which up the spine, uh, does that winged scapula so I can see what you mean. The wings, Kappler, think about things like a long thoracic nerve lesion. Okay, but it's because of the ah, scoliosis, the actual curvature of the spine. That's why this capsule is pretreat protruding backwards. Okay, It's not because there's ah, it's not. This isn't winging, okay? This is because of the scoliosis. Uh, next one. Yeah. This is a decision that you have stage areas. Well, anything about this one. Yeah. Okay. This is an example of kyphosis. Okay, so we'll talk about this during the spine station. I get all this sort of different abnormalities. You have the spine by this example off hyper kyphosis. Okay, this is excessive. Kypros to stop the spine on. Why is that? Why the both of these relevant to our respective station? What's the problem with these spinal deformities? What can that walk in the course? Yeah, yeah, they both in the moved in limit the expansion of the lungs. Okay. So you could get basically a restrictive pattern off lung disease. Okay, so that's why the it's important to pick up on any of these deformities. Uh, next one. Okay, so I got this video. So once you expect that the spine check for posterior chest infection. Okay, So I've got this video to just show you the technique. Um, so just make sure your put your fingers on the side and make sure you're thumbs are touching each other really close to each other, the starts and activation to breathe in deeply and then exhale and look to see your thumbs move apart from each other. Okay, so you're looking to see if it's moving symmetrically, um, typically know, asking you can just do it from behind again. Just do a standby and the patient and do it. This is the this video he's reaching over to do it. Um, yeah, this is the sort of general technique, but thank you about have a look at this video then. So this this is how to do chest expansion, like from the back. And I want you to have a look closely at the thumbs moving apart from each other. Breath then and relax. What do you play it again? What do you think is how would you describe the chest X ray and relax. So it's a symmetrical chest expansion. Okay, that's what one where you can describe it. And where is the chest expansion reduced? Yeah, on the left side. Okay. So you can see on the right side that thumb was moving and okay and moving naturally. But here, the thumb was not moving. Okay, Does the trump is not expanding on the left side? Okay, so this is indicating reduced chest expansion on the left side. Okay, so that's the sort of technique and how to pick up on the findings. Um, then so we don't have chest expansion now. Now we're going to move on to percussion off the back. Okay. Uh, general technique for percussion. I know a lot of people struggle with this. Is that bad? When you put cuss, you aiming to hit the dip, stole, planned your joints. Okay, So the last doing on your finger and when you're actually tapping on your fingers, um, use your fingertips. Okay. Don't use the pump or your fingers trying to hit. Um, trying top on your D i p using your fingertips. Okay, so we're looking for a sort of snappy pattern on the percussion. Okay, so I'll see you. So no. Should I? Well, they were able to hear, but it's about just that sort of snappy technique. Okay, so using your fingertips strong strike that distal intraphalangeal joint. Okay? And the key thing is, you don't do it over the boat, okay? If you're doing on the chest, do it in between the bones. Okay? There's no point cussing off the boat because that's gonna mosque any residence. Okay, So you want to do it between between rip spaces? Yeah. That's the sort of principles of percussion. And when you when you're always when you're percuss in, do it side by side. Okay, so the cost one sided neck. So on the back, this is the sort of distribution I would go about the custody. Um, but yeah, that's the sort of general to meet the percussion. Um, just honestly, just practice as much as much as you can, Okay? Percussion is and I know something. A lot of people struggle with. But it's also something you just need to practice and train your fingers to do it effectively. So we're gonna talk about percussion finding. So when you're describing the findings on percussion, you want to either use one of these terminologies so you I don't want to describe it as a resident. And if something is residence on percussion, that is a normal finding. Okay, that's normal. Normal is residents. Okay, It's the same thing. Oh, you want to describe it as dullness on percussion all you want to use them hyper residents. Okay, so if you want to describe something that's either being hyper residence on percussion or either dull on percussion or either residence on percussion Okay, can you send me one of the causes off hyper residence on percussion for the Yeah, you're a pneumothorax is a big, big, big close to be thinking about what else? What else can cause hyper resistance? Asthma? Yeah, COPD In particular, COPD is a big one. Um, good. So there's there's some of the key things. Okay, so generally with hyper residence, it's indicating that when you tap for cussing, it's indicating that there's a lot of vibration, vibration off happening. So indicating that there's increased air in the chest cavity. Okay, for example, in the pneumothorax or because of getting at trapping, for example, in COPD or asthma? Um, can you tell me What about dullness? What did the different causes off dullness on percussion? So, yeah, plural effusions. A big one, Okay. And pneumonia. Okay, so specifically, describe it as consolidation. So, yeah, those are the two big ones to be thinking about with dullness on percussion. That's a consolidation and a pleural effusion. Classically, with the pleural effusion, you can describe it as stony dull on percussion, but I wouldn't recommend using this term. And you're all ski. Okay? Because if you say that the there is stony dullness on percussion, you're telling the Examiner that you are 100% confident that the patient has a problem. Fusion? Um, so you wouldn't risk it in case you are wrong in your osteo. I guess I just say dullness to percussion on if you do. If you really do think that the percussion notes was adult, but yeah, those are the sort of, um, findings to be thinking about with percussion technique. Now we're gonna move on to Auscultation, and we're gonna be using the diaphragm to auscultate the lung. Okay, so, um, you're gonna also take the different areas of the lung. Um, so let's talk about your script A shin. So we're gonna listen to all the different breath sounds. I hope these breath sounds play. Okay, um, but have a listen and let me know what you guys think. Um, so is the first one, uh, getting a bunch of different findings this Well, I'll show you what the actual pathological sounds about this person was actually just No, this is actually just normal breath sounds. Okay, this is actually just normal. Basically, breath sounds are played again. So with normal breathing, typically when your auscultated the inspired to face is a lot longer than your exploit your face. Okay. Um, so they didn't know they it normally I'll show you the abnormal sounds later. Okay, so I recommend it. If you if it's not playing that well, just I recommend is auscultated as many normal patients as you can, so you can really be able to identify what normal particular sounds are. Okay, So, basically, breath sounds. That basically just means normal breath sounds against just a a more fancy term for saying normal graph sounds. Have a listen to this one. Get okay. I see. It's probably playing. Okay, so it's a week's. But if you can better describe the weeks, how would you describe the weeks? Is that, um what terms and use? Yes, Someone's got a polyp. Phonic weeks. Very good. Okay, so it's a, uh that was an example off polyphonic weeks. Okay, so we can we can describe as a we. So hopefully you're you're able to recognize wheezes. It's ah, um, is a sign of sort of airway narrowing. Okay. Typically, we're thinking about things like asthma COPD. Okay, especially because this is a polyphonic release, which means that there was weaken if you hear it properly. There are different musical notes happening at the same time. Okay. At the all the different musical notes, they were starting and finishing at the same time. So that's a polyphonic weeks. So I'll listen again to have a listen to the fact that it's polyphonic. Yeah, so hopefully you're able to appreciate that There's a whole bunch of different musical notes at the same time, So that's a polyphonic weeks. Okay? And it's generally indicative off obstructive airway disease. Okay. Such as asthma. COPD. Okay, have a listen to this one. This one's a bit trickier. What do you think? So Yeah, I see. Everyone's at CF. Runs can admit that they were crackles there. Okay, So you can be the way to think about crackles. Generally is to think about sort of Belco coming off. Ah, shoot. Okay, the way you Belco appeals off. Okay, that's the best. That's the way I like to think about it. We'll think about what? Sort of rubbing your hit. Be rubbing a piece of hair over your year. Okay, that's the way to think about crackles Sounds. But I think there's a bit of a argument as to whether this is course crackles or find crackers on. In that case, it was actually fine. Okay, so the key difference between fine crackles and course crackles is the pitch. Okay, course crackers. They're low pitched. Sounds fine. Crackles there. High pitch sons. Okay. And course crackles bit more indicative off. Sort of larger airways. Um, opening up. Okay, So crackles in general is indicative. Off away, suddenly opening up. Okay. Close that way suddenly opening up. Okay, would find with fine crackles. It's a bit more high pitched. Okay, So if I If you listen again, you can hear that the crackle sounds They're actually hot by high pitched, like. Okay, so do those are fine Crackles, and I'll have a listen to this one. Do you think about that one? Um, I played again. I'm sorry If you can't hear it. Probably if it's not thing. Um, probably. I think this one was indicating a horse crackles. Uh, sorry about that. If you couldn't hear it was, um I was It was think right, well, on my laptop, but yeah, this was in need. Of course. Crackles if you can hear it, just go on YouTube and have a listen, But course crackles. The F four crackles there a bit more lower pitched compared to your high pitched crackles that you see and fine and crackles. Okay. But that's the sort of difference if you're not able to accurately differentiate between fine crackles and course sparkles. Do you guys know? Uh, a little trick to help you? What else can you do to sort of help you tell? Tell Tell them apart. There's a There's a trick you can do to help differentiate. Yeah, I get the patient to cough. Okay? If if the crackles change when the patient coughs Okay, that's much more indicative. Off course crackles. Okay, so if you're struggling to differentiate, it's fine. Crackles or course crackles, which can be hard. Just ask patient a cough and it's the sort of crackles disappear or change in pitch. That's indicative, of course, Crackles. I still got a couple of more breath sounds for you. I hope these sounds play. Okay, let's have a listen. You guys hear that? Probably be able to hear the sounds or not. Let me know. If not, otherwise we'll do it. We can just, uh What if you can't hear What do you think? Do you have any idea? If not so that was a sound off, uh, bronchial breathing. Okay, so with bronchial breathing, it's a I like to imagine it. Imagine you're blowing into ah, hollow tube. Okay. And imagine that sound. That's Bronco breathing. I'm so typically bronchial. Breathing is the sound you hear when you also take over the sternum. Okay. So cause bronchial breathing is the sort of, um, sound you hear over the trachea. So if you all stay over the trachea, Um, that's what bronchial breathing is. Okay, but if you hear bronchial breathing anywhere else Okay. If you had Broncho breathing in the periphery off the lungs, what is that? Indicative off? You have bronchial sounds and the purpose here that if they hear this hollow, um, tube like stand Yes. Consolidation. Okay, so if you hear this sort of bronco prep sounds in the peripheries and the lung tissue, that's definitely indicative of consolidation. Have a listen to this one. Hopefully, this one's a bit more easier to pick up Strider. Not quite, Strider. It's very close that that it's a very similar to the Strider. But that was actually a week is okay, just right on the next one. But this is actually a monophyletic weeks. Okay, so remember the last one? I showed you a polyphonic least, but this one was actually a monophyletic least. Okay? There was still a week. There's still a sort of musical tone, but it was a monofonal. Please. Okay, There was only one pitch to it, Okay? They were there wasn't changing and sounds have a listen and hope you can recognize there was only one pitch on the actual wheeze. Okay? And it sounds very similar to Strider. Okay, the key difference it's tried is that the actual is a lot louder Strider, and we'll show you strider on this side. But what would a monitor on it we can be indicative of? What would you be worried about with a monofonal grease? Yeah, Smile. Okay, Reason General is very sick. It's for asthma, but also more a phone agrees Obstruct, obstruction, obstruction The big one to be thinking about if someone has the, um, obstruction lower down if they even just a foreign body, for example that I could cause about monofonal police. Okay, Now listen to this one. This is Strider, Okay? This is actually stridors have a listen. Oh, okay. So hopefully you can reset. That was quite quite It's quite a musical sound. Okay, Strider on it. It's a very worrying sound because a Z talked about in the pediatric session uh, stridors very concerning for upper airway obstruction. Okay, um, it's a very worrying sound. You hear it? Um but yeah, that strider. Okay. You see any conditions like croup and other cause of, uh, upper airway obstruction. Last one had a listen and trying to let me know what you guys think. Yeah, I think that was quite an interesting sound you could almost describe as a rubbing sound. Yes. So you so when you got it was a little rub. Okay, I'm sorry. You can hear it. But I was a little rub, so pull rubs were thinking about. I like to think of it as you're rubbing leather together. Okay, That's the kind of sound you thinking about with a pool rub. Okay, you see it with things that goes up a little information, Okay, but yeah, those are some different high yields lung sounds to try and also take. Okay, I hope that was useful. Just if you're struggling with them, Just trying to listen to as many of them as you can go and examine is many patients as you can, because it can be difficult. But those some abnormal love lung sounds. Um, here's a table summarizing all these different lung sounds. Okay. Abnormal lung sounds and what they indicate And this sort of pathology behind them. Okay, so you can hope this is useful for your revision. Now we're gonna move on to a local residents, so we just auscultated The next thing you want to do is check vocal residents. So, uh, the way people tend to get torture is to just auscultate and ostentation. It is, say, 99. Okay, that's a There's other words you can use by 99. Pretty common way on your trying to listen to, um, you're trying to listen to the way the patient says 99 over with the Oscar with the stethoscope. Um, So if there's increased vocal resonance, what do you guys think of the causes or increased vocal residents? Yep. Consolidation. Okay, So, um, so why does consolidation cause increased vocal residence is a pretty common question. So the he thing to realize is that normal lung tissue, it filters out low pitched sounds. Okay. The actual normal lung, pleural flora and Frank, um, I typically filters out a lot of the low pitched sounds, but if you have a consolidated lung, Okay, if you have things like pneumonia, that pneumonia is actually a very good transmitter off sound. Okay? Sound out low frequencies and normal frequencies so that if you have a consolidated long that sounded actually going to transmit that sound effectively compared to a normal lung tissue. So that's why the local residents actually increases where they consolidated lung. Okay, So, like someone said, solid travels better would solid as sound travels better with solids. Very good physics knowledge. But yeah, that's the That's the reason why consolidation increases local residents. What about what can cause a decrease? Residents? Yeah. Pull effusions. Um, pneumothorax is well, okay, so if there's a role fluid that's between the lung tissue and the skin. Okay, that's basically they're going to reduce vocal residents. Okay? Because it's going to and basically obstructs sound. Okay, so that's why things like plural effusions and pneumothorax a new Taurasi's. They can all reduce local residents. Okay, so those are the key concept with local residents. Uh, also at this point. So you you've just done chest expansion. You just percussed the back. You then auscultated and then you've checked vocal residence on because you're still examining the patients back at this point, I would check sacred. Um a Okay, just make sure to remember to check sacred a Dema. Just This is just tips to make you look slick. Okay. Rather than making the patient's sit back up at the end of the examination and checking it because you're already auscultated in the back, just check signal edema quickly, and then get the patient to lie back down to examine the chest. Okay? Um but yeah, Just make sure to remember to check your stapler, Dema because we're thinking about heart failure. Okay, so we just examined in the back, okay? This is pretty much where you remain. The bulk of the examination is gonna happen. So the back we examined Oh, yeah. This is important thing when you're exam in the back. It's good. A good practice to examine with their arms crossed inspector scars and all of these other things we talked about. Okay, so that's what we're doing with the back. Now we're gonna move on to the chest s so we'll go to the chest quickly because it's basically we're just repeating the steps, But with the chest, we got all these lung and cardiothoracic scar us again. We talked about all of these scars last week with the cardiology station. Okay, I just put it in again for reference but again, when you're inspecting the chest, look for all of these different scars in case they have it. Okay, but the big thing we're looking for with the respiratory station is that poster lateral thoracotomy SCA. Okay, that's the big surgical scar to be looking for with the, um, Risperdal station. But just have a good awareness of these other scars as well. Okay, inspecting the chest. What is this? These two pictures indicative off. Yeah, this is a barrel chest. Okay. Classically seen in COPD This approach, Chester, we see that increase in the AP diameter, okay. And treprostinil diameter. Okay, we can. And we can see this as well on this lateral chest, X ray, this is an increase in the AP diameter. Classically, that's the classic appearance of a bowel test. Okay. And we classically seen in hyperinflation due to COPD on in terms of some examination planning for COPD have listed some common ones here. Okay, these are all the different examination findings to be able to pick up with COPD. So I hope this is gonna be useful for your revision. Have a look at this video and tell me, what do you guys think so. This is the chest cavity. This is a looking at the patient's chest here. Patients breathing. Very good. This is a flail chest. Okay, this is what we call a flail chest with a male chest. Classically received it in situations off chest trauma. Eso, particularly someone has multiple rib fractures. So what we're seeing here is that instead of the rib cage moving outwards well, while the pain when the patient's breathing. Okay, do you know that normal chest wall movement we see during inspiration expiration There were The opposite is happening here. Okay, so during an inspiration, the actual test can be skin is moving in words. Okay, which is paradoxical. Okay, It's the opposite of what should be happening. And again, That's because this patient likely has multiple rib fractures. And this is what's known as a flail chest. Okay. Very interesting video. Um, so yeah, let's keep going. So what about this image here? We talked about this last week is Well, what is this imaging showing here? This excavatum very good at the end of this is practice. Extra weight. Um, what do you think about this image? Yep. Practice. Carry needs. Um Okay. Important chest wall deformities to pick up on the examination. Uh, let's get going. Uh, what is this device here? But if you see this in your ski, what do you think? This little devices? Yes, this is a chest rain or get very good. Okay, this is Ah, This commonly might show up in your skis. Okay. You might they might. You might actually get patients who have just strained inserted into them. Uh, one of the main indications to do a chest pain. More of the two main reasons to do a chest doing okay. Made the common ones for a pleural effusion on for a pneumothorax. Okay, Someone has a really big pneumothorax. I'm also for hematuria. You can say hemothorax empyema PSAs well, but your infusions and you move your Axert the really common ones. Um, if this is a chest pain, what do you think this is? What? Is this indicating you? Yeah. So this is the Scott. Okay, So this is a typical Scott's someone might have if they had a chest pain in certain. So, um, it's not part of the surgical incisions, cause this is a chest training incision. Scott. Um So you just be able to pick up on that and try and have a look at where the scar is located. Because that's my next question for you guys. Um, where should I A chest pain be inserted. So a little bit of an anatomy Question. What? You guys, where would you insert a gesture? Yeah. 15 to cost of spin face Midaxillary. I actually Excellent. Very good. Safe. Try and go. Good. One of the borders off the safe triangle. Major anterior border of lettuce. Missed dose. I, um, 15. Because of space. Yeah. Those are all the key things. Um, also, when you insert the chest pain, do you insert it above or below a rib about, uh, so you instead of above a rib. Okay. So you don't if you do it below, there's a risk of damaging the neurovascular bundle below the rib. Okay, so always do it above the rim, but yeah, there is a sort of anatomical borders. Okay, in case you get asked about it. So it's these borders off the safe triangles. So until your body of the distance dose I the lateral border of pack major and in the horizontal line from the nipple. Okay, so they left intercostal space. That's all we're thinking about. But yeah, those are the anatomical landmarks. And another question. So, in terms of chest pain management's, uh, what are the different things you guys would be doing to check a chest? X ray is working. Um, how do you monitored strains? One of the different things you look at to see if the chest pains working. Yes, Good imaging is very important. Okay, check the chest rate in place swinging and bubbling. Very good. Always check if there's swinging on the chest. Pain. Um, fluid fluctuation yet. So I'll just cover some of the key things. Um, so with just a management so always whether you're assessing a chest pain and sure, the patient is upright again that the chest rate is below the chest because they weigh the chest and the work is it's, ah, the suction system. Okay, so you need to make sure that the progesterone is below the chest, cause if it's above, it's not. It's not gonna work properly because it's against gravity. Also, make sure that the chest pain is swinging, So what we mean by swinging is that you want to look at the meniscus in the chair straight bucket, and you want to see that it's moving up and down. It's moving with the patient breathing. Okay, so the chest rain is basically an extension off your pleural cavity. Okay, if it's, ah, properly work in chest pain. If, if it's, um, if there's no. If there's no air leaks or anything, it should be a continuation of your pleural cavity. Basically. So if your breathing in, um, and breathing out okay, you should see that the fluid moves up and down. Okay, and that's known as swinging. Also, if it's a new order extremity oh, putting in the chest or in to drain the pneumothorax, you should see that it's bubbling okay, because you're draining out. So if it is draining out there for a new model extreme that's working properly, it's not bubbling, and it's a new one for Extreme. That probably indicates that there's some blockage somewhere again, and you need to do something about it if it's a mess of the animation, So I've talked to the rest of it. If it's an infusion drink, so it is a drink for a little a fusion, then if it's bubbling, which it shouldn't be, that that my indicates an early okay, bigger as if it's a chest ring for a plural effusion. You shouldn't expect bubbles because you're draining fluid. I'm so if a fusion doing is bubbling, that suggests an early remember every important never clamp a your pneumothorax chest, Ray. Uh, what's the problem If you company pneumothorax Estring What might that cause? What could that lead to? A few trump chest pain, which is raining a pneumothorax. Yeah, you can close it and you could cause a tension pneumothorax. Okay, so because yeah, like someone said, you could basically close the pneumothorax okay, and create a one valve system if you could clamp it, so that could lead to tension. Okay, so never clamp a new with your ex chest pain, especially if it's still bubbling. Um, if you if you need to clamp it, always get senior support. But that's a very important safety thing. And generally, if you seek senior supported, there's any signs of respiratory distress. If there's blood leaking into the chest, rain off the suddenly there's an increase in fluid draining into the chest. Rain He's the big safety things to be thinking about with a chest pain. Okay, um, there's a lot more to think about with chest pains, but I think this is a sort of level of knowledge you should have for on skis. Uh, okay, so then we've moved done on inspection of the chest. Then you want to check anterior chest expansion quickly. So here's a technique so similar to the back. Just check you about. The thumbs are moving away symmetrically. Okay. Uh, so that's your anterior chest expansion. Then you're gonna percuss okay. Same technique, but again, always percussed bilaterally on. We talked about the percussion findings as well. But here's the sort of, um, percussion technique. Always because the exhilarate well, just quickly because the exhilaration Well, um, so similar to the posterior aspects. Okay, so we just on the chest, okay? I don't remember. Um, so it's basically the same as the back is just repeating, but we can see that because we started with the back. We've already done most of these examination. Okay, with the chest will literally just, uh, going through the motions quickly. And if you're trying to pick up any you might be able to pick up examination findings, but usually most of the examination finding things is in the back. All right, The chest is very hard to listen generally and percussed, but yeah. Sticky things we're looking for with the chest. Um, So here's the stuff we talked through with the chest. Uh, finally, we're gonna move on to the legs, which is very quick for the respiratory examination. So what is this finding here on the legs? Yep. Everything on the dose. Um, okay, so he's raised red patches on the shins, on the legs. Okay. Erythema nodosa, kidney eyes. Tell me, what are the different causes for everything? One of those, um, even examiner ask you what would be the different causes of erythema medicine? Yeah. Sarcoidosis is a big one. And a respiratory station is Ah, good one. Ah, pregnancy groans, inflammatory bowel disease goods. Yeah. So I've got this low. Then you monitor you guys. So, uh, you can use in your Monica know dose. Um, okay, so no for no coasts. Okay. So idiopathic be for drugs. So if they're taking drugs, like, so far, um, I've not sellin over the combined or contraceptive pill. As for sarcoidosis, Okay, if they've developed a complication off a subtype of soccer does is known as Laughlin syndrome. Back and present with that would part of that syndrome is a routine medicine. You for also medical itis. Eso inflammatory bowel disease in general can cause everything you know, dose. Um, because it can be a extra intestinal manifestations. And em for microbes of certain infections, like strep pharyngitis histoplasmosis infection can also cause erythema nodosa. Um, okay, so hopefully that's a useful you monitor. You guys, uh what? All this one? What? Okay, I forgot the animated. So this is an example off pitting edema. Okay. So always check the pitting edema. Ah, in a respiratory station would be a cause of pitting edema. Yeah. So how failure called pulmonale E. Okay, there's the big one with the respiratory station. Okay, so I've got some We're gonna finish up with some spot diagnosis on pitting edema causes, and then we will be done. So it I promise. It's the last last activity. Eso on examination. Patient has pitting edema in both legs. There's evidence of juggle a venous distention and parastatal hurt IV. There's also evidence off ta staining. So, what do you think? Right, sided heart failure. But what because of call pulmonary? Very good. So this is likely corporate Manali. So this patient has evidence off congestive heart failure Raised a VP evidence of right ventricular hypertrophy. So a Paris tunnel he evidence of smoking, which suggest COPD. Okay, so that's why the likely cause of the pitting edema is called pulmonale e next one on examination. Patient has pitting edema in both legs is also evidence off periorbital edema. There's a photo sensitive rush over the face and a catheter bag shows cross the urine. What do you think about this situation? Yep. In the front. Like syndrome. Very good. So Nephronic syndrome So losing protein into the urine on. But so you get, um, features off hypoalbuminemia. So things like peri orbital edema is very suggestive off nephrotic syndrome from a year. And so there's protein urea. What is this stuff about a photosensitive rash over the place? Yeah, sle. So with the Lupus, Um, classically, you get this mail or Russia of the face on day. One of the big complications of Lupus is Lupus nephritis on DA. That can cause a nephrotic syndrome. Okay, next one on examination. Patient has a demon, both legs. Evidence of abdominal distention, shifting doughnuts, evidence of dilated umbilical veins, Palmer erythema and scale electricity. What do you think about this one? Yeah. So the cause of the pitting edema and this patient is likely because off chronic liver disease, okay, Or liver cirrhosis. And there's evidence off fibrosis and irreversible, um, liver disease, but yes. So this patient has a bunch of stick marta of chronic liver disease. So there's evidence off ascites. Okay, Because as shifting dullness evidence off. Um um, compartment. Okay. Dilated umbilical veins. Palmer erythema s. So it's a sign off. Lack of estrogen metabolism and square electricity. Jaundice. Okay, all peaches off. Liver disease. Okay, all stigmata on. What about the next one on examination? Patient has a swollen, painful leg. It's very damages and very warm. Past medical history of type two diabetes. She has a fever and tachycardia. Yep. So this is classic for cellulitis. Okay, this is a picture of cellulitis. So this every time it is warm, swollen, painful leg diabetes, a big risk factor for infection, skin infections, like cellulitis. Okay. And she also has a fever and tachycardia. It's suggestive of cellulitis. Okay, um, and it is pretty, very, very common. Okay, so things like necrotizing fasciitis is super super red like it, but yes, steady. Like this is likely one that. But this one the patient has pitting edema in both legs. Evidence of palpable, dilated, tortuous subcutaneous pains, red brown skin pigmentation. And she has pain. Worse when standing. What do you guys think about this one? This is a a bit of ah, different specialty. Yeah. So this is a venous insufficiency, like a chronic venous insufficiency. So, um, why is this is likely about basketball problems. There is palpated dilated, tortuous subcutaneous pain. So what is one of these veins? Good. Yes. So these are varicose veins is a classic description from varicose veins. Red brown skin pigmentation on. That's classic for venous insufficiency on pain. Worse when standing again. That's very classic for being a sense efficiency. Okay, basketball, er, problems. Well, hopefully talk about this someday when we do our basket examination, but let's finish up with the last one. So on examination, a patient has pitting edema in the left leg. It is erythematous and warm, tender upon dosage flexion. She recently came from an overnight flights. Yes. Yeah. Big vein thrombosis. Okay. Eh, So why is the DVT so it's a clot in your legs. What's this sign called Tender upon Dorsiflexion? Yeah, it's the home inside. Okay, so, uh, the dorsiflex having a pain? That's classic for DVT on this stuff about returning from an overnight flight. So that's a big respective or DVT formation. So, yeah, those are some different pitting edema scenarios. I've just emphasize that there's loads of different causes for pitching a Dema. So it's just important to get some good good history, good context on do a good clinical examination again, You can really determine what the cause of the pitting edema is. Um, I've got some pictures for you guys. So this is a picture of varicose beans. Here's a picture of cellulitis. Sorry. Deep vein thrombosis. Okay, so you see this swollen like here, and this is a picture off cellulitis. Okay, So this womb, every time it just like a classic picture of cellulitis. Uh, so let's finish off. So we just talked to the legs, so we wanted to check for ankle edema. Going to inspect the legs for DVT and any evidence of erythema nodosa. Um, also to check for a DVT, make sure you squeeze the cough so I can ask if they have any pain. Okay, that's very important to check in a respiratory examination. What's you've done all that you've done with the examination. So thank the patient's restore clothing. And that is your respiratory examination. Okay, so I hope this slide is very useful. Okay, this is the different steps of the respiratory example. Um, and here's the summary slide on all the different examination findings for common respect to pathologies. So I hope this light is useful for your vision as well as a little bit of a visual learning and slide, but yeah, that's it for me. Uh, I think I accidentally added in this slide, but yeah, Here's how I would go about President in the examination on a couple of different lines. Eso again? Just find your own method of presenting your your examination In terms of investigations for the respect to exam. Always recommend you take a formal history. Okay. What? This is a big thing. Whenever you present a history, you always tell the examiner that you were doing examination, Okay? And when he presents an examination, always tell these the examiner that you would take a formal history. Okay, cause that's what you were doing. So good practice. You wouldn't just do a examination. Okay? You need to take a history of well, so make sure you tell them that you take a formal history. Uh, with respect to you can say you'd examine the cardiovascular system to do a peak flow check auction saturations get a chest X ray and get a sputum sample. Okay, Just something that makes sense. Okay, whatever you want. But that's how I would go about it, and yeah, that's it. Um, you guys enjoy that was another long one. But we pretty much run through all the key physical findings with the respiratory examination and went through a lot of important techniques with the respect exam. I hope it was useful, I hope. I'm sure you guys have probably sick of seeing my basement out. The next section will have a different teacher. I'll be back next Thursday to teach the abdomen examination. So hope you guys will be excited. Sanibel be teaching next week as well um, but yeah. Keep turning into the series. I hope you guys enjoying it. Ah, you know, the be back for me For the slides and recordings, Yeah.