The Pulmonary Exam / Lung Sounds (Strong Exam)

A deep dive on the "core" pulmonary exam - the exam of the lungs that one would perform on a new primary care patient, or on a patient being admitted to the hospital for an issue not directly related to the lungs. I discuss abnormal respiratory patterns, signs of respiratory distress, barrel chest, clubbing, and of course, lung auscultation (e.g. crackles, wheezes, rhonchi, etc...)
@0:00 Introduction
@1:40 Inspection of the respiratory pattern
@5:31 Remainder of inspection (e.g. resp. distress, barrel chest, clubbing)
@12:27 Review of lung anatomy for auscultation
@13:57 Demonstration of lung auscultation
@17:30 Lung Auscultation - breath sounds
@19:25 Lung Auscultation - adventitious sounds (e.g. crackles, wheezing)
@27:34 Concluding clinical pearls & documentation of the lung exam
References:
McGee S. Evidence Based Physical Diagnosis. 5th Ed. Elsevier; 2021.
Hooker EA, O’Brien DJ, Danzl DF, Barefoot JAC, Brown JE. Respiratory rates in emergency department patients. J Emerg Med. 1989;7:129-132.
McFadden JP, Price RC, Eastwood HD, Briggs RS. Raised respiratory rate in elderly patients: a valuable physical sign. Br Med J. 1982;284:626-627.
McGee SR. Cheyne-Stokes breathing and reduced ejection fraction. Am J Med. 2013;126:536-540.
de Mattos WL, Signori LGH, Borges FK, Bergamin JA, Machado V. Accuracy of clinical examination findings in the diagnosis of COPD. J Bras Pneumol. 2009;35:404-408.
Pierce JA, Ebert RV. The barrel deformity of the chest, the senile lung and obstructive pulmonary emphysema. Am J Med. 1958;25:13-22.
Golub RM. Validity and Reliability of the Schamroth Sign for the Diagnosis of Clubbing. JAMA. 2010;304:159-161.
Holleman DR, Simel DL. Does the Clinical Examination Predict Airflow Limitation? JAMA. 1995;273:313-319.
Piinla P, Sovijarvi ARA. Crackles: recording, analysis and clinical significance. Eur Respir J. 1995;8:2139-2148.
Wang CS, et al. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA. 2005; 294:1944-1956.
#physicalexam #respiratory #OSCE

[@canas_fe4815]

Regardless of how much attention this series gets, I hope you will continue. This material is GOLD. I'm sharing these videos with all my fellow med students, and everyone appreciates them SO much. Thanks again from all of us!! 🙏

[@StrongMed]

I'm very glad you've found them to be helpful! There are more of this series on the way. 10 more videos have already been filmed, it's just a matter of finding the time to edit them.

[@AllThingsToeseen]

I agree, I'm a pgy-1 and I still find myself referring to Dr Strong's videos many many times.

[@TheMaddijoy]

thank you so much for this! I'm a soon-to-be RN and i've always struggled with the front respiratory exam on people with breasts, this was super helpful.

[@sivajinidarmendra2250]

It is such a wonderful gift to us to learn from a great educator. These golden educational videos and your kindness....Thanks a million, dear Dr Strong.

[@krystenme6841]

This lessons are so good!!! My father had COPD with emphysema and clubbing fingers, his doctor said it was cause he was eating a lot of pasta and he was becoming coeliac . It took my father 3 months to convince him to do a thorax Xray and then another 3 months to get the blood test to confirm lung cancer. At the hospital they told him, sorry if we only had found about this 6 months ago maybe we could have done something, now it's too late....maybe if that doctor had known or made the association of cold and clubbing finger my father would have lived a few extra years...

[@warbler1984]

That's terrible sorry to hear about your father's case

[@fakhrizaidan6718]

great video as always

[@fantasticweb6384]

this is Gold for me ! Thank You all and really appreciate your work ♥️

[@aishab9286]

AMAZING Waiting for the rest of body systems

[@fastmohawk3903]

thanks for the valuable ,detailed presentation!!! prolonged expiration is also observed in pulmonary edema

[@psydocthepsyduck8382]

Thank you from a medical student in Canada

[@ksaianirudh9449]

Thank u for creating great content ❤

[@waelfadlallah8939]

Our favorite practitioner ❤

[@nathanmurage]

Loved this!

[@T2HI]

I think adding the key words like "respiratory system", "clinical examination", "OSCE" might help with getting a lot more engagement with the content. Thank you for the generous contribution, Dr. Strong! Looking forward to more lectures. From an avid follower

[@StrongMed]

Thanks for the suggestion. I'm a little conflicted about too explicitly attaching this series to "OSCEs" because by design, the series will teach a different exam (i.e. one that is fully grounded in evidence and practicality) than what is usually expected on an OSCE (i.e. an exam that is based on the outdated notion of what an exam is "supposed" to include - according to a bunch of old men from the 1950s.). I'll think this over more before posting the CV and abdominal exams...

[@T2HI]

Great to hear that, Doc! Even though the term OSCE isn't necessary, I believe "Clinical examination", "respiratory system" would be better terms to include since most of the other available videos on YT and the searches for them use the same keywords.@@StrongMed

[@jonny5676]

amazing...

[@mrng245]

Great content! I hope You cover all the systems

[@StrongMed]

That's the plan. I've filmed the pulm, CV, and abdominal exams so far. Unfortunately, our simulation center (where these are filmed) and standardized patient program have since gone back to mandatory face masks for all activities - meaning that I may need to defer filming more systems until after flu season is over (i.e. April at the earliest). I'll still be rolling out what I've already filmed from now through February.

[@AhsanKhan1998]

​@@StrongMedI seriously can't wait for all the videos. Thank you so much.

[@ShadiFSharqawi]

I so appreciate your work in recording these videos. I wonder which book do you recommend to follow with your videos rather than references? Bate's, Talley and O'Conner's, or others?!

[@StrongMed]

I honestly don't think there is a perfect book to use for learning the physical exam, which was part of the motivation for this series. Evidence-based Physical Diagnosis by McGee does the best job with discussing the evidence supporting (or refuting) the use of specific maneuvers, but it doesn't do as well with teaching the maneuvers themselves (i.e. relatively few diagrams of patients actually being examined). Talley and O'Connor is ok, but I think it may actually be too comprehensive. By not highlighting or separating out what's actually important from findings and maneuvers that are more esoteric, it can seem overwhelming for the learner. There is also a lot of discussion of maneuvers in the "textbook exam" only (i.e. things that have no evidence in favor of them, and which clinicians generally don't do in actual practice). I actively dislike Bates - it is the most beholden of all texts and references to the historic relic of the "textbook exam", and it is not as comprehensive as Talley and O'Connor. Because of its popularity, it has probably actively harmed medical education by continuing to promote an exam not grounded in reality to multiple generations of learners.

[@ShadiFSharqawi]

Great answer as expected. Thank you doctor!

[@Hector-ec6fu]

What would be the best way to describe the snoring/gurgling + mucus sound produced often in those with COPD exacerbations instead of rhonchi in the clinical setting?

[@StrongMed]

That's a great question. I document such sounds similarly to this: "Both lungs with prominent gurgling sounds throughout the respiratory cycle consistent with excessive airway secretions, mucus and/or recent aspiration"

[@abdullahrahmanzai7210]

Great

[@anilkarameti484]

Finally!! 😊😊 Doctor, can i ask you what kind of stethoscope do you use? 🙂

[@StrongMed]

For years, my "walking around" stethoscope was a Littmann Cardiology III. Then I lost it. So for now am borrowing my wife's Littmann Master Cardiology, which is good. The recordings for this video were made with a Thinklabs One digital stethoscope - I used to be a huge fan (and even posted a spontaneous review of it on the channel), but have since become more lukewarm on it.

[@anilkarameti484]

​@@StrongMedI want to buy Littman Cardiology IV since i've read a lot of good reviews about it, but i don't know if it's really worth the money. Or maybe a Litmann Classic III would do the job just as good?

[@musataz]

Dr Strong, do you have videos on blood products and blood transfusion? Studying a topic without your video doesn't feel right XD

[@StrongMed]

I've a whole series on thrombosis, one on anemia, and one on blood types, but unfortunately none of them are focused on blood products and transfusion per se.

[@5omethingsBetterThanNothing]

dr strong consider collaborating with amboss to create a clinical / evidence based exam subsection and get further credit

[@StrongMed]

Thanks for the suggestion. However, while I certainly don't turn down the occasional (and much appreciated) donation, this channel has always been focused on providing free education focused predominantly on clinical skills and patient care. No disrespect to Amboss intended, but a collaboration would necessarily take time away from that primary mission.

[@5omethingsBetterThanNothing]

@@StrongMed agreed and much respect to you and your mission!

[@AhsanKhan1998]

​@@StrongMedThanks Dr. Strong, this is the reason I have so much respect for you and your selfless work. Amboss is a good resource but for people outside of the western countries (especially so for developing countries) it is just too expensive for only study material.

[@user-wz6oo9bq5j]

Any intent for POCUS ?

[@ragediraqi]

How to differentiate snoring, stertor from stridor?

[@StrongMed]

Snoring is typically more prominent during expiration and relatively low pitched. Stridor is typically more prominent during inspiration and relatively high pitched. As an adult internist in the US, I have literally never heard or read a colleague use the term stertor, and would advise against its use for the same reason I advise against using "rhonchi" in adult medicine - it's too likely to be misunderstood. The term stertor is occasionally used in pediatrics and veterinary medicine, and would defer to those fields for a definition and description.

[@ragediraqi]

Thank you very much for clarification

[@drrehmanvlog7487]

Sir pdf of these examination videos??

[@StrongMed]

Sorry, there aren't any.

[@zuhairyassin505]

can we auscultate with the patients clothes on ?

[@StrongMed]

It's not recommended and I personally avoid doing it if at all possible, but that's primarily because it's a missed opportunity to inspect the skin, and because the movement of fabric/cloth under the stethoscope head could potentially introduce artificial adventitious sounds (e.g. crackles). However, if the clothing is thin (i.e. a T-shirt or hospital gown) and firm pressure is applied with the stethoscope to minimize movement of the underlying clothing, it probably has relatively mild impact on the quality of auscultation itself. In other words, the impact on sound transmission by 0.1cm of cotton is trivial compared to the underlying 3+ cm of fat, muscle, bone, and subcutaneous tissue. Physical exam purists freak out on this point, but it's supported by the only available study on the issue: karger.com/res/article/75/1/85/289069/Transmission-of-Lung-Sounds-through-Light-Clothing

[@zuhairyassin505]

@@StrongMed thanks a million doc