Nursing education

1. KURSK STATE MEDICAL UNIVERCITY
DEPARTMENT OF PROPEDEUTICS OF INTERNAL DISEASES
Chief of Department:
M.D., Professor Konoplya E. N.
Lecturer:
Ph. D., assistant professor Polyakov D.V.
KURSK 2013
Subjective and objective
(inspection, palpation, percussion)
examination of the
respiratory system

2. sharp.com

3. System review
Complains:
Subjective examination of the respiratory system
Anamnesis
morbi
Anamnesis
vitae
Main
1. Cough
2. Expectoration of the sputum
3. Haemoptysis
4. Pain in the chest
5. Dyspnea
6. Suffocation
Secondary
1. General weakness
2. General malaise
3. Chill
4. Hyperhidrosis
5. Headache

4. Cough – is difficult
protective adaptive reaction,
which provides safety and
clearing the
tracheobronchial tree from
irritating agents (sputum,
pus, blood) and foreign
bodies (dust, food particles,
etc.).
medportal.ru

5. The positive role of
cough
The negative role of
cough
- cleanse the airways
from of mucus,
blood,
inflammatory
exudate, etc.;
- removal of the
respiratory tract
from foreign bodies.
- leads to emphysema
due to increased
intrathoracic
pressure (dry
bronchitis);
- causes of
hemoptysis due to
increased venous
pressure;
- a strong cough a
rupture of lung tissue
due to high pressure
in the alveoli.

6. The main reasons of cough
Irritation of cough receptors in the
respiratory tract:
- Infectious process (tracheitis,
bronchitis, etc.),
- Allergic reactions (asthma, etc.),
- Intoxication irritating substances
(nicotine, etc.)
- Foreign bodies,
- Violation of the pulmonary
circulation,
- Pressure on n. vagus, the
bifurcation of the trachea, bronchi
(mediastinal lymph nodes,
mediastinal tumor, aneurysm, etc.)
Stimulation of receptors in
other areas:
- Pleura (pleurisy),
- Pathology of the
abdominal cavity
(pancreatitis, cholecystitis,
appendicitis, etc.)

7. The mechanism of cough
Cough act begins a short
and deep inhalation
(about 2 seconds), the end
of which is closed glottis.
At the same time increases
the tone bronchial
muscles.
Strong contractions the
abdominal muscles, aimed
at overcoming resistance
to a closed glottis (in this
period intrathoracic
pressure is 100 mm Hg).
Following this, the glottis
opens and is immediately
forced expiration.

8. Productive cough Nonproductive cough
Pneumonia,
- Bronchitis,
- Chronic obstructive
pulmonary disease,
- Bronchiectasis
- Lung abscess, etc.
- Interstitial lung disease,
- Tumors,
- Viral infections
- Allergic diseases
- Increase bronchopulmonary
lymph nodes, etc.
Classification of cough

9. Classification cough by time of appearance
Night cough (tuberculosis, lymphoma,
tumors (enlarged mediastinal lymph
nodes irritate reflexogenic zone
bifurcation of the trachea, especially
at night, in a period of increased
vagal tone).
Morning cough (chronic
inflammation of the
upper respiratory tract :
nose, nasopharynx,
pharynx, larynx,
trachea), smoker's
bronchitis, alcoholism,
bronchiectasis, lung
abscess, cavernous
pulmonary tuberculosis
etc.)
Persistent cough -
inflammation of the
larynx, bronchi,
bronchogenic lung
cancer or metastases to
mediastinal lymph
nodes, pulmonary
tuberculosis, etc.
Evening cough (pneumonia,
bronchitis, etc.)

10. Classification of cough by rhythm
Lung and bronchial cough
- cough until sputum
discharge.
Hacking cough (pharyngitis,
laryngitis, primary TB,
smoker's
coughtracheobronchitis) - in
the form of separate cough.
Paroxysmal cough
(asthma, foreign body,
whooping cough, a cavity
in the lung, damage to the
bronchial lymph node)

11. Classification of cough in timbre
Barking - swelling of the false vocal cords, and
compression of the trachea (tumor, goiter), the
defeat of the larynx.
Husky - inflammation of
the vocal cords.
Short and careful (dry
pleurisy, the initial period
of lobar pneumonia) - with
a grimace of pain on his
face.
Silent - ulceration of the
vocal cords, vocal cord
edema, severe weakness.

12. Classification according
to the terms or gain of a cough
Sputum mouth full
(opening a cavity -
abscesses of the lung)
Changing the position of
the body (abscess,
bronchiectasis)
Meal (whooping cough,
esophageal-tracheal
fistula, cancer of the
esophagus, etc.)
Cough with vomiting
(whooping cough and
bronchiectasis)

13. Sputum - pathological secretion tracheobronchial
tree with a mixture of saliva and secretions of the
mucous membranes of the nose and paranasal
sinuses.
Productive cough
Properties of sputum:
 number of sputum during the day and at once;
 consistency;
 color;
 odor;
 character;
 admixture;
 body position and time of the day expectoration of
sputum.

14. Number of sputum during the day
The normal amount of tracheobronchial secretions to
100 ml per day, and swallowed by man.
In the pathology: from a few milliliters till 1.5-2.0
liters at the opening of the cavities.
The consistency of sputum
Liquid
(serous)
Viscous
(mucous, muco-purulent,
purulent)

15. By color of sputum
 colorless or paly - mucous expectoration,
 yellowish or greenish – purulent,
 yellow - with bile,
 black - with anthracosis or siderosis,
 brown (rusty) - from the decay products of
hemoglobin with lobar pneumonia,
 color raspberry jelly - in neoplasia.
wikipedia.org
The odor of sputum
 is often absent or insignificant insipid smell,
 in some cases, sputum takes unpleasant putrid
smell - bronchiectasis, lung abscess, gangrene of
the lung.

16. Character of sputum
intranet.tdmu.edu.ua
Mucous (asthma starting bronchitis, pneumonia) -
viscous, colorless, transparent .
Serous (pulmonary edema) - liquid, transparent, easily
foams, often pink due to the impurities of blood.
Purulent (abscess of of the lung during the opening,
bronchiectasis, gangrene of the lung) - greenish or
brown, creamy consistency, large volume, fetid odor
(upper layer - the serous or mucoserous, colorless frothy, middle layer –
mucous, lower layer – purulent).
Muco-purulent (most of inflammation in the bronchi
and lungs) - viscous, yellow-gray or gray-green color.
Mucous Serous Purulent
Muco-purulent

17. Admixture in the sputum
 the particles of the tumor - a tumor in the
decay,
 food particles - in the presence of the
trachea-oesophageal fistula,
 foreign bodies,
 admixture of blood,
 parasites (echinococcus hooks - with
echinococcosis, etc.).

18. Hemoptysis - is the presence of blood in the sputum,
allocated with a cough.
Hemoptysis
The mechanism of hemoptysis:
1. The destruction of the
impaired integrity of the blood
vessels (tumor destruction, cavities,
etc.);
2. Diapedesis of red blood cells
through the capillary wall (lobar
pneumonia, mitral stenosis,
hemorrhagic diathesis, leukemia,
traumatic injury).
www.spruce.ru
old.consilium-medicum.com

19. Сause of hemoptysis
Infectious diseases
(acute and chronic bronchitis,
bronchiectasis, tuberculosis,
acute pneumonia,
lung abscess, parasitic diseases of
lungs)
Neoplasms
(bronchogenic carcinoma, adenoma of
the bronchus)
Cardiovascular disease
(pulmonary hypertension: mitral
stenosis, primary pulmonary
hypertension, pulmonary edema,
pulmonary embolism)
Injuries
(lung wound fracture ribs,
contused lung,
inhalation of smoke or toxic
substances
Congenital anomalies
(hypoplasia of the pulmonary vessels,
bronchial cysts, telangiectasia (Rendu-
Osler disease-Weber)
Disease of unknown etiology
(Wegener's granuloma,
systemic lupus erythematosus,
sarcoidosis, etc.)
Iatrogenic pathology
(bronchoscopy,
transbronchial biopsy,
pneumonocentesis,
pulmonary artery catheterization,
anticoagulant treatment)
Other reasons
(idiopathic pulmonary
hemosiderosis,
Amyloidosis of the lung)

20. Differential diagnosis of the bleeding cause
Hemoptysis Haematemesis
Blood allocated during
coughing
Blood allocated during
vomiting
Scarlet color, bright red Dark red (brown) by the action
of hydrochloric acid
Alkaline reaction Acid reaction
Foams as usually mixed with
air
------------
------------- Melena is always evidence of
gastrointestinal bleeding
Diseases of the respiratory
system in history
Diseases of the digestive
system in the history
Hemoptysis duration usually
lasts a few hours / days
Short and abundant

21. Pain in the chest in diseases of the respiratory organs depends on
irritation of the pleura, especially of the costal and diaphragmal parts
where sensitive nerve endings are found.
Causes of development of pleural pains:
- dry pleurisy (systemic lupus erythematosus, rheumatoid arthritis,
sarcoidosis, heart or kidney failure, drug reaction, tuberculosis,
etc.)
- subpleural pathological process in the lung tissue (lung abscess,
pulmonary tuberculosis, lobar pneumonia, subpleural lung
carcinoma, etc.)
- lung infarction;
- tumor metastasis into pleura or development in it of the primary
tumor (malignant mesothelioma);
- injury (rib fracture);
- spontaneous pneumothorax;
- reactive pleurisy (eosinophilic pleuritis, in acute pancreatitis, in
myocardial infarction, subdiaphragmal abscess).

22. Characteristics of pain
Localized in the chest, especially in the side of it (with
diaphragmatic pleurisy - in the abdomen). Acute character,
increases with inspiration, coughing and inclination in a health
side, is reduced by compression of the chest and lying on the
affected side, irradiation of the pain is absent. For spontaneous
pneumothorax occurs by a sudden, sharp, intense pain.
The following anatomic locations can all be potential sources of
chest pain:
the chest wall including the ribs, the muscles, and the skin;
the back including the spine, the nerves, and the back muscles;
the heart including the pericardium (the sac that surrounds the
heart);
the aorta;
the esophagus;
the diaphragm, the flat muscle that separates the chest and
abdominal cavities; and
referred pain from the abdominal cavity including organs like
the stomach, gallbladder, and pancreas, as well as irritation
from the underside of the diaphragm due to infection, bleeding
or other types of fluid.

23. Dyspnea – is subjective feeling shortness of breath,
often accompanied by changes in the frequency,
intensity and rhythm of the respiratory movements.
Classification of the dyspnea
inspiratory
expiratory
mixed
Dyspnea
subjective
objective
mixed
physiological
pathological

24. Inspiratory - difficult
inhalation
- typical of mechanical
obstruction in the upper
respiratory tract (nose,
pharynx, larynx, trachea),
- pathological processes
involving compression of the
lung and characterized by a
limited excursion of the
lungs (hydrothorax,
pneumothorax),
- pathological processes in the
lungs, accompanied by a
decrease stretching the lung
tissue (pulmonary edema).
openi.nlm.nih.gov
beltina.org

25. Mechanism for early expiratory bronchial closure:
- increasing the pressure, leading to the collapse of
small airways at the beginning of exhalation,
- the phenomenon of Bernoulli - narrowing of bronchi
air velocity increases, and lateral pressure
decreases, which promotes early narrowing of the
bronchial tubes in the beginning of exhalation.
Expiratory - difficult exhalation - with decreasing
elasticity of lung tissue (emphysema), and narrowing
of the small airways (bronchiolitis, asthma).
drugs.com detaomsk.ru

26. Mixed - difficult and inhalation and
exhalation – with a decrease in the
respiratory surface of the lungs
(pleural effusion, pneumothorax,
pulmonary edema, and high standing
of the diaphragm).

27. Pathogenetic mechanisms of dyspnea
1.Centrogenic:
- organic damage to the nervous system and the
respiratory center;
- humoral effects (fever, elevated levels of CO2 and
other incompletely oxidized products).
2. Shortness of breath on the restriction of the upper
respiratory tract:
- foreign body,
- tumor,
- spasm,
- inflammation,
- compression from outside,
- cicatricial stenosis.

28. 3. Dyspnea of bronchoconstriction (COPD, bronchitis,
bronchial asthma, etc.).
4. Reduction of respiratory surface by interstitial lung
disease (pneumonia, tuberculosis, pulmonary edema,
etc.).
5. Reduction of respiratory surface due to
compression of the lungs (hydrothorax,
pneumothorax, etc.).
6. Reducing excursions lung tissue (emphysema).
7. Difficulty straightening the lungs (scars, wrinkling,
fibrosis, etc.).
8. Violation chest mobility (kyphoscoliosis, rib
cartilage ossification, etc.).
9. The defeat of the respiratory muscles (myositis,
nervous disorders, etc.).
10. Coarse skin scars on the surface of the chest
(burns).

29. Stridor
Breathing that occurs during mechanical obstruction
in the upper airway, which find it difficult to
inhalation and exhalation. It is noisy, loud, audible
at a distance.
Suffocation - pronounced, sudden dyspnea,
accompanied by feelings of fear, anxiety.
The main reasons:
 bronchial asthma,
 acute pulmonary edema (left ventricular failure),
 spasm of the vocal cords,
 spontaneous pneumothorax,
 pulmonary artery occlusion,
 pulmonary embolism.
Suffocation

30. INSPECTION OF THE RESPIRATORY SYSTEM
Forms of the chest
normosthenic
hypersthenic
asthenic
 paralytic
 emphysematous
 rachitic
 funnel
 scaphoid
 deformity of the chest
 change due to increase or
decrease the volume of one
part of the chest
Pathological forms of the chest

31. rudocs.exdat.com
 state supraclavicular and infraclavicular
fossae
 intensity of the angulus Ludovici
 epigastric angle
 direction of the ribs
 width of the intercostal spaces
 fit scapula to the chest
 the ratio of anterior-posterior and lateral
sizes of the chest
The main criteria used in determining
the form of the chest:

32.  smooth, slightly pronounced
supraclavicular and
infraclavicular fossae
 distinct angulus Ludovici
 epigastric angle of about 90°
 oblique and downward direction of
ribs
 moderate wide intercostal spaces,
the width of the ribs equal to the
width of the ribs
 close fitting of the scapula to the
chest
 the ratio of anterio-posterior and
lateral dimensions is 2:3 – 3:4
(0,65 – 0,75)
Normosthenic form of the chest
intranet.tdmu.edu.ua

33. Аsthenic form of the chest
 distinctly pronounced
supraclavicular and
infraclavicular fossae
 angulus Ludovicihe is not
visualized, straight plate
 epigastric angle < 90°
 oblique direction of ribs, almost
vertical
 intercostal spaces are wide
 the scapula is not close fitting to
the chest
 the ratio of anterio-posterior and
lateral dimensions is 1:2 (<0,65 –
0,5)

34. Hypersthenic form of the chest
 supraclavicular and
infraclavicular fossae are
smoothed
 distinct angulus Ludovici
 epigastric angle > 90°
 the ribs are nearly horizontal
 intercostal spaces are narrow,
wide ribs
 scapulars are close fitting to the
chest
 ratio of anterio-posterior and
lateral sizes is > 3:4 (> 0,75) odnoboko.net

35. Pathological forms of the chest
Paralytic form of the chest
The reasons: Marfan's disease, tuberculosis,
cancer, etc.
 supraclavicular and infraclavicular fossa
significant pressed into and uneven
 atrophy of muscles of the chest,
asymmetrical location the clavicles,
scapula
 angulus Ludovicihe is not visualized,
straight plate
 epigastric angle < 60°
 vertical direction of ribs, intercostal
spaces are wide
 the scapula is not close fitting to the
chest
 the ratio of anterio-posterior and lateral
dimensions is 1:2 (<0,65 – 0,5)
dic.academic.ru

36. Emphysematous or barrel form of the chest
The reasons: chronic lung disease
(most commonly with obstructive
syndrome) accompanied by
emphysema, is an increase in
volume and decrease in elasticity.
 supraclavicular and
infraclavicular fossae are
smoothed or protrusion
 distinct angulus Ludovici
 epigastric angle > 90°
 the ribs are nearly horizontal
 intercostal spaces wide
 scapulas are close fitting to
the chest
 increased anteroposterior
size of the chest
pulmonolog.com

37. Rachitic (pigeon) form of the chest
The reasons: rickets (deficiency
of solar radiation, nutritional
factors, malabsorption
syndrome, chronic liver and
kidney disease, etc.)
 rib cartilage at the junction
of the bone thickening
("rachitic rosary")
 increase of the anterio-
posterior size
 anterio-lateral surface of the
chest flattened on both sides
and are connected to the
sternum at a sharp angle
spina.net.ua

38. Funnel (cobbler) form of the chest
The reasons: a prolonged
compression, abnormal
development, in some cases
the cause is not set.
The patient may have criteria
of asthenic, normosthenic or
hypersthenic form of the
chest, but has a funnel-shaped
depression in lower part of the
sternum (" cobbler" form of the
chest). intranet.tdmu.edu.

39. The cause:
syringomyelia disease
(pathology of spinal
cord).
Deepening located in
the upper and middle
parts of the anterior
surface of the sternum
and its form resembles
a boat.
Scaphoid form of the chest
intranet.tdmu.edu.ua

40. Deformity of the chest
Combination of curvatures - kyphoscoliosis
Curvature to lateral directions – scoliosis.
Curvature to back - kyphosis
Curvature forward - lordosis
osanka.in.ua gfmer.ch
kyphosis lordosis scoliosis. kyphoscoliosis
Deformity of the chest
physiological
curves of the spine

41. Change in the volume of the chest
Temporary
(hydrothorax,
pneumothorax, etc.)
Constant
(pulmonary fibrosis,
pulmonoectomy, etc.)
plaintest.com

42. Increase the volume of
one part of the chest
Decrease the volume of one
part of the chest
 pneumothorax
 hydrothorax (exudate,
transudate)
 possible extension of
only the lower part of
the chest with one or
two sides (bloating,
ascites, hepatomegaly,
splenomegaly)
 compensatory
emphysema
pleural adhesions or
complete imperforate
pleural cavity
pulmonary fibrosis
(carnification of lung,
pulmonary infarction,
lung abscess,
tuberculosis, syphilis of
lung, etc.)
pulmonoectomy
obstructive atelectasis
Possible limitations protrusion of the chest (rib‘s
tumor, abscess of the chest wall, periostitis, etc.)
Litten‘s symptom

43. Lag of one half of the chest in breathing
The reasons:
 unilateral pulmonary involvement
(pulmonary fibrosis, abscess, obstructive
atelectasis, lung resection, etc.),
 pathological processes in the pleural cavity
(hydrothorax, hemothorax, pneumothorax,
dry pleurisy, fibrotorax, etc.),
 pathology of the musculoskeletal system
accompanied by severe pain (broken ribs,
intercostal neuralgia, paresis of the
diaphragm, etc.).
Increase the volume of
one part of the chest
Chest is symmetrical Decrease the volume of
one part of the chest

44. Methods of determination:
Inspection:
 the patient breathes quiet and deeply,
 inspection of the front and back of the body in the
forward and side lighting.
Palpation
 the index finger is located at the angle of the scapula,
 in normal mobility of both parts of the chest thumbs
raised to the same level on the right and left, and the
other fingers due to the expansion of the chest in the
lateral directions, some extended.
applied-kinesiology.ru
uninursety.com

46. Types of respiration
Thoracic type of breathing
Respiratory movements
performed by cutting the
intercostal muscles. The chest
expands and raised during
inhalation, during exhalation,
narrows and slightly lowered
(mostly women).
Abdominal type of breathing
Respiratory movements performed
diaphragm, in inspiratory phase
diaphragm contracts and
lowered, and the exhalation
phase is relaxation and lifting
the diaphragm (mostly men).
Mixed type of breathing
Respiratory movements performed by cutting the
intercostal muscles and diaphragm (acute
cholecystitis, dry pleurisy, etc.).
commons.wikimedia.org

47. Disorders of the respiratory rate
Tachypnea is the increase of the
respiratory rate.
Bradypnea is the decrease of the
respiratory rate.
Dyspnea is the distress during
breathing.
Apnea is the termination of
breathing.
Respiration rate may be determined by counting the movements of
the chest or the abdominal wall, invisible to the patient (during
examination of his pulse, for example). In norm the respiration
rate is within 16-20 breathing movements a min.
Disorders of the respiratory depth
Hyperpnea is an increased depth.
Hypoventilation is a decreased depth and
irregular rhythm.
Hyperventilation is an increased rate and depth.
xn--80adfdru0c.xn--p1ai

48. Pathological changes of rhythm and depth of
respiration are as follows:
The type of respiration
disorder
In which pathological
conditions it takes place
Cheyne-Stoke’s respiration
gradually increasing rate and
depth with periods of apnea
Acute and chronic insufficiency
of cerebral circulation and
brain hypoxia, heavy poisoning
Grocco’s respiration
gradually increasing rate and
depth without periods of apnea
Early stages of the same
pathological conditions (acute
and chronic insufficiency of
cerebral circulation and brain
hypoxia, heavy poisoning)

49. The type of respiration
disorder
In which pathological
conditions it takes place
Biot’s respiration
periods of hyperpnea
alternating with apnea
Meningitis, agony with
disorders of cerebral
circulation
Kussmaul’s respiration
is hyperventilation, gasping
and labored respiration,
usually seen in diabetic coma
or other states of respiratory
acidosis
Deep coma

50. Measuring the circumference of the chest
Three dimensions:
during quiet breathing
at the maximum inspiration
at the maximum expiration.
The difference between the sizes on inhalation and
exhalation - excursion of the chest.
To determine it with a tape measure
the circumference:
Back - at the angle of scapula (the
seventh rib)
Front - at the level of the fourth rib(
at the point of connection to the
sternum)
tonfly.com

51. Palpation (from lat. palpatio «feeling») through touch,
sliding, pressure, and a combination of pressure and
sliding, assess the following:
 temperature,
 humidity,
 location,
 size,
 shape,
 position of the object,
 the nature of the surface,
 texture,
 elasticity,
 mobility,
 pain,
 vibration,
 relation to other organs and tissues.
Palpation

52. Tasks of palpation of the chest:
 refinement of the data obtained during the inspection
(form of the chest, its size, etc.),
 identification of local or diffuse pain in the chest,
 lag of one half of the chest in breathing,
 evaluation of its elasticity or rigidity of the chest,
 definition vocal fremitus, pleural friction rub, splashing
fluid in the pleural cavity and crackling with
subcutaneous emphysema.
Types of palpation
 superficial (tentative, approximate)
 deep palpation (assessment of organs and tissues that lie deep
in the body):
- deep palpation of muscle, bone, joint space, etc.,
- sliding deep palpation in the investigation of the abdominal
cavity,
- ballotment - displacement organ in the surrounding fluid.
 bimanual palpation - feeling both hands (combined with the
superficial and deep palpation)
 palpation c using two fingers of one hand (minor joints, coccyx,
muscles, etc.)

53. Determination of elasticity of the chest
Determination of elasticity of the chest
performed at squeezing to anterio-posterior
and lateral directions. Palm of one hand is
placed on the sternum, and the other hand in
the interscapular space. Pressing produces
mainly base of the palm (1-2).
Reasons for the increasing
rigidity of the chest:
hydrothorax, pneumothorax,
a tumor of the pleura,
ossification of the costal
cartilages, emphysema,
pathological forms of the
chest (funnel chest,
kyphoscoliotic chest).

54. Defining vocal fremitus based on
the ability of tissues to conduct low-
frequency sound vibrations (thirty-
three or ninety-nine) occurring at
the voltage of the vocal cords.
Vocal (tactile) fremitus

55. Palpation exercise
tips of the fingers of
both hands, which is
placed on the
symmetric parts of
the chest in the
supraclavicular,
infraclavicular
region, lateral
surface and in the
suprascapular,
interscapular and
infrascapular places.
1
2
3
1
2
vmede.org
Vocal (tactile)
fremitus

56. 4 4
5 5
6 6
7 7
vmede.org
Vocal (tactile) fremitus
ccjm.org

57. Physiological reasons
for the change of vocal fremitus
INCREASED
upper parts of the lung
men with low voice
asthenic form of chest
DECREASED
lower parts of the lung
women and children with a high tone of voice
well developed muscles
hypersthenic form of chest

58. Vocal fremitus is decreased from both sides:
 weakened patients,
 weak voice,
 as well as obesity,
 emphysema,
 with subcutaneous emphysema.
Vocal fremitus is decreased from one side:
 thickening of the chest wall (inflammatory
infiltrate, hematoma, lipoma, limited subcutaneous
emphysema);
 pleural thickening (fibrosis, tumors of the pleura);
 filling of fluid in the pleural cavity (exudate,
transudate, blood, lymph);
 the presence of air in the pleural cavity
(pneumothorax);
 obstructive atelectasis (bronchial foreign body, tumor,
compression of the bronchus from the outside);
 resection of a lung or part of it.

59. Vocal fremitus is increased from both sides:
weight loss, changes in voice (laryngitis, acromegaly,
myxedema).
Formation in the lung
cavity of a large (opened
abscess, tuberculous
cavity, large
bronchiectasis, cystic
formation).
Compaction of lung
tissue(lobar pneumonia,
tuberculous infiltration,
not opened abscess,
stroke, lung cancer,
compression atelectasis, a
local pulmonary fibrosis).
Vocal fremitus is
increased from one side:

60. Tracheal deviation technique
The normal trachea is located in the middle of the
neck.
Palpation technics
One finger technic Two fingers technic Three fingers technic
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61. When unilateral after suffering tuberculosis,
abscesses, gangrene, aplasia of the lung, partial or
complete resection of one lung trachea shifted to the
pathological process.
When hydrothorax, pneumothorax massive formation
on the neck (nodular goiter), aortic aneurysm,
mediastinal tumor, trachea shifted to the healthy
side.
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nodular goiter
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aortic aneurysm
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aplasia of the
right lung

62. Percussion (Latin percussio - tapping) - method of investigating by
tapping on the surface of the patient's body with simultaneous
evaluation arising in this sounds.
Percussion
Percussion as an independent method invented by Austrian
physician Leopold Auenbrugger. In 1761 he published a book
in Latin «Inventum novum ex percussione thoracis humani ut
signo abstrusos interni pectoris morbos detegendi».
In 1808, Jean Nicole Corvisart Mare translated this book,
updated with their observations.
In 1826 Piorri proposed use to improve the quality of
percussion plessimetry - plates of different materials.
In 1846 Wintrich suggested using percussion hammer.
Bimanual percussion used G.I. Sokolsky (1835). In this
pleximeter served fingers of his left hand, and a hammer - 2-3
fingers of his right hand.
In Russia since 1817 has taught percussion professor
F.Oudin.
In 1825, P. Charukovsky published the first textbook on
general semiology, where a study of percussion of the chest in
a special section.

63. L. Auenbrugger
Methods of percussion
Immediate (direct)
percussion - tapping
fingertip or fingertips on
the surface of the body
(L. Auenbrugger, F.G.
Yanovsky, V.P. Obraztsov)
Mediate (indirect) percussion -
tapping hammer (plexor) to a
plate (pleximeter) or a finger on
the finger
(P.Piori, G. Sokolsky, Plesch)
F.G. Yanovsky
V.P. Obraztsov
Plesch
finger on the finger
tapping hammer and plate
Percussion hammer - an instrument
for tapping or striking various parts of
the body.

64. Classification according to the purpose of percussion
Comparative percussion - an assessment of the character of
percussion sound the symmetric parts of the body
Topographic percussion is used to determine the borders, size and
configuration of the bodies, and pathological formations.
Classification by strength of percussion
Superficial percussion - dissemination
of sound waves of 3-4 cm, 2-3 cm in
width. The method used for finding the
borders containing air and airless
bodies, revealing the superficial solid
tissue and cavity formation.
Loud percussion - dissemination of sound
waves of 7-8 cm, 4-6 cm in width. Method
is used to determine the borders of
organs and pathological formations were
located deep in the body, in tissues and
of sufficient quantity.
Light percussion - dissemination of
sound waves of 5-6 cm. The
topographic method used for finding
the boundaries and sizes.

65. Quality of percussion sound
Loudness
loud - aerial organs (lungs, stomach, intestines)
quiet - airless organs (heart, liver, spleen, muscle,
bone)
Pitch
high - airless organs (short, soft)
low - aerial organs (prolong, loud)
Duration
long aerial organs
short airless organs

66. Clear lung sound
(resonance)
Relative dullness
Absolute dullness
Tympanic sound
Dulled -tympanic sound
600hz
400hz
120hz – 130hz
50hz – 60hz
Bandbox sound
(hyperresonance)
70hz -80hz

67. Resonance sound Absolute dullness
Tympanic sound
Distribution of percussion sound

68. Characteristics of the main of percussion sound
Criteria of
sound
Clear lung
sound
Tympanic
sound
Absolute
dullness
Loudness loud loud quiet
Duration long long short
Pitch low low to high high
Musicality unmusical musical unmusical

69. Rules of percussion
 Position of the doctor and the patient should be
comfortable
 The room should be warm and quiet
 Doctor's hands should be warm
 Finger-pleximeter pressed tightly to the skin and
should not touch with the neighboring fingers
 Finger-hammer should be perpendicular
 Apply two percussion blow over short time intervals,
the impact force must be the same
 Hand movements made in the wrist joint
 The right hand should be placed parallel to the left
 In comparative percussion finger-pleximeter set to
symmetrical parts
 When topographic percussion - along the expected
border

70. 1 – mid clavicular line
2 – parasternal line
3 – sternal line
4 – anterior median line
5 – anterior axillary line
6 – mid axillary line
7 – posterior axillary line
8 – scapular line
9 – paravertebral line
Topographic lines

71. Comparative percussion
Anterior surface Lateral surface

72. Comparative percussion
Posterior surface

73. Physiological reasons sound change
 on the right apex of the lung percussion sound
quieter and shorter than the above left
 in the II and III intercostal space on the left lung
sounds also quieter and shorter
 over the lower parth of the right lung percussion
sound will be shorter and quieter
 in the lower path of left lung percussion sound is
tympanic shade
 lung sounds over the upper lobes of the lungs
compared with the lower lobes sounds quieter and
shorter

74. Dullness sound
Dull sound over the entire surface of the chest is determined by
the thickening of the chest wall (obesity).
Dull sound in a limited area can be obtained at the local
thickening of the chest wall (inflammatory infiltrate, hematoma,
talc, swelling, muscle).
Dull sound is detected in the accumulation of fluid in the pleural
cavity (exudate, transudate, blood, pus, lymph).
Dull sound occurs when the solid tissue:
 interalveolar edema, alveolar filling inflammatory or
edematous fluid (lobar pneumonia, tuberculous infiltration,
pulmonary edema);
 formation of an abscess (not opened abscess);
 pulmonary infarction;
 complete obstructive atelectasis;
 compression atelectasis;
 carnification lung;
 local development of connective tissue (scarring of tuberculous
cavities, abscesses, gangrene of the lung);
 swelling of the lung;
 is not open echinococcus cyst.

75. Tympanic sound and its variants
Tympanic sound can be found by:
 accumulation of air in the pleural cavity (1);
 cavity in the lung tissue (2) (This should be a combination of a
number of conditions conducive to the resonance:
• size of the cavity at least 3 cm;
• superficial cavity;
• thin dense chest wall).
 increasing the airiness of lung tissue;
 subcutaneous emphysema.

76. Metalic sound: tension
pneumothorax,
hydropneumothorax (1), a large
cavity with a smooth and tense
walls, the presence of liquid
level (pus, blood) (2).
Cracked-pot sound (cavity (often
slotted) reported a narrow
bronchus, open pneumothorax
in the bronchus. Sound
increases with the patient's
mouth open during inhalation.
Bandbox sound (emphysema of
lung).
Tympanic sound can be
combined with
• pulmonary sound
• dull sound.

77. Topographic percussion of the lungs
Used to determine:
Lung mobility
Anterior upper border
Posterior upper border Kroenig’s isthmus
Lower lung borders

78. Anterior upper border Posterior upper border
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Finger-plessimeter
located in the
supraclavicular
fossa, parallel to
the clavicle.
Direction of
percussion to
mastoid process.
Measurement technique
Normally - 3-4 cm
above the clavicle
Finger-pleximeter
located above the
spine of the
scapula. Direction
to CVII.
Normally - level of CVII
(3-4cm from 7th cervical
vertebra)

79. Kroenig’s isthmus
Kroenig’s isthmus normally is
5-8 cm.
Finger-plessimetr have the upper
border of the trapezius muscle, in
the middle path. Percussing first in
the medial direction and then in
the distal direction. Finger-
plessimetr move on 0,5-1 cm.
1
2

80. Percussion: lower lung borders
Anterior and lateral surface Posterior surface
1 - parasternal line
2 - mid-clavicular line
3 - anterior axillar
4 - mid axillary line
5 - posterior axillary line
6 - scapullar line
7 - para-vertebral line
5
1
4
3
2 7 6

81. Normal lower border of the lungs
Percussion point Right lung Left lung
Parasternal line 5th intercostal space -
Mid-clavicular
line
6th rib -
Anterior
axillary line
7th rib 7th rib
Mid axillary line 8th rib 8th rib
Posterior
axillary line
9th rib 9th rib
Scapular line 10th rib 10th rib
Para-vertebral
line
Spinous process of
11th thoracic
vertebra
Spinous process
of 11th thoracic
vertebra

82. Lung mobility
2
1
Used topographical lines
a - method of examine
the lung mobility
1 - during quiet
breathing,
2 – during deep
inspiration,
3 - during deep
expiration;
b - measurement of
maximum excursion.
a b
Used topographical lines
1 - mid-clavicular line
2 - mid axillary line
3 - scapullar line

83. Mobility of lungs
Topogra-
phic lines
Mobility of the lower border of the lung ( in cm )
Right lung Left lung
Inhalation Exhalation Total Inhalation Exhalation Total
Mid-
clavicular
line
2 – 3 2 – 3 4 – 6 - - -
Mid-
axillary
line
3 – 4 3 – 4 6 – 8 3 – 4 3 – 4 6 – 8
Scapular
line
2 – 3 2 – 3 4 – 6 2 – 3 2 – 3 4 - 6

84. Thanks for your attention

88. .plaintest.com
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Положение руки и пальцев при проведении
пальпаторного исследования.

89. pulmonolog.com
iqmed.ru