The document consists of a lecture on the examination of patients with respiratory system diseases, covering key aspects such as patient anamnesis, objective examinations, cough characteristics, dyspnea, and various types of chest pains. It details the importance of symptoms like chest pain, cough, and dyspnea in diagnosis and emphasizes the need for careful evaluation of respiratory examinations. The lecture also highlights diagnostic techniques, including assessing thorax shape, breath characteristics, and palpation for vocal tremor.

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KAZAN STATE MEDICAL UNIVERSITY
DEPARTMENT OF INTERNAL
DISEASES PROPAEDEUTICS
Professor V.N. Oslopov
Lectures in Internal Diseases
Propaedeutics
LECTURE 4
GENERAL PROBLEMS OF
EXAMINATION OF PATIENTS WITH
RESPIRATORY SYSTEM DISEASES

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Topic: GENERAL PROBLEMS OF EXAMINA
TION OF PA TIENTS WITH RESPIRA TORY
APPARA TUS DESEASES
Lecture outline:
1. Anamnesis: patient "complaints (chest pain,
dyspnea, asphyxiation), case history, previous
diseases.
2. Objective examination: external inspection
(patient position, skin color, cyanosis,halitosis).
3. Thorax inspection (its shape, etc.)
4. Breath characteristics: respiration rate, depth of
inhale and exhale, type of breathing,rhythm.
5. Palpation of chest. Vocal tremor.

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1. Anamnesis
Patients having respiratory system diseases may present the following
problems: chest pain, cough, dyspnea, asphyxiation.
Pains caused by respiratory apparatus lesion depend on pulmonary pleura
involvement. If the process is confined to lungs only, no pain can be registered
since the lung tissue has no pain receptors. Thus, pain can accompany any
lung process provided it spread as far as pleura. Pleural pains are
characterized by the following features: they are of shooting character, not of
radiating nature, and are usually aggravated or detected only at the maximum
of inhale or while coughing and sneezing, that is, when pleural leaves overlap.
It is important to specially note some specific character of pains arising due
to diaphragmatic pleurisy. They are peculiar in having ability to spread to
jugular region via phrenic nerve. On the other hand, these pains radiate to
abdominal cavity and can be mistaken for abdominal diseases.
This phenomenon is characteristic of children since they can poorly
differentiate between different sensations of pain or algesthesia. Authors relate
instances of pneumonia with inferior lobe of right lung and diaphragmatic
pleura lesion diagnosed as appendicitis, cholecystitis, etc., even to the point of
inappropriate surgical intervention. Pains caused by pneumothorax are of
peculiar character: these are acute knife-like pains in the right or left half of
thorax, frequently accompanied by shock and abrupt dyspnea. If left-side
localized, these pains can be mistaken for cardiac infraction symptoms by an
inexperienced doctor. Pleural pains should be distinguished from other kinds
that can arise in the thorax region

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Classification of chest pains.
Caused by thorax diseases:
intercostal muscles myosites.
intercostal nerves pleurisy and nerve root
compression (osteochondrosis)
rib injuries (fractures, fissures, etc.)
Pleural pains.
Cardiac and vascular pains (stenocardias,
cardiac infraction, aortitis, etc.).
Reflex pains (cholecystitis, diaphragmatic
hernia, ulcer, appendicitis).

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With intercostal muscles myosites. pains are of superficial character
hardly linked with the breathing process, they increase drastically with
palpation and especially with intercostal muscle strain (upon lateral
bending on the healthy side).
With intercostal nerves pleurisy and nerve root compression, pains
are of permanent and belting character, there are particular Vaale pain
zones (in the spine area, at the point of nerve outlet and in the area rib
bone merging into its cartilaginous part). The pains increase with nerve
compression upon lateral bending on the painful side.
With rib injuries (fractures, fissures, etc.), pains are localized,
superficial, increasing with palpation.
Pains of cardiac or vascular origin (stenocardia, cardiac infraction,
aortitis, etc.) are characterized by no links with the breathing process,
they are localized beneath the breast bone or in the heart region, often
are of constringent or constricting character, increasing with physical
activity.
Reflex pains caused by abdominal diseases radiate into thorax due
to the pain stimulation of phrenic nerve.

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The second characteristic feature is cough
Cough characteristics
According to pathogenesis:
pulmonary,
reflex,
central.
According to duration:
permanent,
occasional.
According to timbre:
barking,
hoarse,
noiseless, etc.
According to character:
dry
productive (nature,
smell, amount, period
of expectoration).

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According to its origin (pathogenesis), cough may be linked with the respiratory
apparatus (lesion of lungs and bronchi), yet, it can also be of reflex or central
character. Pleurisies provide an example of reflex cough. Central cough occurs due
to cough center stimulation caused by cerebral disorders. Most frequently cough
occurs due to respiratory apparatus lesion, its cause being mucoid, purulent, or
bloody sputum or foreign particles in the bronchi. Frequently cough occurs with
stimulation of cough zones at primary bronchus bifurcation.
According to duration, cough is divided into permanent or occasional.
Permanent cough occurs, for instance, with chronic bronchitis, occasional with
bronchial asthma, bronchiectases, whooping-cough, etc. in some cases, cough
acquires a specific timbre characteristic of a number of diseases: barking with
laryngites, hoarse and noiseless with destruction of vocal chords, etc.
According to the presence or absence of expectoration., they distinguish
between dry and productive cough. Special attention should be given to the nature
of expectoration (rusty, bloody, mucoid, etc.), its amount and the time of day it is
mostly secreted. Almost pure blood flow accompanying cough is termed pulmonary
hemorrhage.

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The third characteristic patient complaint is dyspnea
Dyspnea characteristics
I.Depending on breathing stages:
inspiratory,
expiratory,
mixed.
II.According to pathogenesis:
pulmonary,
cardiac,
anemic, etc.

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Dyspnea is a subjective sensation of heavy breathing and/or objective respiratory
impairment. Its pathogenesis is mainly connected with two factors: 1) accumulation of
carbonic acid in the blood and stimulation of the breathing center: 2) lung tissue mobility
reduction, that is, increasing lung resistance.
Depending on the predominant impairment of a certain breathing stage, they
distinguish between inspiratory, expiratory, and mixed dyspnea.
Inspiratory dyspnea occurs with air passage disorder in primary bronchi, larynx, and
trachea (laryngeal edema, tumors, foreign particles). Inhale can be hampered up to the
point of hissing and noisy breath which is called stridor (> Lat. hiss). Stridor is
characterized by a distant breath that may be heard at some distance from the patient
and is similar in timbre (!) to tracheal breathing, bronchial respiration or amphoric breath
sounds. It can also be characterized by hissing hoarse or even sonorous rasping noise at
hampered inhale which becomes less evident at exhale.
Stridor can accompany spasmophilia, hysteria, craniocerebral injury, eclampsia, liquids
or solids aspiration, larynx trauma, its incomplete obstruction by a foreign particle, allergic
edema, tumors, etc.
Acute stridor can be caused by laryngotracheites accompanying measles, influenza,
chickenpox, scarlatina, and other infectious diseases.
Gradually progressive stridor can mostly be caused by tumors either obtruding larynx
or trachea lumen or constraining them from the outside.
Expiratory dyspnea is mainly connected with exhale impairment. It occurs with
accessory bronchus and bronchiole spasm. Most frequently it accompanies bronchial
asthma. Mixed dyspnea is characteristic of lung diseases, and it can also accompany
heart diseases.
According to pathogenesis, there can be pulmonary, cardiac, anemic dyspnea, etc.
Asthma is an attack-like abrupt dyspnea. It occurs not only with lung diseases
(bronchial asthma), but also with a number of other disease states

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Asthma types
Bronchial
Cardiac
Mixed
Cerebral
Hysteric

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5. Objective examination.
External inspection. On examining "for some lung diseases,
a forced patient position becomes important. For instance,
when having fibrinous pleurisy, the patient prefers lying in the
position on sick side, when having bronchial asthma (OHT
305), the patient sits leaning with his/her hands onto
something.
Face might have hyperemia of one cheek when having
pneumonia. On general examination, patients having chronic
lung diseases may show diffuse (pulmonary) cyanosis.
Pulmonary cyanosis is central since blood is not sufficiently
arterialized already in the center, that is, in the lungs. As a
result of this, it is diffused. Such patients still have warm skin,
sometimes their hands are even hot to the touch; this is
connected either with hypercapnia causing vascular dilatation
or, not infrequently, with compensatory erythrocytosis
commonly accompanying chronic lung pathologies.

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3. Thorax inspection.
On static examination, thorax shape characteristics are
described. There exist three normal types of thorax: alar chest,
normosthenic (athletic) type, and hypersthenic chest. Its
pathologic shapes are paralytic chest, emphysematous (barrel)
chest, rickets breast, funnel breast, kyphoscoliotic chest. It is
necessary to explain here the notions of scoliosis, lordosis, and
kyphosis. On static examination of thorax, there can also be
detected distortion in terms of restriction or enlargement of one
side. Examples can be given of the restriction of one side of
"Chest when having pulmonary fibrosis, and enlargement with
exudative pleurisy.
Dynamic inspection allows to evaluate the extent of thorax
share in the breathing process, lagging of one side, etc. It also
allows to characterize breathing process

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Breath characteristics
a)respiration rate
b) depth of inhale and exhale
c) type of breathing
d) rhythm

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Respiration rate. Normally, 16-18 breaths a minute. Breath/pulse
ratio should make 1:4.
Breathing accelerated in comparison with pulse often occurs when
lungs are affected by a disease. Accelerated breathing is called
tachypnoe, decelerated, bradipnoe.
Depth. Breathing can show normal depth or such abnormalities as
hypopnoe or excessively deep breathing. Deep and infrequent
respiration is termed Kussmaul's respiration.
Examples can be provided of its significance for some comas (diabetic
(hyperglycemic, Kussmaul's) coma, uremic coma).
Type of breathing - thoracic and abdominal/ventral.
Rhythm. Spasmodic breath can be exemplified by Cheyne-Stokes
(tidal) respiration or Biot's respiration. It should be borne in mind that
these types of breath occur with respiratory center depression (central
nervous system depression, drug poisoning). Examples of pathologic
breath rhythms significance for diagnosing can be given.

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Chain - Stock’s breathing.
It was first described by John Chain in 1818 ,and in detail by William Stock in 1854.
John Chain (1777 - 1836) is the British (Irish) doctor, one of the founders of the
scientific medicine in Ireland.
William Stocks is the British (Irish) doctor.
Chain - Stocks’s breathing is one of the varieties of the periodic breathing. It is
characterized by the repeating cycles of the gradual increase and decrease of the
amplitude of the breathing excursions(hyperpnea) and complete cessation of the
breathing movements (apnea), which continue during 15 seconds and more between
such cycles.
It is observed in practically healthy elderly people during the sleep,living at a big
height .Chain - Stocks’s breathing takes place in pathology because of decreasing
excitability of the breathing centre due to the oxygen lack - in heart failure, expressed
hypertensive encephalopathy, Morgagni - Adams - Stockes syndrome, in cerebral and
cerebral membrane lesion - cerebral hemorrhage (meningeal hemorrhage)[as Stalin had
got], tumors , meningitis, infection diseases, hypnotic and drug intoxications [clinical
case of patient with hemorrhoids], autointoxications in renal insufficiency, diabetic
acidosis, in the atherosclerosis of arteries , supplying medulla oblongata.

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4. Palpation of chest
It determines:
Thorax flexibility or resistance.
Pain zones
Vocal tremor (fremitus pectoralis)
While detecting vocal tremor, sound production
is evaluated. Thus, to achieve the goal of this kind
of palpation, the patient should produce words
containing the R sound. States which cause vocal
tremor to alter are shown in

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Vocal tremor alteration
Weakening
Exudative pleurisy
Hydrothorax
Pneumothorax
Pleura tumors
One-sided abnormality of patency of bronchus with pulmonary
atelectasis
Intensification
With lung tissue carnification: pneumonia, pneumosclerosis
With the presence of cavities adjacent to bronchus