4.2. Theoretical questions:

1. Rules of general visual inspection of the respiratory patient.

2. Main sings of the respiratory disease that can be revealed at visual examination.

3. Static visual inspection of the chest

4. Types of the normal chest shape, their description.

5. Barrel chest, its description and diagnostic value.

6. Paralytic chest its description and diagnostic value.

7. Pigeon and funnel chests, their description and diagnostic value.

8. Scoliotic and kyphoscoliotic chest, its description and diagnostic value.

9. Dynamic visual inspection of the chest, rules and diagnostic value.

10. Pathologic types of breathing, their diagnostic value.

11. Rules of chest palpation, diagnostic value

4.3. Practical task that should be performed during practical training

1. Performing general visual inspection of the respiratory patient

2. Recognizing respiratory signs at visual examination.

3. Performing static visual inspection of the chest and assessing obtained data

4. Performing dynamic visual inspection of the chest and assessing obtained data

5. Palpation of the chest and assessing obtained data

Topic content

General inspection

The patient should be undressed; the examination room should be warm and well lit. An anthropometric caliper and a measuring tape are used to do anthropometry.

The appearance of the patient is described: general condition, carriage, gait, position in bed, consciousness, expression of the face, constitution, nourishment, stature, chest circumference at calm breathing, skin, visible mucosa, and conjunctiva, subcutaneous fat, edemas, muscles, bones, joints.

General patient's condition may be good, satisfactory, moderate grave, grave, extremely grave. The criteria's of patient's condition are the following clinical features: consciousness, posture, gait, the facial expression, weight, and mental condition.

Good patient's condition is characterized by clear consciousness, ac­tive posture, free gait, sensible facial expression, sufficient weight, and good mood. This condition occurs in patients with remission of chronic disease favorable course of a disease, or during recovery.

Satisfactory patient's condition (status morboacili) is characterized by clear consciousness, active or active with restriction posture, free or partial deranged (specific) gait, sensible facial expression, and adequate mental reaction. This condition occurs in patients with remission of prolong chronic disease, or during recovery from acute disease.

Moderate condition (status ingravescens) is characterized by deranged consciousness, alteration of facial expression and posture (forced), uncertain gait, partial deranged mental state and may be observed in patients with recurrence of chronic disease, acute diseases, or due to the traumas and poisoning.

Grave condition (status morbogravi) is characterized by disorders of practically all clinical features: deranged consciousness, changed facial expression (fear, suffer, hopelessness, indifference). The patients have forced or passive posture, loss of weight, edema, and inadequate mental state. Grave condition is observed in patients with infections and oncologic diseases, heart failure, disorders of renal, liver functions, abnormalities of nervous and endocrine systems, after operations, traumas.

Extremely grave condition (status gravissimus) is characterized by unconsciousness, passive posture, and indifferent facial expression and observes in the patient with coma, shock, and agony.

The general condition of the patient is characterized by his/her position in bed and the state of the consciousness.

Consciousness (sensorium) may be clear or deranged. The criteria's of consciousness condition are the following features: orientation to the surroundings, adequate answers, concentrated attention, reflexes, and pupil reaction on light.

Clear consciousness (sensorium lucidum) is characterized by adequate behavior, correct orientation to the surroundings, timely answer to the question, and preservation of all reflexes.

The deranged consciousness develops due to the different causes: disorders of cerebral or cardiac circulation; endogenic and exogenic intoxication; infectious affections; hormonal, mineral, metabolic abnormalities; and traumas of the brain.

The deranged consciousness is divided into two groups - depressed (stupor, sopor, coma) and excited consciousness (irritative disorder, delirium).

Attention should be paid to gait and carriage. In healthy persons the carriage is straight, the gait is steady.

Position in bed. Three types of the patient's position are distinguished: active, passive, forced.

An active position is that which the patient can change as he needs.

A passive position is taken due to exclusively the law of gravity; this is the sign of poor condition of the patient.

A forced position is taken instinctively or consciously to elicit the suffering.

These positions can be specific and an experienced physician may determine the character of the disease seeing the patient's position.

In dry pleurisy, lung abscess, bronchiectasis, the patient prefers to lie on the affected side. In dry pleurisy, this position relieves the pain because it limits pleura movement; in abscess, it relieves coughing because the content of the cavity does not get to the bronchial tree.

During an attack of bronchial asthma the patient sits upright or resting the hands on the edge of the table of chair, this position allows mobilizing accessory respiratory muscles.

Constitution (body-build)

After the consciousness evaluation the physician assesses the constitution of the patient as to his constitution, nourishment, the shape of the body, degree of the muscles development and their tone. After that the constitution type should be determined.

Nourishment is assessed chiefly in accordance with the thickness of the subcutaneous fat. Its state is evaluated on inspection as well as by measuring the thickness of the skin fold in the area of the left hypochondrium.

If the thickness of the fold is >2 cm, development of the subcutaneous fat is abundant, if <0,7 cm, this is insufficient.

Frequent causes of weight loss are chronic diseases of the respiratory system (COPD, tuberculosis) or cancer.

The findings of the constitution investigation as well as measuring the stature and chest circumference allow determining the constitution type. Constitution is the entity of the congenital and acquired morphological and functional features of the person formed during the lifetime under the environmental influence. According to M.V. Chernorutsky, normosthenic, asthenic and hypersthenic types are distinguished.

In normosthenic constitution all parts of the body are proportional.

Asthenic constitution (habitus asthenicus) is characterized by the following features: longitudinal dimensions of the body prevail, the chest is narrow and flat, the neck is thin and long, the extremities are long and thin, the skull is long, the muscles are inactive, the shoulders are narrow, the subcutaneous fat is poorly developed.

In hypersthenic constitution (habitus hypersthenicus) transverse dimensions prevail, the patients are stocky, the chest is wide, the neck is short, the extremities are short and wide, the skull is wide, the muscles and subcutaneous fat are well-developed, early holding is typical.

Examination of the skin.

It is necessary to pay attention to the color, humidity, turgor, presence of hemorrhages, rashes, scars, the state of the body hair and venous system.

Color of the skin. The normal skin is pale pink due to development of the vascular network of the skin, the amount of the blood in the capillaries, morphological and chemical composition of the blood, skin thickness.

The skin can be cyanotic, pale, hyperemic.

In a number of respiratory diseases, i.e. pneumonia, emphysema, pneumosclerosis, pulmonary tuberculosis, supportive conditions of the lungs, as well as in patients with pulmonary insufficiency, the skin and mucous membranes are cyanotic. Acute development of cyanosis is seen in pulmonary embolism and spontaneous pneumothorax. The cause of cyanosis is disturbances of gas exchange in the lungs resulting in accumulation of increased amount of reduced hemoglobin.

A pale skin is observed in patients with exudation pleurisy. A pronounced paleness is present in excessive pulmonary hemorrhage, decaying lung tumor, cavities, bronchiectasis, vasculitis (Goodpasture's syndrome, Wegener's syndrome).

At the patients with pleuropneumonia, cyanotic face can be associated with hyperemia.

Increased humidity is observed in fever.

Turgor is skin elasticity. This is determined by touching the skin and depends on the degree of subcutaneous fat development and the amount of fluid in the skin. Decreased turgor is present in severely ill patients.

Lymph nodes. Peripheral lymph nodes (subclavicular, cervical, supraclavicular, submaxillary, axillary, elbow, inguinal) are not evident on inspection. They should be palpated. Palpation is accomplished symmetrically on the both sides strictly following the sequence: beginning from occipital, anterior and posterior cervical supra- and subclavicular lymph nodes. Attention should be paid to their size, consistence, tenderness, adhesions with the skin, scar formation after fistulas. Lymph node enlargement may be generalized or isolated.

Isolated enlargement of the axillary lymph nodes can be observed in breast cancer and suppurative processes on the upper extremities. Multiple generalized symmetrical enlargement of lymph nodes is noted in tuberculosis, cancer metastases. Dense lymph nodes with an uneven surface are characteristic for malignant tumors.

When examining the skeletal muscles it is necessary to determine the degree of development (good, moderate, weak), local hypertrophy, atrophy, tenderness, spasms. Muscular tone is determined by palpations, this can be preserved, decreased, increased. Muscular tone is decreased can be at the chronic diseases of lights, cancer. Muscular atrophy is developed at the COPD patient.

The digits are inspected for clubbing (abnormal enlargement of the distal phalanges). Clubbing is a nonspecific finding often associated with chronic respiratory diseases (cystic fibrosis, bronchiectasis, hypoplasia, fibrosing alveolitis, mesothelioma), lung cancer and some chronic cardiac disorders (e.g., congenital cyanotic heart disease). The exact mechanism for it remains unknown.