1. Respiratory system

(systema respiratorium)

Examination of the chest.

1. Static inspection. The shape of the chest: normal (normostenic, astenic, hyperstenic), pathological (emphysematous (barrel), cylindrical, paralytic, rachitic, lordotic, kyphotic, scoliotic). The symmetry of both halves of the chest and over-and subclavian space ( inflow or protrusion); position of collarbone and shoulder blade (a tight seal or gap), the deformation of the chest (the presence of a diverticulum and the confluence, the deformations resulting from curvature of the spine). Features of intercostal intervals.

2. Dynamic examination. Symmetric motion of both halves of the chest in breathing, retardation of one half with a deep breath, the involvement of accessory muscles, the number of respiratory movements per minute; type of breathing (thoracic, abdominal, combined), depth (superficial, deep); rhythm (rhythmic or arrhythmic - Biota, Cheyne-Stokes equations, a large noisy breathing of Kusmaulya).

Shortness of breath: the degree of severity, nature (expiratory, inspiratory, mixed); measuring the girdle of the chest at the angles of blades and the fourth intercostal space in the front at a height of inhalation and exhalation.

Palpation of the chest: resistance, pain, swelling in different parts of the chest along the ribs, intercostal intervals, in the intercostal nerve exit points (points of Valais). Determination of friction to touch the pleura. Voice trembling at symmetric areas: the same, invariable, strengthened, weakened (accurately indicated localization).

Percussion of the chest: comparative (the sound is clear - pulmonary; dull-to-tympani dull shortered, obtuse, bund-box, tympanic) with the precise boundaries of the detected change; topographic (elevation standing tops of light in front and behind, Kernig’s area width to the left and right, lower border of right and left lung on all orientation lines, left of parasternal and midclavicular line indeterminate); size of passive and active excursion of the lower lung border (along the right midclavicular line, mid-axial and miscapular line on both sides) Traube semilunar space (size, base width and height).

Lung auscultation: assessment of strength and pattern of primary respiratory sounds over symmetric sections of the right and left lung: vesicular respiration (normal, exaggerated, diminished, harsh, saccaded), bronchial (cavernous, combined, indeterminate), absence of primary respiratory sounds. Precise indication of location of each respiratory sound alteration needed. Additional respiratory sound rattling – dry (low-tone – bass, high-tone – discant, sibilant); wet – (small, medium and large vesicular, subcrepitant); consonant and non-consonant; crepitation, pleural membrane friction murmur. Broncophony in symmetric chest sections.

2. Cardiovascular system

(systema circulationis sanguinis)

Overview: cardiac hump, apex beat (intercostal space where it is located is identified, pulse), pulse under apex, under the collar bone and in the 2^nd intercostal space on the left and the right side of the chest, altered large neck vessels (carotid flutter, jugular vein bulging and pulsation).

Arterial pulse: similar or different on the right and the left hand; rhythm (regular, irregular); frequency, deficiency, strength and intensity, pulse size and shape; large blood vessels auscultation (whether there is double Traube tone, double Vinogradov-Durosier murmur in pelvic arteries and nun’s murmur in jugular veins); determination of the arterial blood pressure under the Korotkov method (maximum, minimum, sphygmic); capillary and vein pulse examination.

Palpation: apex beat (area, localization, strength, height and resistance); cardiac impulse; flutter (systolic, diastolic, “cat purr”) in the heart area (localization, cardiac phase in which it is determined); beat in the upper-abdominal section (differentiation of aortic pulse, right heart ventricle and liver) and suprasternal notch.

Percussion of heart: determination of the right, upper and left borders with respect to cardiac dullness; vascular bundle diameter (determined in centimeters in the 2^nd intercostal space); borders of absolute cardiac dullness (right, upper, left).

Auscultation: performed consistently on the top (bicuspid valve) next to the base of the ensisternum (tricuspid valve), in the 2^nd right (aortic valve) and left (pulmonary trunk valve) intercostal space and in the 5^th auxiliary point of Botkin-Erb (3^rd intercostal space to the left from the chest border).

Tone character and sonority: first tone (normal sonority, suppressed, intense, split, bifurcate), “quail” rhythm (additional tone of bicuspid valve opening - clicking); second tone (normal, emphasized, split, bifurcate), tripartite galloping rhythm (protodiastoic, mesodiastolic, presistolic); pendulous rhythm, embryocardia; number of cardiac contractions per minute (tachycardia, bradycardia); cardiac contractions rhythm (regular, irregular, - extrasystole, flickering arrhythmia).

Murmurs: relation to cardiac phases – systolic, diastolic (protodiastoic, mesodiastolic, presistolic), pattern (blowing, scratching etc.), intensiveness (strong, faint), timbre (soft, harsh, high, low), duration (long, short, rising, falling); areas of better hearing of murmurs, changes in murmur pattern depending on the respiratory phase and the patient’s position (from vertical to horizontal and vice versa), hearing of murmurs on the left side, Sirotinin-Kukoverov symptom (systolic, intensifies when the patient raises hands and places them on back of the head), pericardium friction rub, pleuropericardial friction rub, aorta abdominal region hearing.