The most typical complaints of the patient with respiratory pathology dyspnoea, cough,

1. Theme of lecture: Symptoms and syndromes in diseases of respiratory organs based on data of inquiry and general inspection of a patient, palpation and percussion of a chestN. Bilkevych

3. The most typical complaints of the patient with respiratory pathology • dyspnoea, • cough, • bloody expectorations, • pain in the chest. • Fever, asthenia, indisposition and loss of appetite(secondary complaints)

4. Dyspnoea in its manifestation can be subjective, objective, or subjective and objective simultaneously. • Subjective dyspnoea - the subjective feeling of difficult or laboured breathing. • Objective dyspnoea is determined by objective examination and is characterized by changes in the respiration rate, depth, or rhythm, and also the duration of the inspiration or expiration. • Diseases of the respiratory system are often accompanied by mixed (i.e. subjective and objective) dyspnoea. It is often associated with rapid breathing (tachypnoea). These symptoms occur in pneumonia, bronchogenic cancer, and in tuberculosis. Cases with purely subjective dyspnoea (in hysteria, thoracic radiculitis) or purely objective dyspnoea (in pulmonary emphysema or pleural obliteration) occur less frequently.

5. Three types of dyspnoea are differentiated by the prevalent breathing phase: inspiratory dyspnoea, expiratory dyspnoea and mixed dyspnoea when both expiration and inspiration become difficult. Dyspnoea may be physiological (caused by heavy exercise) and pathological (associated with pathology of the respiratory organs, diseases of the cardiovascular and haemopoietic systems, and poisoning).

6. Aetiology of dyspnoea in respiratory pathology • obstruction of the respiratory ducts (expiratory) due to inflammatory oedema and swelling of fine bronchi and bronchioles mucosa, or else in spasms in the smooth muscles (bronchial asthma), mechanical obstruction in the upper respiratory ducts (larynx, trachea) • contraction of the respiratory surface of the lungs due to • their compression by liquid or air accumulated in the pleural cavity, • decreased pneumatization of the lung in pneumonia, atelectasis, infarction • decreased elasticity of the lungs.

7. Pronounced dyspnoea which develops suddenly is called asphyxia. Paroxysmal attacks of dyspnoea are called asthma. Bronchial asthma, in which an attack of dyspnoea occurs as a result of spasms of smaller bronchi and is accompanied by difficult, lengthy and noisy expiration, is differentiated from cardiac asthma which is secondary to left heart failure and is often accompanied by lung oedema with very difficult expiration.

8. Coughis a complicated reflex act which is actually a defence reaction aimed at clearing the larynx, trachea, or bronchi from mucus or foreign material. An inflamed bronchial mucosa produces a secretion which acts on the sensitive reflexogenic zones in the respiratory mucosa to stimulate the nerve endings and to activate the coughing reflex.

9. Cough may be: dry and moist Morning, evening and night permanent and periodic.

10. Sputum

11. Haemoptysis is expectoration of blood with sputum during cough. The physician must determine the origin of haemoptysis and the amount and character of blood expectorated with sputum.

12. The amount of blood expectorated with sputum is mostly scant. Blood appears in the form of thin streaks, or it may give diffuse colouration to the sputum, which can be jelly-like or foamy. Cavernous tuberculosis, bronchiectases, degrading tumor and pulmonary infarction may be attended by lung haemorrhage, which is usually accompanied with strong cough. Blood expectorated with sputum can be fresh and scarlet, or altered.

13. Painin the chest may arise during the development of a pathological condition in the thoracic wall, the pleura, heart, and the aorta, and in diseases of the abdominal organs (by irradiation). Pain in the chest in diseases of the respiratory organs depends on irritation of the pleura

14. Localization of pain depends on the pathological focus. Pain in the left or right inferior part of the chest (pain in the side) is characteristic of dry pleurisy. Inflammation of the diaphragmal pleura may be manifested by pain in the abdomen to simulate acute cholecystitis, pancreatitis, or appendicitis. Pleural pain is often piercing, while in diaphragmal pleurisy and spontaneous pneumothorax it is acute and intense. Pain is intensified in deep breathing, coughing, or when the patient lies on the healthy side (the respiration movements in this position become more intense in the affected side of the chest to strengthen friction of the inflamed pleura (rough from deposited fibrin). Pain lessens when the patient lies on the affected side. Pleural pain is also lessened when the chest is compressed to decrease the respiratory excursions.

16. General weakness • Tuberculosis – 93 % of patients. • Cancer - 92 % of patients. • Purulent lung diseases – 90 % of patients.

19. Sweating(sudatio, hyperhydrosis) Symptom of wet pillow with smell of rotten hay(tuberculosis). Exaggerated sweating with chills (abscess, gangroene).

20. Diffuse cyanosis in the case of respiratory failure

21. General appearance of a patient with pulmonary emphysema

22. History of present illness (anamnesis morbi) • When and under which circumstances did the disease develop, • Course of the disease, • Past examinations and treatment, their efficacy (in chronic disease).

23. Life history (anamnesis vitae) • Living conditions in childhood. • Living and working conditions in the past and now. • Diseases on the past • Harmful habits. • Heredity. • Allergy.

24. Objective examination. General inspection(inspectio) • General condition of the patient. • State of conscioussness. • Bearing and gare. • Woice. • Skin and visible mucosa.

26. Data of objective examination of the patients with respiratory pathology. The patient should be better examined in the upright (standing or sitting) position with the chest being naked. Examination of the chest should be done according to a definite plan: Static inspection: • general configuration of the chest (position of the clavicles, supra- and subclavicular fossae, shoulder blades); • Chest symmetry Dynamic inspection: the type, rhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder girdle, involvement of the accessory respiratory muscles in the breathing act.

27. The shape of the chest may be normal or pathological. A normal chest is characteristic of healthy persons with regular body built. Its right and left sides are symmetrical, the clavicles and the shoulder blades should be at one level and the supraclavicular fossae equally pronounced on both sides. Since all people with normal constitution are conventionally divided into three types, the chest has different shape in accordance with its constitutional type. Pathological shape of the chest may be the result of congenital bone defects and of various chronic diseases (emphysema of the lungs, rickets, tuberculosis).

29. Normal form of the chest. 1.Normosthenic (conical) chest in subjects with normosthenic constitution resembles a truncated cone whose bottom is formed by well-developed muscles of the shoulder girdle and is directed upward. The anteroposterior (sterno vertebral) diameter of the chest is smaller than the lateral (transverse) one, and the supraclavicular fossae are slightly pronounced. Тhe epigastric angle nears 90°. The ribs are moderately inclined as viewed from the side; the shoulder blades closely fit to the chest and are at the same level; the chest is about the same height as the abdominal part of the trunk.

30. 2. Hypersthenic chest in persons with hypersthenic constitution has the shape of a cylinder. The anteroposterior diameter is about the same as the transverse one; the supraclavicular fossae are absent (level with the chest). The epigastric angle exceeds 90°; the ribs in the lateral parts of the chest are nearly horizontal, the intercostal space is narrow, the shoulder blades closely fit to the chest, the thoracic part of the trunk is smaller than the abdominal one.

31. 3. Asthenic chest in persons with asthenic constitution is elongated, narrow (both the anteroposterior and transverse diameters are smaller than normal); the chest is flat. The supra- and subclavicular fossae are distinctly pronounced. The epigastric angle is less than 90°. The ribs are more vertical at the sides, the tenth ribs are not attached to the costal arch (costa decima fluctuens); the intercostal spaces are wide, the shoulder blades are winged (separated from the chest), the muscles of the shoulder girdle are underdeveloped, the shoulders are sloping, the chest is longer than the abdominal part of the trunk.

32. Pathological chest. 1. Emphysematous (barrel-like) chest resembles a hypersthenic chest in its shape, but differs from it by a barrel-like configuration, prominence of the chest wall, especially in the posterolateral regions, the intercostal spaces are enlarged. This type of chest is found in chronic emphysema of the lungs. Active participation of accessory respiratory muscles in the respiratory act (especially m. sternocleidomastoideus and m. trapezius), depression of the intercostal space, elevation of the entire chest during inspiration and relaxation of the respiratory muscles and lowering of the chest to the initial position during expiration become evident during examination of emphysema patients.

33. 2. Paralytic chest resembles the asthenic chest. It is found in emaciated patients, in general asthenia and constitutional underdevelopment; it often occurs in grave chronic diseases, more commonly in pulmonary tuberculosis and pneumosclerosis. During examination of patients with paralytic chest, marked atrophy of the chest muscles and asymmetry of the clavicles and dissimilar depression of the supraclavicular fossae can be observed along with typical signs of aslhenic chest. The shoulder blades are not at one level either, and their movements during breathing are asynchronous.

34. Paralytic chest

35. 3. Rachitic chest (keeled or pigeon chest). It is characterized by a markedly greater anteroposterior diameter (compared with the transverse diameter) due to the prominence of the sternum (which resembles the keel of a boat.) The anterolateral surfaces of the chest are as if pressed on both sides and therefore the ribs meet at an acute angle at the sternal bone, while the costal cartilages thicken like beads at points of their transition to bones (rachitic beads). As a rule, these beads can be palpated after rickets only in children and youths.

36. 4. Funnel and 5. Foveated chest Funnel chest has a funnel-shaped depression in the lower part of the sternum. This deformity can be regarded as a result of abnormal development of the sternum or prolonged compressing effect. In older times this chest would be found in shoemaker adolescents. Foveated chest is almost the same as the funnel chest except that the depression is found mostly in the upper and the middle parts of the anterior surface of the chest. This abnormality occurs in syringomyelia, a rare disease of the spinal cord.

38. The shape of the chest can readily change due to enlargement or diminution of one half of the chest (asymmetry of the chest). These changes can be transient or permanent. The enlargement of the volume of one half of the chest can be due to escape of considerable amounts of fluid as the result of accumulation of fluid in the pleural cavity, or due to penetration of air inside the chest in injuries (pneumothorax).

39. One part of the chest may diminish due to • pleural adhesion or complete closure of the pleural slit after resorption of effusion (after prolonged presence of the fluid in the pleural cavity); • contraction of a considerable portion of the lung (pneumosclerosis); • resection of a pan or the entire lung; • atelectasis (collapse of the lung or its portion)

40. Respiratory movements of the chest should be examined during inspection of the patient. In physiological conditions they are performed by the contraction of the main respiratory muscles: intercostal muscles, muscles of the diaphragm, and partly the abdominal wall muscles. The so-called accessory respiratory muscles (mm. sternocleidomastoideus, trapezius, pectoralis major et minor, etc.) are actively involved in the respiratory movements in pathological conditions associated with difficult breathing.

41. The type, frequency, depth and rhythm of respiration can be determined by carefully observing the chest and the abdomen. Respiration can be costal (thoracic), abdominal, or mixed type.

42. Thoracic (costal) respiratio. Respiratory movements are carried out mainly by the contraction of the intercostal muscles. The chest markedly broadens and slightly rises during inspiration, while during expiration it narrows and slightly lowers. Abdominal respiration. Breathing is mainly accomplished by the diaphragmatic muscles; during the inspiration phase the diaphragm contracts and lowers to increase rarefaction in the chest and to suck in air into the lungs.

43. Respiration rate may be determined by counting the movements of the chest or the abdominal wall, while the patient is being unaware of the procedure (during examination of his pulse, for example). In norm the respiration rate is within 16-20 breathing movements a min. It is increased in dyspnea and rises in the case of inhibition of respiratory center.

44. Pathological changes of rhythm and depth of respiration are as follows:

46. Palpation of a chest It is used for assessment of: • Pain • Elasticity of the chest • Assessment of vocal fremitus • Assessment of epigastric angle

47. Assessment of vocal fremitus • Intensifies on affected side: • Pulmonary tissue consolidation syndrome • Lessens on affected side: • Pneumosclerosis • Bronchial tumor with partial obstruction of bronchial lumen • Accumulation of small amount of fluid or air in pleural cavity • Pleural adhesions • Disappears on affected side: • Hydro- or pneumothorax • Lessens on both sides: • Pulmonary emphysema

48. Percussion of lungs • Comparative • Topographic

49. The rules of percussion (mediate): • The plessimeter is index or medial finger of the left lung. • 2.Percussion strokes should be done with terminal phalange of medial finger of the right arm on the junction of medial and terminal phalange of plessimeter finger. • The nales should be cut, arms of a doctor should be warm.

50. Comparative percussion • Nornal percussion sound is resonant (clear pulmonary sound) • Pathological sounds: • Dull sound (pulmonary tissue consolidation, hydrothorax) • Thympanic sound (abscess, cavern, pneumothorax) • Hyperresonance (bundbox sound): pulmonary emphysema