Inquiry and general examination of a patient of pulmonological profile

1. Inquiry and general examination of a patient of pulmonological profile Description

2. COMPLAINTS OF PATIENTSWITH RESPIRATORY PATHOLOGY • The main complaints typical for the respiratory system are: • dyspnoea, • cough, • bloody expectorations, • pain in the chest. • Fever, asthenia, indisposition and loss of appetite are not infrequent.

3. Dyspnoea • Subjective dyspnoea • ( is understood the subjective feeling of difficult or laboured breathing) • Cases with purely subjective dyspnoea (in hysteria, thoracic radiculitis). • Objective dyspnoea • is characterized by changes in the respiration rate, depth, or rhythm, and also the duration of the inspiration or expiration. • (determined by objective examination) • Cases with purely objective dyspnoea - in pulmonary emphysema or pleural obliteration)

4. THREE TYPES OF DYSPNOEA ARE DIFFERENTIATED BY THE PREVALENT BREATHING PHASE: • inspiratory dyspnoea • (inspiration become difficult) • expiratory dyspnoea • (expiration become difficult). • mixed dyspnoea • (both expiration and inspiration become difficult)

5. Dry cough ( without sputum) (laryngitis, dry pleurisy or compression of the main bronchi by the bifurcation lymph nodes (tuberculosis, lymphogranulomatosis, cancer metastases, etc.). moist cough (various amounts of sputum of different quality are expected) Bronchitis, pulmonary tuberculosis, pneumosclerosis, abscess, or bronchogenic cancer of the lungs can be first attended by dry cough, which will then turn into moist one with expectoration of the sputum COUGHIS A COMPLICATED REFLEX ACT WHICH IS ACTUALLY A DEFENCE REACTION AIMED AT CLEARING THE LARYNX, TRACHEA, OR BRONCHI FROM MUCUS OR FOREIGN MATERIAL.

6. Cough • Morning cough • (is characteristic of patients with chronic bronchitis, bronchiectasis, lung abscess, and cavernous tuberculosis of the lungs) • Cough attacks during • the entire day • (In patients with pneumonia and bronchitis but attacks may intensify by night ("evening" cough) • "Night" cough • ( is characteristic of tuberculosis, lymphogranulomatosis, or malignant newgrowths)

7. Haemoptysis is expectoration of blood with sputum during cough. • Haemoptysis can develop in diseases of the lungs • (Pulmonary tuberculosis and cancer, virus pneumonia, bronchiectasis, abscess and gangrene of the lung, actinomycosis, tracheitis and laryngitis associated with virus influenza are often attended by haemoptysis) • and air ways (bronchi, trachea or larynx), • . • as well as in diseases of the cardiovascular system. • (characteristic of some heart defects, thrombosis or embolism of the pulmonary arteries and subsequent pulmonary infarction)

8. BLOOD EXPECTORATED WITH SPUTUM CAN BE FRESH AND SCARLET OR ALTERED. Scarlet bloodin the sputum is characteristic of pulmonary tuberculosis, bronchogenic cancer, bronchiectasis, and actinomycosis of the lungs. Blood expectorated with sputum in acute lobar pneumonia (second stage) has the colour of rust (rusty sputum) due to decomposition of the red blood cells and formation of the pigment haemosiderin. • Blood in the sputum is fresh and scarlet during the first 2-3 days in lung infarction while in subsequent 7-10 days it becomes altered.

9. Pain in the chest • 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. • Pain in the chest is classified by its location, origin, character, intensity, duration, and irradiation, by its connection with the respiratory movements, cough, and the posture. Special clinical signs are characteristic of pain of any particular origin, and in this respect pain may have diagnostic value.

10. Anamnesis morbi:determine the time the disease began • Acute onset • (is characteristic of acute pneumonia, especially acute lobar pneumonia • The onset of many diseases may be provoked by chills (bronchitis, pleurisy, pneumonia). • Gradually onset (Pleurisy) • Non-manifest onset • (tuberculosis and cancer)

11. the life anamnesis:conditions under which the patient lives and works. • Damp premises with inadequate ventilation or work in the open (builders, truck drivers, agricultural workers, etc.) can become the cause of acute inflammation of the lungs with more frequent conversion into chronic diseases. • Some dusts are harmful and cause bronchial asthma. • Coal dust causes a chronic disease of the lungs called anthracosis. • Regular exposure to silica dust (cements, pottery, etc.) causes silicosis, the occupational fibrosis of the lungs.

12. The patient should give a detailed report of his past diseases of the lungs or pleura, which helps the physician establish connections between the present disease and diseases of the past history.

16. Cyanosis of nail beds

18. Examination of the chest is done according to a definite plan. Inspection of a chest is divided on • Static • general configuration of the chest • Body symmetry • The shape of the chest • dynamic • type, rhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder girdle, and involvement of the accessory respiratory muscles in the breathing act.

19. NORMAL FORM OF THE CHEST 2. Normosthenic (conical) chest 1.Asthenic chest 3. Hypersthenic chest

20. PATHOLOGICAL CHEST • Emphysematous (barrel-like) chest • Paralytic chest • Rachitic chest (keeled or pigeon chest).   • Funnel chest   • Foveated chest • Kyphoscoliotic chest • 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.

23. Dynamic inspection. Inspection of the lungs involves primarily observation of respiratory movements. • Respirations are evaluated for: • (1) rate (number per minute), • (2) rhythm (regular, irregular or periodic) • (3) depth (deep or shallow), • (4) quality (effortless, automatic, difficult or labored).

24. Pathological respiration Pathological changes of rhythm and depth of respiration are as follows: • Disorders of the respiratory rate: • Tachypneais the increase of the respiratory rate. • Bradypnea is the decrease of the respiratory rate. • Dyspneais the distress during breathing. • Apneais the cessation of breathing. • 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. • The type of respiration disorder • 1.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) • 2.Grocco’s respiration gradually increasing rate and depth without periods of apnea. (Early stages of the same pathological conditions as (1)) • 3. Biot’s respiration periods of hyperpnea alternating with apnea. (Meningitis, agony with disorders of cerebral circulation) • 4. Kussmaul’s respiration is hyperventilation, gasping and labored respiration, usually seen in diabetic coma or other states of respiratory acidosis. (Deep coma)

25. Palpation as a method of examination • Palpation of the chest in user for determination of following: •  1. Tolocate the pain in the chest and its irradiation • (carefully press with your fingers along each intercostal space) • 2. Resistance or elasticity of the chest • ( is determined by exerting preassure of the examining hands from the front to the sides and on the back and the , sternum and also by palpation of intercostal spaces). • 3. The strengs of voice conduction to the chest surface • (vocal fremitus) • ( The palms of the hands are placed on the symmetrical parts of the chest and the patient is asked to utter loudly words with the letter “r” in them) • 4. The epigastricangle as determined by palpation as well.

26. Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations.

29. Percussion of the chest • Comparative percussing the chest. • Topographic percussion • In topographic percussing the chest, the doctor looks for the lungs’ borders in the main lines, thelocation of the apex of the lung and width of Kroenig’s areas. • The excursion of the lung. • (distance between the lower costal margin of the lungs in the maximum inspiration and maximum expirations).

34. Pulmonary auscultation Pulmonary auscultation has been a principal feature of standard physical examinations for many years and is a very useful initial noninvasive test for lungdiseases.

35. Before you begin, there are certain things that you should keep in mind: • a) It is important that you try to create a quiet environment as much as possible. • b) The patient should be in the proper position for auscultation. • c) Your stethoscope should be touching the patient’s bare skin whenever possible or you may hearrubbing of the patient’s clothes against the stethoscope and misinterpret them as abnormal sounds.

36. D) ALWAYS ENSURE PATIENT COMFORT. BE CONSIDERATE AND WARM THE DIAPHRAGM OF YOUR STETHOSCOPE WITH YOUR HAND BEFORE AUSCULTATION.

37. AS YOU ARE AUSCULTATING YOUR PATIENT, PLEASE KEEP IN MIND THESE 2 QUESTIONS: . 1. ARE THE BREATH SOUNDS INCREASED, NORMAL OR DECREASED? 2. ARE THERE ANY ABNORMAL OR ADVENTITIOUS BREATH SOUNDS?

38. Points and lobes of auscultation. Anterior view

39. Posterior view

40. categoriesof breath sounds • Normal • Tracheal • Vesicular • Bronchial • bronchovesicular • Abnormal • absent/decreased • bronchial • Adventitious • crackles (rales) • wheeze • Rhonchi • Stridor • pleural rub • mediastinal crunch (Hamman's sign)

41. Vesicular Breath Sound • The vesicular breath sound is the major normal breath sound and is heard over most of the lungs. They sound soft and low-pitched. The inspiratory sounds are longer than the expiratory sounds. Vesicular breath sounds may be harsher and slightly longer if there is rapid deep ventilation (eg post-exercise) or in children who have thinner chest walls. As well, vesicular breath sounds may be softer if the patient is frail, elderly, obese or very muscular.

42. Thevesicularbreathsoundisthemajornormalbreathsoundandisheardovermostofthelungs. Theinspiratorysoundsarelongerthantheexpiratorysounds. Expiration Inspiration heard only during the first third of the expiration phase

43. Vesicular breathing may be louder or softer for both physiological and pathological reasons.1.Vesicular breath sounds may be harsher and slightly longer if there is rapid deep ventilation or in children(“ puerile respiration”).2.Vesicular breath sounds may be softer if the patient is frail, elderly, obese, or very muscular.!Physiological changes in vesicular respiration always involve both parts of the chest, and respiratory sounds are equally intensified at the symmetrical points of the chest.

44. Alterations in vesicular respiration in pathologydepend on: • ―the amount of intact alveoli; ― the properties of their walls; ― the amount of air contained in them; ― the length and strength of the expiration and inspiration phases;― the conditions of sound conduction from the vibrating elastic elements of the pulmonary tissue to the surface of the chest.

45. Pathologically decreased vesicular respiration can be: • ~due to a significantly diminished number of the alveoli; ~due to inflammation and swelling of the alveoli walls in a part of the lung; ~ decreased also in insufficient delivery ofair to the alveoli through the air ways; ~ due to obstructed conduction of soundwaves from the source of vibration (alveolar walls) to the chest surface.

46. 1. Abnormally increased vesicular breathing depends on obstruction to the air passage through small bronchi or their contracted lumen (increased expiration). 2. Harsh vesicular breathingoccurs in marked and nonuniform narrowing of the lumen in small bronchi and bronchioles due to inflammatory oedema of their mucosa (the inspiration and expiration phases are intensified). 3. Interrupted or cogwheel vesicular respirationis characterized by short jerky inspiration efforts interrupted by short pauses between them; the expiration is usually normal (occurs in non-uniform contraction of the respiratory muscles, when a patient is auscultated in a cold room, or when he has nervous trembling, or diseases of the respiratory muscles, Interrupted breathing over a limited part of the lung indicates pathology in fine bronchi (their tuberculous infiltration)

47. Bronchial Breath Sound • Respiratory sounds known as bronchial or tubular breathing arise in the larynx and the trachea as air passes through the vocal slit. As air is inhaled, it passes through the vocal slit to enter wider trachea where it is set in vortex-type motion. Sound waves thus generated propagate along the air column throughout the entire bronchial tree. Sounds generated by the vibration of these waves are harsh. During expiration, air also passes through the vocal slit to enter a wider spase of the larynx where it is set in a vortex motion. But since the vocal slit is narrower during expiration, the respiratory sound becomes longer, harsher and longer. This type of breathing is called laryngotracheal

48. Respiratory sounds known as bronchial or tubular breathing arise in the larynx and the trachea as air passes through the vocal slit. Еxpiration Inspiration

49. Bronchial breathing can be heard instead of vesicular ( or in addition to the vesicular breathing) over the chest in pulmonary pathology. This breathing is called pathological bronchial respiration.

50. BRONCHIAL BREATH SOUNDS. • If these sounds are heard anywhere other than over the manubrium, it is usually an indication that an area of consolidation exists • (i.e. space that usually contains air now contains fluid or solid lung tissue).