Ministry of Health of Ukraine

Kharkiv National Medical University

MAIN COMPLAINTS OF PATIENTS WITH

RESPIRATORY ORGANS DISEASES. STATIC AND DYNAMIC
INSPECTION OF THE CHEST. PALPATION OF THE CHEST

Methodical instructions for students

Рекомендовано
Ученым советом ХНМУ
Протокол №__от_______2017 г.

Kharkiv
KhNMU
2017

Main complaints of patients with respiratory organs diseases.

Static and dynamic inspection of the chest. Palpation of the chest:
Меthod. instr. for students / Authors. Т.V. Ashcheulova, O.M.
Kovalyova, G.V. Demydenko. – Kharkiv: KhNMU, 2017. – 26 с.

Authors: Т.V. Ashcheulova

O. M. Kovalyova
G.V. Demydenko

INQUIRY
1
 The main complaints of the patients with disease of the
respiratory system are: dyspnoea (breathlessness), cough, and chest pain.
Dyspnoea is determined as an abnormally uncomfortable
awareness of breathing.
All normal subjects will have experienced dyspnoea on heavy
exertion – physiological dyspnoea. Pathological dyspnoea is the same
sensation occurring at lower workloads or at rest, and includes a
perception that the awarness of breathing is unpleasant and/or
inappropriate to the situation. The gradation of dyspnoea may usefully
be based on the amount of physical exertion required to produce the
sensation.
Dyspnoea in its manifestation can be subjective, objective, and
mixed. By subjective dyspnoea is understood the subjective feeling of
difficult breathing. Objective dyspnoea is characterized by changes in
respiration rate, depth, or rhythm, and also the duration of inspiration
and expiration. Respiratory diseases are often accompanied by mixed
dyspnoea.
Dyspnoea is possible with normal, rapid breathing (tachypnoea),
and slow rate of breathing (bradypnoea).
Three types of dyspnoea quality are differentiated by the
prevalent breathing phase: inspiratory dyspnoea (more difficult to breath
in than out), expiratory dyspnoea (more difficult to breath out than in),
and mixed dyspnoea when both inspiration and expiration phases
become difficult.
Of the greatest value in separating out conditions likely to be
associated with breathlessness is noting its rate of onset. There are five
categories (Tab.1.1).
Dyspnoea may be of dramatic onset (over minutes), acute onset
(over hours), subacute onset (over weeks), or chronic onset (over month
or years), or it may be intermittent.
Cough is a defensive reflex designed to clear and protect the
lower respiratory tract. The cough reflex can be initiated by stimulation
of irritant receptors in the larynx, trachea, and major bronchi.
The clinical description of cough relies to its character, its timing,
and whether or not there is expectoration.
A cough may fail to produce expectoration; such type of cough is
called dry. The cough productive of sputum can be described as moist.
A dry cough with irritative barking quality, short and often
repeated, is heard in inflammatory conditions of pharynx,
tracheobronchitis, and early pneumonia. With laryngitis the sound is
2
 harsh and hoarse. The long inspiratory sound that gives whooping cough
its name is also produced by tracheal and laryngeal inflammation.

Table 1.1. Conditions causing dyspnoea classified by rate of onset

№ Categories Causes
1. Dramatically sudden: Pneumothorax
over minutes Pulmonary embolism
Pulmonary oedema
2. Acute: Pneumonia
over hours Acute pulmonary infiltrations, e.g.
allergic alveolitis
Asthma
Left ventricular failure
3. Subacute: Pleural effusion
over weeks Bronchogenic carcinoma
Subacute pulmonary infiltrations, e.g.
sarcoidosis
4. Chronic: Chronic airflow obstruction
over month or years Diffuse fibrosing conditions
Chronic non-pulmonary causes, e.g.
anaemia, hyperthyroidism
5. Intermittent: Asthma
Episodic breathlessness Left ventricular failure

Cough with expectoration on rising in the morning is

characteristic of chronic bronchitis (‘morning cough’), although it may
also be reported in asthmatics. Patients with pneumonia and acute
bronchitis may complain of cough attacks during the entire day, but
attacks may intensify by night (‘evening cough’). ‘Night cough’ is
characteristic of tuberculosis, lymphogranulomatosis, or tumor.
Cough may be periodic or permanent. Periodic cough occurs
more frequently. Such cough is characteristic of influenza, pneumonia,
pulmonary tuberculosis, and chronic bronchitis. Permanent cough occurs
in laryngitis, acute bronchitis, bronchogenic tumor of the lungs, and in
certain forms of tuberculosis.
If the patient complains of cough with sputum you should try to
determine:
o the amount of sputum during one fit and during entire day;
o the time of day when sputum is expectorated;

3
o posture of the patient at which cough is provoked;
o properties of the sputum (the color, odour, etc.).
In the patients with chronic bronchitis, bronchiectasis, lung
abscess, and cavernous tuberculosis of the lungs, the sputum
accumulates during the night sleep in the lungs and bronchi. When the
patient gets up in the morning, the sputum moves to stimulate the reflex
zones of the bronchial mucosa and cause cough and expectoration of
sputum. The amount of the morning sputum is two thirds of the entire
daily expectoration. The daily amount of sputum may vary from 10-15
ml to 2 liters. In unilateral bronchiectasis, sputum may be better
expectorated when the patient lies on the healthy side.
Haemoptysis defined as the expectoration of blood from the
respiratory tract.
In the assessment of the haemoptysis it is important to establish
first that the blood-stained material has come from the chest and not
from the gastrointestinal tract. Haemoptysis is produced with a “cough”
not a “retch”. Gastric contents should be acid, bronchial contents should
be alkaline.
The most common site of bleeding is the airways, i.e.,
tracheobronchial tree, which can be affected by inflammation (acute or
chronic bronchitis, bronchiectasis) or by neoplasm (bronchogenic
carcinoma, or bronchial carcinoid tumor). Blood originated from the
pulmonary parenchyma can be either from a localized source, such as an
infection (pneumonia, lung abscess, tuberculosis), or from a process
diffusely affecting the parenchyma. Disorders primarily affecting the
pulmonary vasculature include pulmonary embolic disease and those
conditions associated with elevated pulmonary venous and capillaries
pressure, such as mitral stenosis or left ventricular failure.
In tuberculosis frank blood in otherwise mucoid sputum is well
recognized. Heamoptysis following the acute onset of pleuritic chest
pain and dyspnoea is suggesting the pulmonary embolism. In bronchial
neoplasia there may be streaking of the sputum with blood or more
substantial bleeding with clots, often observed daily.
In general context, it may necessary to consider thoracic trauma,
endometriosis, or a blood coagulation disorder as cause of haemoptysis.
Chest pain. The greater part of the lower respiratory tract is
insensitive to pain. However, the parietal pleura, is exquisitely sensitive
to painful stimuli and unpleasant sensations can arise from the
tracheobronchial tree.
Typical pleural pain has a sharp stabbing and knife-like character
in pleurisy and is accentuated by respiratory movement. Hence it is
4
aggravated by respiration and coughing thus leading to rapid shallow
breathing and a suppressed cough. If pleurisy progresses to pleural
effusion, the sharp pain largely disappears and is replaced by a dull and
more constant ache or heaviness, quantitatively roughly proportional to
the amount of fluid.
Most conditions giving rise to pleuritic pain are acute and
inflammatory origin: either infective when there is usually associated
pneumonia (pleurisy is particularly common in pneumococcal
pneumonia) or infarctive as pulmonary embolism.
Pain due to strain or tearing of thoracic muscles can quite sharp,
and since it may be caused by coughing and may cause shallow
respiration, it can easily be confused with pleurisy. However, there is
always local tenderness over affected muscle and none of the ancillary
investigations for pleurisy prove positive. Patients with persistent cough
or distressing breathlessness, particularly due to asthma, may complain
of muscular pain around the lower rib cage.

INSPECTION OF THE CHEST

The patient should be better examined in standing or sitting
position with the chest being naked. Illumination of the body should be
uniform.
To describe an abnormality on the chest, you need to locate it in
two dimensions: along vertical axis and around the circumference of the
chest.

5
 To
locate vertically, you must be able to number the ribs and interspaces
accurately (Fig.1.1).

Fig. 1.1. Anatomy of the chest wall. Anterior view.

Note that an interspace between two ribs is numbered by the rib
above it. As the 1st rib is covered by clavicle, the 1st interspace is below
it.

6
 When
estimating location posteriorly, remember that the inferior angle of the
scapula usually lies at the level of the 7th rib or interspace (Fig. 1.2.).

Fig. 1.2. Anatomy of the chest wall. Posterior view.

When a patient flexes the neck forward, the prominent process
is usually that of the 7th cervical.

7
 To locate findings
around the circumference of the chest, use a topographic vertical lines.
The median (or midsternal) and vertebral lines are precise; the others are
estimated. The midclavicular line drops vertically from the midpoint of
the clavicle. (Fig. 1.3).

Fig. 1.3. Topographic lines. Anterior view.

The anterior and posterior axillary lines drop vertically from the
anterior and posterior axillary folds (the muscles that border the axilla).
The midaxillary line drops from the apex of axilla (Fig. 1.4).

8
Fig. 1.4. Topographic lines. Right anterior oblique view.

9
 Posteriorly, the
vertebral line follows the spinal processes of the vertebra. Paraspinal
lines drop along vertebra; each scapular line drops from the inferior
angle of the scapular (Fig. 1.5).

Fig. 1.5. Topographic lines. Posterior view.

The lungs lobes and fissures can be outlined mentally on the
chest wall. Anteriorly, the apex of the each lung rises about 2 cm to 4 cm
above the inner third of the clavicle (Fig. 1.8). The lower border of the
10
lung passes the 6th rib at the midclavicular line and 8 th rib at the
midaxillary line.
Posteriorly, the lower border of the lung lies at about the level
of the 11th thoracic spinous process at the paraspinal line. On inspiration
it descends (Fig.1.6).

Fig. 1.6. Projection of the lungs on the chest wall. Anterior view.

You should usually locate your pulmonary findings in external

terms, such as these:
11
  Supraclavicular region – above clavicles;
 Infraclavicular region – below clavicle;
 Suprascapular region – above scapulae;
 Interscapular region – between the scapulae;
 Infrascapular region – below scapular;
 Bases of the lungs – the lowerst points;
 Upper, middle, and lower lungs fields.

While examining the chest, note the shape of the chest, its
symmetry (static inspection), type of respiration, participation of the
chest wall in breathing act, respiration rate, depth and rhythm (dynamic
inspection).
Static inspection
The shape of the chest. To estimate form of the chest, pay
attention to:
1. Pronunciation of supraclavicular fosses;
2. Pronunciation of infraclavicular fosses;
3. Pronunciation of intercostal fosses;
4. Direction and width of intercostal spaces and ribs;
5. Epigastrical angle;
6. Anterior-posterior and lateral sizes;
7. Position of scapulas.
Normal and pathological shapes of the chest are distinguished. As
three types of the constitution are existed, the chest has different shape
according to these constitutional types. There are three normal shapes of
the chest: normosthenic chest, hypersthenic chest, and asthenic chest.
Normosthenic chest: the shoulders are under the right angle to
the neck, supra- and infraclavicular fossae feebly expressed, the ribs are
moderately inclined, the interspaces are visible, but moderate expressed,
epigastric angle is near 90˚, the lateral diameter is larger than
anteroposterior, shoulder blades closely fits to the chest and are on the
same level. The thorax is about the same height as abdominal part of the
trunk.
Hypersthenic chest: the shoulders are wide and the neck is short,
supra- and infraclavicular fossae are absent (level with the chest),
direction of the ribs are nearly horizontal, the interspaces are narrow and
slightly expressed, epigastric angle exceeds 90˚, the lateral diameter is
about the same as anteroposterior, the chest has form of a cylinder, the
shoulder blades closely fit to the chest. The thorax is smaller than
abdominal part of the trunk.
12
 Asthenic chest: the shoulders are sloping and are under the dull
angle to the neck, clavicles are well visible, supra- and infraclavicular
fossae are distinctly pronounced, the ribs direct downward abruptly,
more vertical at sides, the interspaces are wide and pronounced,
epigastric angle is less than 90˚, both lateral and anteroposterior
diameter are smaller than normal, the chest narrow and elongated, the
shoulder blades are separate from the chest (scapula alatae) and their
angles are well visible. The muscles of the shoulder girdle are
underdeveloped. The thorax is longer than abdominal part of the trun.
Pathological shapes of the chest can be caused either by chronic
diseases of the lungs and pleura (emphysematous, paralytic chest), or by
pathology of the thorax costal skeleton (rachitic, funnel, and foveated
chest), or by various deformities of the spine (scoliosis, kyphosis,
lordosis, kyphoscoliosis). Pathological shapes of the chest caused by
chronic pulmonary diseases.
Emphysematous or barrel chest resembles hypersthenic in its
shape. Supra- and infraclavicular fossae are absent or even protruded,
the ribs are horizontal, the interspaces are enlarged, epigastric angle is
more than 90˚, the chest wall is prominent, chest has an increased
anteroposterior diameter and that is why chest has a barrel-like
configuration.
Emphysematous chest observes in emphysema of the lungs. The
lungs seem to be as if at the inspiration phase due to decreased elasticity
of the lungs. The volume of the lungs increases, the natural expiration
become difficult (expiratory dyspnoea). Accessory respiratory muscles
active participate in the breathing act, especially m.
sternocleidomastoideus and m. trapezius. Elevation and lowering of the
entire chest during breathing become evident. A barrel shape is normal
during infancy, and often accompanies normal aging.
Paralytic chest. The same signs that peculiar to the asthenic
chest but more pronounced characterize paralytic chest. The shoulders
are sloping, clavicles are asymmetrical and pronounced, supra- and
infraclavicular fossea depresses, the ribs are vertical, the interspaces are
wide and depressed, marked atrophy of the chest muscles, epigastric
angle is less than 90˚, the shoulder blades are not on the same level, and
their movement during breathing are asynchronous.
Paralytic chest is found in emaciated patients, in general asthenia,
constitutional underdevelopment and in the patients with long-standing
pulmonary pleural diseases, such as pulmonary tuberculosis and
pneumosclerosis. Growing of the connective tissue contracts the lungs
and diminished their size due to progressive chronic inflammation.
13
o Pathological shapes of the chest caused by pathology of the thorax
costal skeleton.
Rachitic or pigeon chest (Pectus Carinatum) is a result of
abnormal skeleton formation in childhood in the patients with rachitis.
In a pigeon chest, the sternum is displaced anteriorly, increasing
anteroposterior diameter, resembling the keel of the boat. The ribs meet
at an acute angle at the sternum, the costal cartilages thicken like beads
at points of their transition to bones (rachitic beads).
Funnel chest (Pectus Excavatum) is characterized by a
depression in the lower portion of the sternum near the xiphoid process.
This deformity can be the result of abnormal development of the
sternum or prolonged compressing effect. But exact cause is now
unknown. In older times such shape of the chest was found in
shoemaker adolescents, and was explained by permanent pressure of the
chest against the shoe. Therefore, the funnel chest is also called ‘cobbler
chest’. Compression of the heart and great vessels may cause murmurs.
Foveated chest is characterized by vertical depression on the
upper and middle parts of the anterior surface of the chest. This
deformity arises in syringomyelia, a rare disease of the spinal cord.
o Pathological shapes of the chest caused by various deformities of
the spin as a result of injuries, tuberculosis of the spine, rheumatoid
arthritis, etc.
Four types of spine deformities are distinguished:
Scoliosis – lateral curvature of the spine, is most common. It
develops in schoolchildren due to bad habitual posture.
Kyphosis – backward curvature of the spine with formation of
the gibbus, occurs less frequently.
Lordosis – forward curvature of the spine, generally in the
lumber region, occurs in rare cases.
Kyphoscoliosis – combination of the lateral and backward
curvature of the spine.
Kyphosis, lordosis, and kyphoscoliosis change physiological
position of thoracic organs and thus interfere with their normal function.
The symmetry of the chest. The right and left sides of the
normal chest are symmetrical, the clavicles and shoulder blades are on
the same level, the supra- and infraclavicular fossae, and interspaces
equally pronounced on both sides. One-sided enlargement or
diminutions of the chest (asymmetry) due to the pulmonary and pleural
diseases are of great diagnostic value. These changes can transient or
permanent.

14
 Enlarged volume of one half of the chest observes in
accumulation of considerable amount of fluid (exudates, transudate,
blood, pus) in the pleural cavity, or in penetration of air inside the chest
in injuries (pneumothorax).

During examination of the enlarged part of the chest you can see
asymmetry of the clavicles; leveling or protrusion of the interspaces, and
they more wide; the distance between nipple and median line, and from
inside edge of scapula to the spine on affected side is larger than on
healthy one. Enlarged part of the chest lags in the breathing act. The
patient slightly bends to the affected side of the chest. The chest assumes
normal symmetrical shape after the fluid or air is removed from the
pleural cavity.
Decreased volume of the one part of the chest observes in:
 contraction of a considerable portion of the lung due to the growth
of connective tissue – pneumosclerosis, after acute or chronic
inflammatory processes, such as acute pneumonia (with subsequent
carnification of the lung), lung infarction, pulmonary abscess,
tuberculosis;
 pleural adhesion or contraction of the pleural membranes after
resorption of fluid;
 obstructive athelectasis;
 resection of a part or the entire lung.
During examination of the decreased part of the chest you can
see that the shoulder and clavicle lowers, supra- and infraclavicular
fossae are more depressed, the interspaces are decreased in size or
invisible, the nipple is nearer to the sternum as compared with healthy
side, and the scapula lowers. The respiratory movement of clavicle and
scapula become slower and limited on affected side.
Dynamic inspection
In dynamic inspection of the chest the pattern of breathing (type
of respiration, participation of the chest wall in breathing act, respiration
rate, depth and rhythm) must be observed.
Breathing in and out (inspiration and expiration, together called
respiration or external respiration) is essential for taking O2 and getting
rid of CO2. Respiration is largely an automatic act, controlled in the
brain system and mediated by the muscles of respiration. The main
respiratory muscles - diaphragm, intercostals muscles, and partly the
abdominal wall muscles are normally used for this propose. The
accessory muscles – mm. sternocleidomastoideus, trapezius, pectoralis

15
major et minor, etc., join the respiratory effort in pathological
conditions, associated with difficult breathing.
Respiration type. Respiration can be thoracic, abdominal or
mixed type.
Thoracic (costal) respiration. Mainly the intercostals muscles
carry out respiratory movements. In inspiration the intercostals muscles
contract and elevate the ribs, these movements increase the internal
capacity of the lungs. As the thoracic wall expands, the lungs also
expand and draw in air. In expiration, the thoracic capacity decreases as
the inspiratory muscles relax – the lungs then shrink by their own
elasticity. This type of breathing is known as costal and is mostly
characteristic of women (Fig. 2.9).
Abdominal respiration. The diaphragm is the primary muscle in
this type of respiration. In inspiration the diaphragm contracts, descends
in the chest and enlarges the thoracic cavity. The thoracic enlargement
decreases intrathoracic pressure, draws air through the tracheobronchial
tree into the alveoli, and expands the lungs. At the same time it
compresses the abdominal contents, pushing the abdominal wall
outward. In expiration the chest wall and lungs recoil, the diaphragm
rises passively, air flows outward, and the chest and abdomen return to
their initial position (Fig. 2.9). This type of breathing is also called
diaphragmatic and is mostly characteristic of men.
Mixed respiration. The diaphragm and the intercostals muscles
simultaneously carry out respiratory movements. This type of respiration
observes in the aged persons and some pulmonary and digestive
diseases.
In women mixed respiration occurs in dry pleurisy, pleural
adhesion, myosytis, thoracic radiculitis, and lung emphysema.
In men mixed respiration occurs in persons with underdeveloped
diaphragmatic muscle, diaphragmatitis, acute cholecystitis, perforating
ulcer.
Participation of the chest wall in breathing act. In observing
respiratory movement, particular attention must be paid to expansion.
Poor movement of the chest on one side only always indicates pathology
on that side. One part of the chest lags in the breathing act in
inflammatory infiltration of extensive part of the lung, dry pleurisy,
hydrothorax, pneumothorax, ribs fractures, intercostals neuralgia, and
myositis. In paralysis or paresis respiratory excursion on the
corresponding part is limited.

16
 Respiration rate. In order to determine respiratory rate count the
movement of the chest or abdominal wall, with patient being unaware of
the procedure.
The repeated cycles of inspiration followed by expiration
(respiratory cycle) occur in adults at rest about 16-20 times per minute
(the respiratory rate), with inspiration lasting approximately 2 seconds
and expiration 3 seconds (Fig. 1.7).

Fig 1.7. Normal breathing.

The respiration rate in newborn is 40-45 per minute, this rate
gradually decreasing with age. During night sleep respiratory rate
decreases to 12-14 per minute, and increases in physical and emotional
exertion, and after heavy meals.
Pathological rapid breathing above 20 per minute is called
tachypnea (Fig.1.8).

Fig. 1.8. Tachypnea – rapid shallow breathing.

Tachypnea has a number of causes:

 conditions associated with decreased respiratory
surface of the lungs: inflammation, tuberculosis, compressive atelectasis
(hydrothorax, pneumothorax, mediastinal tumor), obstructive atelectesis,
pulmonary emphysema, and pulmonary edema;
 narrowing of the small bronchi due to spasm or diffuse
inflammation of their mucosa (bronchiolitis), which interfere normal air
passage into alveoli;
 shallow respiration as a result of difficult contractions
of the respiratory muscles in acute pain (dry pleurisy, acute myositis,

17
intercostals neuralgia, rib fracture) and in elevated abdominal pressure
and hight diaphragm level (ascitis, meteorism, late pregnancy).

Pathological slow breathing below 16 per minute is called

bradypnea (Fig. 1.9).

Fig. 1.9. Bradypnea – slow breathing.

Bradypnea may be secondary to such causes as increased
intracranial pressure (cerebral tumor, hemorrhage, meningitis, brain
edema) due to inhibition of the respiratory center, and also due to the
toxic effect on respiratory center in uraemia, diabetic or hepatic coma,
and drug-induced respiratory depression.
Respiration depth. The volume of the inhaled and exhaled air at
rest in adults varies from 300 to 900 ml (500 ml on the average).
Depending on depth, breathing can be shallow or deep.
Shallow respiration is characterized by short inspiratory and
expiratory phases. Shallow breathing is usually rapid (Fig. 2.11). In
some cases, however, shallow respiration can be slow due to inhibition
of the respiratory center, pronounced pulmonary emphysema, and sharp
narrowing of the vocal slit or trachea.
Deep respiration is characterized by elongation of the inspiratory
and expiratory phases. As a rule, deep respiration is slow (Fig. 2. 12).
Rapid deep breathing has several causes, including exercise, anxiety,
fever, anemia, and metabolic acidosis. Deep rapid breathing, with
marked respiratory movements, accompanied by noisy sound is called
Kussmaul respiration (Fig. 1.10). This type of breathing observes in the
comatose patients due to metabolic acidosis.

Fig. 1.10. Kussmaul respiration – deep rapid breathing

(Hyperpnea, Hyperventilation).
Respiration rhythm. A normal rhythm of breathing is controlled
by groups of nerve cells in the brainstem, called the respiratory center.

18
These nerve cells send impulses down the spinal cord to act on the
spinal nerve fibers that supply the diaphragm and intercostals muscles.
Respiration of a healthy person is rhythmic, and characterized by
uniform depth, and approximately equal duration of inspiratory and
expiratory phases (Fig. 2.10). In depression of the respiratory center
breathing becomes arrhythmic. Periods of breathing alternate with
readily detectable elongation of respiratory pause from few seconds to a
minute or with apnea (temporary arrest of breathing) and also respiration
may be of different depth. Such type of respiration is called periodic and
includes Cheyne-Stokes respiration, Grocco’s respiration, and Biot’s
respiration.
Cheyne-Stokes respiration (Fig. 1.11). Noiseless shallow
respiration quickly deepens, becomes noisy to attain its maximum at the
5-7 inspirations and slows down gradually. Such periods alternate with
periods of apnea (from few second to a minute), during which patient
can loses orientation in surroundings or even faints to recover from
unconsciousness after respiration restores.

Fig. 1.11. Cheyne-Stokes respiration.

Children and aged people normally may show Cheyne-Stokes

respiration in sleep. Other causes include heart failure, uremia, drug-
induced respiratory depression, and brain damage (acute or chronic
failure of the cerebral circulation, cerebral hypoxia, meningitis).
Grocco’s respiration resembles Cheyne-Stokes respiration
except that shallow respiration occurs instead of apnea (Fig. 1.12).

19
 Fig. 1.12. Crocco’s respiration.
Crocco’s respiration caused probably by early stages of the same
conditions as Cheyne-Stokes respiration.
Biot’s respiration (Fig. 1.13). In this type of breathing deep
rhythmic respiration alternate with apnea (from few seconds to half
minute). Causes include respiratory depression and brain damage
(meningitis, agony with disorders of cerebral cerculation).

Fig. 1.13. Biot’s respiration.

PALPATION OF THE CHEST

Palpation of the chest has four potential uses:
1. identification of the epigastric angle;
2. identification of the tender areas;
3. assessment of elasticity of the chest;
4. assessment of tactile fremitus.

Assessment of elasticity of the chest. Fig. 1.14 Assess elasticity

by pressing the chest in anteroposterior and lateral directions. Place your
hands parallel: right on the middle of the sternum, left – on the spine and
press the chest. Then by both hands press the chest in lateral direction.
The chest of a healthy person is elastic, and yields under the
pressure. Rigidity of the chest indicates presence of fluid inn the pleural
cavity or pleural tumor, and pulmonary emphysema. In aged persons the
chest become rigid due to ossification of the costal cartilages.

20
Fig. 1.14. Assessment of chest elasticity. A- anterior; b-posterior view.
Identification of epigastric angle. In order to determine
epigastric angle place your thumbs along the costal arch, their tips
resting against xiphoid process. Your hands should be along the lateral
rib cage (Fig. 1.15).

Fig. 1. 15. Estimation of epigastric angle

Identification of tender areas. Carefully palpate from the 1st
interspaces on the anterior chest (5 steps), then along midaxillary lines
(3 steps), and along the spine on the posterior chest (10 steps).
In rib fracture pain is localized over a limited area, careful
displacement of bone fractures attends by a specific sound (crunch).
Intercostals tenderness commonly has musculoskeletal origin. Such pain
is called superficial, it intensifies during deep breathing, and when the
patient bends or lies on the affected side.
Assessment of tactile fremitus (vocal fremitus pectoralis).
Fremitus refers to the palpable vibrations transmitted through the
bronchopulmonary tree to the chest wall when the patient speaks. Ask
the patient to repeat the words “ninety-nine” or “one-one-one”. If
fremitus is faint, ask the patient to speak more loudly or in a deeper
voice.
Palpate and compare symmetrical areas of the chest, using the
palms of your both hands simultaneously.
21
 Firstly, place your
hands on the patient’s shoulder over the lungs apices projection, then in
the infrascapular regions, and axillary regions, using the vibratory
sensitivity of your hands to detect fremitus (Fig 1.16).

Fig. 1.16. Assessment of tactile fremitus. Anterior view.

22
 Posteriorly, you should assess vocal fremitus in the supra-, inter-,
and infrascapular regions (Fig. 1.17).

Fig. 1.17. Assessment of vocal fremitus. Posterior view.

Identify and locate any areas of increased, decreased or absent

fremitus.
Vocal fremitus is typically more prominent in men than inn
women and children; in the upper lung fields than in the lower one; and

23
more prominent on the right side (voice transmission is better through
the shorter right main bronchus) than on the left.
Vocal fremitus is increased in consolidation of the pulmonary
tissue (lobar pneumonia, lungs infarction, pulmonary tumor,
tuberculosis, compressive atelectasis), and also in the presence of an air
cavity communicated with bronchus.
Vocal fremitus is decreased when the voice is soft in emaciated
patients or when the conduction of vibrations from the larynx to the
surface of the chest is impeded. Causes include separation of the lung by
moderate amount of fluid (pleural effusion) or air (pneumothorax), by
fibrosis (pleural thickening); obstructive atelectasis; and also a very
thick chest wall (edema, subcutaneous fat).
Vocal fremitus can be absent when significant amount of fluid
or air are accumulated in the pleural cavity.

Tests

1. Paralitic chest shape is observed 3. Barrel-shaped chest is typical

in: for:
A. Acute bronchitis A. pulmonary tuberculosis
B. Pneumonia B. emphysema of the lungs
C. Bronchopneumo C. exudation pleurisy
nia D. pneumothorax
D. Lungs tumor E. acute bronchitis
E. Exudation
pleurisy 4. Enlargement of one part of the
chest is observed in:
2. A Boat-shaped chest is observed A. hydrothorax
in: B. pneumosclerosis
A. rachitis C. obstructive atelectasis of
B. scoliosis the lung
C. syringomyelia D. bronchopneumonia
D. tuberculosis E. bronchitis
E. bronchitis
5. Diminished one part of the chest
is observed in:

24
 A. Exudation pleurisy A. hydrothorax
B. pneumothorax B. exudation pleurisy
C. bronchopneumonia C. pulmonary emphysema
D. pneumosclerosis D. pneumothorax
E. pulmonary emphysema E. Acute pneumothorax

6. Kussmaul respiration is 11. The patient has an attack of

observed in: dyspnea. His position is forced; he
A. diabetic coma is sitting resting his hands on the
B. stroke edge of the bed. The voice
C. heart failure resonance over the lungs is weak.
D. lung failure What diagnosis can be supposed?
E. pulmonary tuberculosis A. Pulmonary emphysema
B. Bronchial asthma
7. Lateral curvature of the spine is C. Kussmaul respiration
observed in: D. atelectasis
A. lordosis E. Cheyne-Stokes
B. scoliosis respiration
C. kyphosis
D. rachitis 12. The examination has revealed
E. kyphoscoliosis delay in the act of respiration of
the right part of the thorax. What
8. Cheyne-Stocks respiration is diagnosis can be supposed?
typical for: A. pneumothorax
A. acute insufficiency of the B. hydrothorax
brain circulation C. pulmonary emphysema
B. pulmonary emphysema D. obturation atelectasis
C. pneumothorax E. pneumonia
D. bronchial asthma
E. hydrothorax 13. The right part of the thorax is
protruding, delays in the act of
9. Increased voice resonance is respiration, the voice resonance is
observed in: not observed. The respiration is
A. hydrothorax superficial. The respiratory rate is
B. compression atelectasis 32 per min. What diagnosis can be
C. pulmonary emphysema supposed?
D. pneumothorax A. Pneumonia
E. pneumothorax B. Hydrothorax,
pneumothorax
10. Decreased voice resonance is C. Pulmonary emphysema
observed in D. atelectasis
25
 E. bronchial asthma 17. Respiratory movements are
interrupted with pauses lasting up
14. The chest is asymmetrical, its to 30 seconds. What diagnosis can
right half protrudes. The voice be supposed?
resonance downward the middle of A. Biots respiration
the scapula is weak. What B. Cheyne-Stocks
diagnosis can be supposed? respiration
A. Hydrothorax, C. Bronchial asthma
pneumothorax D. pneumothorax
B. Pulmonary emphysema E. Kussmaul respiration
C. atelectasis
D. pneumonia 18. The left part of the thorax
E. cavity in the lung delays in the act of respiration, the
voice resonance is increased along
15. The chest is ball-shaped. The the paravertebral, scapular,
ratio of anterior-posterior size to posterior-, mid-, and anterior
transverse size is 8.0. The area of axillary lines downwards the fifth
the costal cartilages is thickened. interspace. What diagnosis can be
What diagnosis can be supposed? supposed?
A. Asthenic chest A. atelectasis
B. Rachitic chest B. hydrothorax
C. Hypersthenic chest C. pneumothorax
D. Emphysema chest D. Cavity in the lung
E. Paralytic chest
19. The patient has dyspnea and
16. The right part of the thorax cyanosis. The right half of the
protrudes, delays in the act of chest protrudes, delays in the act of
respiration, the voice resonance is respiration. The voice resonance is
not heard. The respiration is decreased downward the middle of
superficial, 32 per min. What the scapula. What diagnosis can be
diagnosis can be supposed? supposed?
A. Hydrothorax, A. Hydrothorax,
pneumothorax pneumothorax
B. Pulmonary emphysema B. Cavity in the lung
C. Pneumonia C. Pulmonary emphysema
D. Atelectasis D. Atelectasis
E. Cavity in the lung E. Pneumonia

Tests: 1D, 2A, 3B, 4A, 5D, 6A, 7B, 8A, 9B, 10E, 11B, 12D, 13B, 14A,
15B, 16A, 17A, 18B, 19A.
26
27
 Methodical instructions

MAIN COMPLAINTS OF PATIENTS WITH

RESPIRATORY ORGANS DISEASES. STATIC AND DYNAMIC
INSPECTION OF THE CHEST. PALPATION OF THE CHEST

Methodical instructions for students

Authors: Т.V. Ashcheulova

O. M. Kovalyova
G.V. Demydenko

Chief Editor Ashcheulova Т.V.

Редактор____________
Корректор____________
Компьютерная верстка_____________

Пр. Ленина, г. Харьков, 4, ХНМУ, 61022

Редакционно-издательский отдел

28
29
15