Percussion. Normal location of the lower borders of the lungs in normosthenics
Top right lung in front it protrudes above the collarbone by 2 cm, and above the 1st rib by 3-4 cm (Fig. 346). Behind apex of the lung projected at the level of the spinous process VII cervical vertebra. From the apex of the right lung, its anterior border goes down to the right sternoclavicular joint, then descends behind the body of the sternum, to the left of the anterior midline, to the cartilage of the 6th rib, where it passes into the lower border of the lung.
The lower border of the lung crosses the 6th rib along the midclavicular line, the 7th rib along the anterior axillary line, the 8th rib along the midaxillary line, the 9th rib along the posterior axillary line, and the 10th rib along the scapular line. , along the paravertebral line ends at the level of the neck of the 11th rib. Here the lower border of the lung sharply turns upward and passes into its posterior border, going to the apex of the lung.
The apex of the left lung is also located 2 cm above the clavicle and 3-4 cm above the first rib. The anterior border goes to the sternoclavicular joint, behind the body
Rice. 346. Boundaries of the pleura and lungs. Front view.
1 - anterior midline, 2 - dome of the pleura, 3 - apex of the lung, 4 - sternoclavicular joint, 5 - first rib, 6 - anterior border of the left pleura, 7 - anterior edge of the left lung, 8 - costomediastinal sinus, 9 - cardiac notch, 10 - xiphoid process,
11 - oblique fissure of the left lung, 12 - lower edge of the left lung, 13 - lower border of the pleura, 14 - diaphragmatic pleura, 15 - posterior edge of the pleura, 16 - body XII thoracic vertebra, 17 - lower border of the right lung, 18 - costophrenic sinus, 19 - lower lobe of the lung, 20 - lower edge of the right lung, 21 - oblique fissure of the right lung, 22 - middle lobe of the right lung, 23 - horizontal fissure of the right lung, 24 - anterior edge of the right lung, 25 - anterior edge of the right pleura, 26 - upper lobe right lung, 27 - collarbone.
The sternum descends to the level of the cartilage of the 4th rib. Next, the anterior border of the left lung deviates to the left, runs along the lower edge of the cartilage of the 4th rib to the parasternal line, where it sharply turns down, crosses the fourth intercostal space and the cartilage of the 5th rib. At the level of the cartilage of the 6th rib, the anterior border of the left lung abruptly passes into its lower border.
The lower border of the left lung is located approximately half a rib lower than the lower border of the right lung (approximately half a rib). Along the paravertebral line, the lower border of the left lung passes into its posterior border, running to the left along the spine.
Innervation of the lungs: branches vagus nerves and nerves sympathetic trunk, which are in the area lung root form the pulmonary plexus.
Blood supply lungs has features. Arterial blood It enters the lungs through the bronchial branches of the thoracic aorta. Blood from the walls of the bronchi flows through the bronchial veins into the tributaries of the pulmonary veins. The left and right pulmonary arteries supply the lungs with venous blood, which as a result of gas exchange is enriched with oxygen, releases carbon dioxide and becomes arterial. Arterial blood from the lungs flows through the pulmonary veins into the left atrium.
Lymphatic vessels the lungs drain into the bronchopulmonary, lower and upper tracheobronchial lymph nodes.
Pleura and pleural cavity
Percussion of the lungs is performed. This method consists of tapping certain areas of the body. With such tapping, certain sounds, according to the features of which the size and boundaries of organs are determined and existing pathologies are identified.
The volume and pitch of sounds depends on the density of the tissues.
Despite the development of many new diagnostic methods, lung percussion is still widely used in practice. For an experienced specialist it is often possible to deliver accurate diagnosis without application technological means, thanks to which treatment can begin much earlier. However, with percussion, doubts may arise about the intended diagnosis, and then other diagnostic tools are used.
Percussion chest may be different. For example:
- Direct (direct). It is carried out using fingers directly on the patient’s body.
- Indirect. Performed using a hammer. In this case, blows must be struck on a plate attached to the body, which is called a plessimeter.
- Finger-finger. With this method of performing lung percussion, the finger of one hand acts as a plessimeter, and the blows are made with the finger of the other hand.
The choice of technique depends on the preferences of the doctor and the characteristics of the patient.
Execution Features
During percussion, the doctor must analyze the sounds heard. It is from them that one can determine the boundaries of the respiratory organs and establish the properties of internal tissues.
The following types of sounds detected during percussion are distinguished:
- Dull sound. It can occur when a hardened area is detected in the lungs.
- Boxed sound. This type of sound appears when there is excessive airiness in the organ being examined. The name comes from the resemblance to the sound of an empty cardboard box when struck lightly.
- Tympanic sound. It is typical for tapping areas of the lungs with smooth-walled cavities.
Based on the characteristics of sounds, the basic properties of internal tissues are revealed, thereby determining pathologies (if any). In addition, during such an examination, the boundaries of the organs are established. If deviations are detected, a diagnosis specific to the patient can be assumed.
The finger-to-finger technique is most often used for percussion.
It is performed according to the following rules:
To this method diagnosis turned out to be as effective as possible, the doctor must follow the technique of execution. This is impossible without special knowledge. In addition, experience is necessary, since without it it will be very difficult to draw the right conclusions.
Features of comparative and topographic percussion
One of the varieties of this diagnostic procedure is comparative percussion of the lungs. It is aimed at determining the nature of the sounds that arise when tapping in the area above the lungs. It is carried out in symmetrical areas, and the blows must have the same force. During its implementation, the order of actions and correct position fingers.
Such percussion can be deep (if the presence of pathological areas deep inside is assumed), superficial (when pathological areas are close) and ordinary. Tapping is carried out on the front, back and side surfaces of the chest.
Topographic percussion lungs is designed to determine the upper and lower limits organ. The results obtained are compared with the norm (a special table has been developed for this). Based on the existing deviations, the doctor may suggest one or another diagnosis.
This type of percussion of the respiratory organs is performed only in a superficial way. Boundaries are determined by the tonality of sounds. The doctor must strictly follow the technique of performing the procedure and be careful not to miss important details examinations.
Normal indicators
This method of examining the respiratory organs allows you to detect pathological phenomena without the use of more complex diagnostic procedures. Most often, X-rays or MRI are used to identify similar features, but their use is not always advisable (due to exposure to UV rays or high cost). Thanks to percussion, the doctor can detect displacement or deformation of organs during examination.
Most of the conclusions are based on what the boundaries of the patient's lungs are. There is a certain standard that experts are guided by. It should be said that the normal indicator of lung boundaries in children and adults is almost the same. An exception may be the child’s indicators preschool age, but only in relation to the apexes of the organ. Therefore, in preschool children this limit is not determined.
Measurements of the upper border of the lungs are performed both in front of the chest and behind it. There are landmarks on both sides that doctors rely on. The landmark on the front of the body is the collarbone. IN in good condition the upper border of the lungs lies 3-4 cm above the collarbone.
Definition upper limits lungs
From the back, this border is determined by the seventh cervical vertebra (it differs slightly from the others by a small spinous process). The apex of the lungs is approximately at the same level as this vertebra. This border is found by tapping from the collarbone or from the shoulder blade upward until a dull sound appears.
To identify the lower border of the lungs, you need to take into account the location of the topographic lines of the chest. Tapping is performed along these lines from top to bottom. For each of these lines you will receive different result, since the lungs are cone-shaped.
In the normal condition of the patient, this border will lie in the area from the 5th intercostal space (when moving along the parasternal topographic line) to the 11th thoracic vertebra (along the paravertebral line). There will be discrepancies between the lower borders of the right and left lung due to the heart located next to one of them.
It is also important to take into account that the location of the lower boundaries is influenced by the physique of the patients. With a thin build, the lungs have a more elongated shape, due to which the lower limit is slightly lower. If the patient has a hypersthenic physique, then this limit may be slightly higher than normal.
Another important indicator that you need to pay attention to during such an examination is the mobility of the lower borders. Their position may change depending on the phase of the respiratory process.
When you inhale, the lungs fill with air, which causes the lower edges to shift downward; when you exhale, they return to their normal state. The normal indicator of mobility relative to the midclavicular and scapular lines is 4-6 cm, relative to the average axillary line - 6-8 cm.
What do deviations mean?
The essence of this diagnostic procedure is to assume a disease based on deviations from the norm. Deviations are most often associated with a displacement of the boundaries of the organ up or down.
If the upper portions of the patient's lungs are displaced higher than they should be, this indicates that the lung tissues are excessively airy.
Most often this is observed with emphysema, when the alveoli lose their elasticity. Below normal level the apexes of the lungs are located if the patient develops diseases such as pneumonia, pulmonary tuberculosis etc.
When the lower border shifts, this is a sign of chest pathology or abdominal cavity. If the lower border is located below the normal level, this may indicate the development of emphysema or prolapse of internal organs.
If only one lung is displaced downward, the development of pneumothorax can be assumed. The location of these boundaries above the required level is observed in pneumosclerosis, bronchial obstruction, etc.
You also need to pay attention to the mobility of the lungs. Sometimes it may look different from normal, indicating a problem. You can detect such changes that are characteristic of both lungs or one - this also needs to be taken into account.
If the patient is characterized by a bilateral decrease in this value, we can assume the development of:
- emphysema;
- bronchial obstruction;
- formation of fibrous changes in tissues.
A similar change, characteristic of only one of the lungs, may indicate that fluid accumulates in the pleural sinus, or the formation of pleurodiaphragmatic adhesions.
The doctor must analyze all detected features in order to draw the right conclusions. If this fails, additional diagnostic methods to avoid mistakes.
Determining the boundaries of the lungs has great value for the diagnosis of many pathological conditions. The ability to percussion detect displacement of the chest organs in one direction or another allows already at the stage of examining the patient without the use of additional methods studies (in particular, x-ray) to suspect the presence of a certain disease.
How to measure the boundaries of the lungs?
Of course, you can use instrumental diagnostic methods to make x-ray and use it to evaluate how the lungs are located relative to the bone frame of the chest. However, this is best done without exposing the patient to radiation.
Determination of the boundaries of the lungs at the examination stage is carried out using the method of topographic percussion. What is it? Percussion is a study that is based on identifying the sounds that arise when tapping on the surface of the human body. The sound changes depending on the area in which the research takes place. Over parenchymal organs (liver) or muscles it turns out dull, over hollow organs(intestines) – tympanic, and above the filled ones air from the lungs acquires a special sound (pulmonary percussion sound).
In progress this study as follows. One hand is placed with the palm on the area of study, two or one fingers of the second hand hit the middle finger of the first (plesimeter), like a hammer on an anvil. As a result, you can hear one of the variants of percussion sound, which were already mentioned above. Percussion can be comparative (sound is assessed in symmetrical areas of the chest) and topographic. The latter is precisely intended to determine the boundaries of the lungs.
How to properly perform topographic percussion?
The plessimeter finger is installed at the point from which the study begins (for example, when determining the upper lung boundaries along the front surface it begins above middle part clavicle), and then moves to the point where approximately this measurement should end. The limit is determined in the area where the pulmonary percussion sound becomes dull.
For ease of research, the pessimeter finger should lie parallel to the desired boundary. The displacement step is approximately 1 cm. Topographic percussion, unlike comparative, is performed by gentle (quiet) tapping.
Upper limit
The position of the apexes of the lungs is assessed both anteriorly and posteriorly. On the anterior surface of the chest, the reference point is the clavicle, on the back - the seventh cervical vertebra (it has a long spinous process, by which it can be easily distinguished from other vertebrae). The upper boundaries of the lungs are normally located as follows:
Research should be performed as follows:
Displacement of the upper borders of the lungs
An upward shift of the boundaries occurs due to excessive airiness of the lung tissue. This condition is characteristic of emphysema, a disease in which the walls of the alveoli are overstretched, and in some cases, their destruction with the formation of cavities (bullas). Changes in the lungs with emphysema are irreversible, the alveoli are swollen, the ability to collapse is lost, elasticity is sharply reduced. The boundaries of a person's lungs (in this case, the limits of the apex) can shift downward. This is due to a decrease in the airiness of the lung tissue, a condition that is a sign of inflammation or its consequences (overgrowth of connective tissue and shrinkage of the lung). The boundaries of the lungs (upper), located below the normal level, – diagnostic sign pathologies such as tuberculosis, pneumonia, pneumosclerosis.
Lower limit
To measure it, you need to know the main topographic lines of the chest. The method is based on moving the researcher's hands with indicated lines from top to bottom until the percussion pulmonary sound changes to dull. You should also know that the anterior border of the left lung is not symmetrical to the right due to the presence of a pocket for the heart.
In front, the lower borders of the lungs are determined by a line running along the lateral surface of the sternum, as well as along a line going down from the middle of the clavicle. From the side, important landmarks are the three axillary lines - anterior, middle and posterior, which start from the anterior edge, center and posterior edge of the axilla, respectively. The posterior edge of the lungs is defined relative to a line that descends from the angle of the scapula and a line located on the side of the spine.
Displacement of the lower borders of the lungs
It should be noted that during breathing the volume of this organ changes. Therefore, the lower boundaries of the lungs normally shift 20-40 mm up and down. A persistent change in the position of the border indicates pathological process in the chest or abdomen.
The lungs become excessively enlarged with emphysema, which leads to a bilateral downward displacement of the boundaries. Other causes may be hypotension of the diaphragm and severe prolapse of the abdominal organs. The lower border moves down from one side in case of compensatory expansion healthy lung when the second is in a collapsed state as a result, for example, of total pneumothorax, hydrothorax, etc.
The borders of the lungs usually move upward due to wrinkling of the latter (pneumosclerosis), collapse of the lobe as a result of bronchial obstruction, accumulation in pleural cavity exudate (as a result of which the lung collapses and is pressed towards the root). Pathological conditions in the abdominal cavity can also shift the pulmonary boundaries upward: for example, accumulation of fluid (ascites) or air (with perforation of a hollow organ).
Normal lung boundaries: table
Lower limits in an adult
Field of study
Right lung
Left lung
Line at the lateral surface of the sternum
5th intercostal space
-
A line descending from the middle of the collarbone
6 rib
-
A line originating from the anterior edge of the axilla
7th rib
7th rib
A line extending from the center of the armpit
8 rib
8 rib
Line from the posterior edge of the armpit
9th rib
9th rib
Line descending from the angle of the scapula
10 rib
10 rib
Line on the side of the spine
11th thoracic vertebra
11th thoracic vertebra
The location of the upper pulmonary borders is described above.
Changes in indicator depending on body type
In asthenics, the lungs are elongated in the longitudinal direction, so they often fall slightly below the generally accepted norm, ending not at the ribs, but in the intercostal spaces. Hypersthenics, on the contrary, are characterized by a higher position of the lower border. Their lungs are wide and flattened in shape.
How are the pulmonary boundaries located in a child?
Strictly speaking, the boundaries of the lungs in children practically correspond to those of an adult. The tops of this organ in boys who have not yet reached preschool age are not defined. Later they appear in front 20-40 mm above the middle of the collarbone, in the back - at the level of the seventh cervical vertebra.
The location of the lower boundaries is discussed in the table below.
Boundaries of the lungs (table)
Field of study
Age up to 10 years
Age over 10 years
Line running from the middle of the collarbone
Right: 6th rib
Right: 6th rib
A line starting from the center of the armpit
Right: 7-8 rib Left: 9 rib
Right: 8th rib Left: 8th rib
Line descending from the angle of the scapula
Right: 9-10 rib Left: 10 rib
Right: 10th rib Left: 10th rib
Reasons for displacement of the pulmonary boundaries in children up or down relative to normal values the same as in adults.
How to determine the mobility of the lower edge of the organ?
It was already mentioned above that when breathing, the lower boundaries shift relative to normal indicators due to the expansion of the lungs on inhalation and decrease on exhalation. Normally, such a shift is possible within 20-40 mm up from the lower border and the same amount down. Determination of mobility is carried out by three main lines, starting from the middle of the collarbone, the center of the armpit and the angle of the scapula. Research is carried out as follows. First, determine the position of the lower border and make a mark on the skin (you can use a pen). The patient is then asked to take a deep breath and hold his breath, after which the lower limit is again found and a mark is made. And finally, determine the position of the lung at maximum exhalation. Now, based on the estimates, we can judge how the lung shifts along its lower border. In some diseases, lung mobility is noticeably reduced. For example, this occurs with adhesions or a large amount of exudate in the pleural cavities, loss of elasticity in the lungs during emphysema, etc.
Difficulties in performing topographic percussion
This research method is not easy and requires certain skills, and better yet, experience. Complications that arise from its use are usually associated with incorrect execution technique. Regarding anatomical features that can create problems for the researcher, mainly severe obesity. In general, it is easiest to perform percussion on asthenics. The sound is clear and loud.
What needs to be done to easily determine the boundaries of the lung?
And, of course, experience is very important. Practice gives you confidence in your abilities.
Let's sum it up
Percussion is a very important diagnostic method. It allows us to suspect many pathological conditions chest organs. Deviations of the borders of the lungs from normal values, impaired mobility of the lower edge are symptoms of some serious illnesses, timely diagnosis which is important for carrying out full treatment.
The location of the lower borders of the lungs is normal - section Mechanics, Methods of examining the respiratory organs Place of Percussion Right Lung Left...
Bilateral descent of the lower border of the lungs is observed during an attack bronchial asthma and pulmonary emphysema.
The upward displacement of the lower border of the lungs is often unilateral. And occurs when:
1) Wrinkling of the lung as a result of pneumosclerosis.
2) Atelectasis.
3) Accumulation of fluid or air in the pleural cavity, which pushes the lung upward.
4) With a sharp enlargement of the liver or spleen.
Bilateral elevation of the lower border of the lungs is possible with large cluster fluid (ascites) or air in the abdominal cavity.
Auscultation:
You can listen to the patient in any position, but it is better if he sits on a stool with his hands on his knees. When auscultating the lungs, first compare the breath sounds in different phases breathing (during inhalation and exhalation), their nature, duration, volume are assessed, and then these noises are compared with respiratory sounds at a similar point on the other half of the chest (comparative auscultation).
There are two main respiratory sounds: vesicular breathing and bronchial breathing. Basic breath sounds are better heard when breathing through the nose.
Vesicular breathing - heard above the lung tissue, it occurs as a result of vibration of the walls of the alveoli at the moment they are filled with air during the inhalation phase. This noise resembles the sound that is produced when pronouncing the letter “F”. at the moment of inhaling air, as when drinking tea from a saucer. The oscillation of the alveolar walls continues at the beginning of exhalation, forming a shorter second phase of vesicular breathing, heard only in the first third of the expiratory phase. Vesicular breathing is heard on the anterior surface of the chest, below the second rib, lateral to the parasternal line, in the axelar regions and below the angles of the scapulae.
Changes in vesicular respiration.
It can be physiological and pathological. It can change in the direction of both weakening and strengthening.
Physiological weakening is observed when the chest wall thickens due to excessive development of its muscles or obesity.
Physiological enhancement of vesicular respiration. It is observed in persons with a thin chest and pancreas. Increased vesicular breathing is always heard in children - it is called puerile breathing. Intensifies with heavy physical work.
Physiological change Vesicular respiration always occurs simultaneously in both halves and in its symmetrical areas the breathing is the same.
Pathological weakening:
1) Emphysema.
2) Initial stage lobar pneumonia.
3) Insufficient air supply to the alveoli as a result of the formation of a mechanical obstruction in the bronchi.
4) Inflammation respiratory muscles, intercostal nerves, fracture of a rib or ribs.
5) Severe adynamia of the patient.
6) Thickening of the pleural layers, or accumulation of fluid or air in the pleural cavity. When accumulating large quantity fluid or air in the pleural cavity, breathing is not audible at all.
7) Atelectasis.
Causes of pathological increase in vesicular respiration:
1) Narrowing of the lumen of the bronchi ( hard breathing: with it, the exhalation lengthens and becomes equal to the inhalation; saccadic breathing is also vesic breathing, the inhalation phase of which consists of individual, short, intermittent inhalations with minor pauses between them, exhalation usually does not change, observed with uneven contraction of the respiratory muscles or inflammatory process in bronchi of various calibers).
Bronchial breathing. Occurs in the larynx and trachea during the passage of air through the glottis, the sounds formed in this case are the sound “x”, when exhaling, it becomes stronger, rougher and longer, normally bronchial breathing is heard above the larynx, trachea, and in places of projection on chest, bifurcation (division into 2 bronchi) of the trachea. Anteriorly in the area of the manubrium of the sternum, and posteriorly in the interscapular space, at the level of the 3rd and 4th thoracic vertebrae.
If bronchial breathing is heard over other parts of the lungs, then it is called pathological bronchial breathing.
The cause of pathological bronchial breathing is compaction lung tissue, which may be due to:
1) Accumulation of exudate in the alveoli (lobar pneumonia, pulmonary hypertension, pulmonary infarction).
2) Compression of the lung, with accumulation of air in the pleural cavity and compression of the lung at its root (compression atelectasis).
3) When replacing lung tissue with connective tissue.
4) Formation in the lung of a cavity free of contents and communicating with the bronchus.
Types of bronchial breathing:
1) Amphoric breathing - occurs in the presence of a smooth-walled cavity with a diameter of at least 5-6 cm, communicating with a large bronchus; a similar noise can be obtained if you blow strongly over the throat of an empty vessel (amphora).
2) Metal breathing – characterized as loud sound, and a very high timbre, reminiscent of the sound that occurs when hitting metal. Can be listened to with open pneumothorax.
3) Stenotic breathing – characterized by increased bronchial breathing. Occurs when the trachea narrows or large bronchus tumor. And it is found mainly in places where physiological breathing is heard.
4) Vesicle-bronchial breathing - mixed breathing. Heard when focal pneumonia or infiltrative pulmonary tuberculosis, with pneumosclerosis, when the foci of compaction are located deep in the lung tissue and not close to each other.
Adverse breath sounds:
2) Crepitus.
3) Pleural friction noise.
Adverse sounds are heard only in cases of pathology. They are best heard while breathing deeply through an open mouth.
Wheezing:
1) Dry wheezing – formed when the lumen of the bronchi narrows or thick, viscous sputum accumulates in the bronchi. They are heard during the inhalation and exhalation phases. The narrowing of the lumen of the small bronchi causes wheezing, and the bronchi of medium and large caliber cause a buzzing sound. If wheezing is caused by the accumulation of viscous, viscous sputum in the lumen of the bronchi, then during deep breathing or after a cough may in some cases intensify, in others decrease or disappear for a while.
2) Moist rales are formed when liquid sputum accumulates in the lumen of the bronchi. As air passes through it, air bubbles of different diameters are formed. Similar sounds can be obtained by blowing air into a liquid through a narrow tube. Moist rales are heard during the inhalation and exhalation phases. Depending on the diameter of the bronchi in which they arise, they are divided into small-bubble, medium-bubble and large-bubble.
Crepitus:
1) It occurs in the alveoli when a small amount of liquid secretion accumulates in their lumen, while during the exhalation phase the alveolar walls stick together, and during the inhalation phase they come apart with great difficulty. It is heard in the form of a light cracking sound and resembles the sound that is produced when a small tuft of hair is rubbed over the ear. It is observed with inflammation of the lung tissue with lobar pneumonia, infiltrative pulmonary tuberculosis, pulmonary infarction, with stagnation in the lungs. Crepitation is heard ONLY at the height of inspiration and does not change after coughing.
Pleural friction noise. The visceral and parietal layers of the pleura under physiological conditions have a smooth surface and constant “wet lubrication” in the form of a capillary layer pleural fluid. Therefore, their sliding during breathing occurs silently. When the pleura is inflamed, it thickens, becomes uneven, and therefore, when breathing, additional noise is formed - pleural friction noise. It is heard during the inhalation and exhalation phases and is most often detected in the lower lateral parts of the chest. After coughing, it does not change and with strong pressure on the chest with a phonendoscope, it intensifies. The pleural friction noise is heard when the patient retracts and then protrudes the abdomen, with the mouth closed and the nose pinched.
Bronchophony. The conduction of the voice from the larynx along the air column of the bronchi to the surface of the chest is determined by auscultation, in contrast to the definition voice tremors, words containing the sound “r” or “h” when studying bronchophony are pronounced in a whisper (a cup of tea). Increased vocal tremors appear when there is compaction of the lung tissue.
End of work -
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Respiratory examination methods
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- 89. Methods for diagnosing diabetes mellitus (questioning, examination, laboratory and instrumental research methods).
- 90. Determination of glucose in blood, in urine, acetone in urine. Glycemic curve or sugar profile.
- 91.Diabetic coma (ketoacidotic), symptoms and emergency care.
- 92. Signs of hypoglycemia and first aid for hypoglycemic conditions.
- 93. Clinical signs of acute adrenal insufficiency. Principles of emergency care.
- 94. Rules for collecting biological materials (urine, feces, sputum) for laboratory research.
- 1.Urine examination
- 2.Sputum examination
- 3. Stool examination
- 96. Methods of examining patients with pathology of the hematopoietic organs (questioning, examination, palpation, percussion, laboratory and instrumental research methods).
- 1. Questioning, complaints of the patient:
- 2.Inspection:
- B. Enlarged lymph nodes
- D. Enlarged liver and spleen
- 3.Palpation:
- 4.Percussion:
- 5. Laboratory research methods (see Questions No. 97-107)
- 6.Instrumental research methods:
- 97. Methods for determining Hb, counting red blood cells, clotting time, bleeding time.
- 98. Counting leukocytes and leukocyte formula.
- 99. Methodology for determining blood group, the concept of the Rh factor.
- II (a) group.
- III (c) groups.
- 100. Diagnostic value of a clinical study of a general blood test
- 101. The concept of sternal puncture, lymph node and trepanobiopsy, interpretation of the results of bone marrow puncture examination.
- 102. Methods for studying the blood coagulation system
- 103. Hemorrhagic syndrome
- 104. Hemolytic syndrome.
- Causes of acquired hemolytic anemia
- Symptoms of hemolytic anemia
- 105. General ideas about coagulogram.
- 108. Study of the musculoskeletal system, joints
- 109. Ultrasound in the internal medicine clinic
- 110. Computed tomography
- 112. Emergency care for an asthma attack
- 115. Emergency care for cardiac asthma, pulmonary edema
- 116.Emergency help for bleeding
- 118. Emergency care for gastrointestinal bleeding
- 119. Emergency care for nosebleeds
- 121. Emergency care for anaphylactic shock
- 122. Emergency care for angioedema
- 127. Pulmonary edema, clinical picture, emergency care.
- 128. Emergency care for biliary colic.
- 129. Emergency care for acute urinary retention, catheterization of the bladder.
The upper border of the lungs at the back is always determined by the relation of their position to the spinous process of the VII cervical vertebra. To do this, a finger-pessimeter is placed in the supraspinatus fossa parallel to the spine of the scapula and percussion is carried out from its middle; in this case, the finger-pessimeter is gradually moved upward towards a point located 3-4 cm lateral to the spinous process of the VII cervical vertebra, at its level, and percussed until a dull sound appears. Normally, the height of the posterior apex is approximately at the level of the spinous process of the VII cervical vertebra.
The so-called Kroenig fields are areas of clear pulmonary sound above the apexes of the lungs. The width of Krenig's fields is determined by the anterior edge of the trapezius muscle. On average it is 5-6 cm, but can vary from 3 to 8 cm. The trapezius muscle divides the Krenig field into
the anterior part, extending to the clavicle, and the posterior, expanding towards the supraspinatus fossa. To determine the width of the apex of the lung, it is usually used quiet, or subthreshold, percussion. In this case, the pessimeter finger is placed in the middle of the trapezius muscle perpendicular to its anterior edge and percussed first medially and then laterally until a dull sound appears. The distance between the points of transition of clear pulmonary sound to dull sound is measured in centimeters.
The position of the upper border of the lungs, as well as the width of the Kroenig fields, may vary depending on the amount of air in the apexes of the lungs. With increased airiness of the lungs, which can be caused by acute or chronic emphysema, the apex of the lung increases in volume and moves upward. Accordingly, the Kroenig field expands. The presence of connective tissue in the apex of the lung, usually formed as a result of inflammation (tuberculosis, pneumonia) or inflammatory infiltrate in it, is the reason for the decrease in the airiness of the lung tissue, and therefore the reason for the change in the position of the upper border of the lung and the width of the apex. With a unilateral process, the upper border of the pathologically changed lung is located slightly lower than the unchanged one, and the width of the Krenig field decreases due to wrinkling of the apex.
The lower boundaries of the lungs are determined using percussion from top to bottom along conventionally drawn vertical topographic lines. First, the lower border of the right lung is determined from the front along the parasternal and midclavicular lines, laterally (from the side) - along the anterior, middle and posterior axillary lines (Fig. 18), from behind - along the scapular (Fig. 19) and paravertebral lines.
The lower border of the left lung is determined only from the lateral side along three axillary lines and from the back along the scapular and paravertebral lines (from the front, due to the attachment of the heart to the anterior chest wall, the lower border of the left lung is not determined).
During percussion, the pessimeter finger is placed on the intercostal space parallel to the ribs and weak and uniform blows are applied to it. Percussion of the chest, as a rule, begins on the anterior surface from the second and third intercostal spaces (if the patient is in a horizontal or vertical position); on the lateral surface - from the axillary fossa (with the patient sitting or standing with his hands raised up on his head) and on the posterior surface - from the seventh intercostal space, or from the angle of the scapula, which ends at the level of the VII rib.
The lower border of the right lung, as a rule, is located at the site of the transition of a clear pulmonary sound to a dull one (pulmonary-hepatic border). As an exception, if there is air in the abdominal cavity, for example, when a gastric or duodenal ulcer is perforated, hepatic dullness may disappear. Then, at the location of the lower border, the clear pulmonary sound will turn into a tympanic sound. The lower border of the left lung along the anterior and middle axillary lines is determined by the transition of a clear pulmonary sound to a dull tympanic sound. This is due to the fact that the lower surface of the left lung comes into contact through the diaphragm with a small airless organ - the spleen and the fundus of the stomach, which gives a tympanic percussion sound (Traube's space).
The position of the lower border of the lungs may vary depending on the constitutional characteristics of the body. In persons of asthenic physique, it is slightly lower than in persons of normosthenic physique, and is located not on the rib, but in the intercostal space corresponding to this rib; in persons of hypersthenic physique, it is slightly higher. The lower border of the lungs temporarily shifts upward in women in the last months of pregnancy.
The position of the lower border of the lungs can also change in various pathological conditions developing both in the lungs and in the pleura, diaphragm, and abdominal organs. This change can occur either due to a shift or lowering of the border, or due to its rise; it can be either one-sided or two-sided.
Bilateral descent of the inferior border of the lungs observed with acute (bronchial asthma attack) or chronic (pulmonary emphysema) expansion of the lungs, as well as with a sharp weakening of the tone of the abdominal muscles and prolapse of the abdominal organs (splanchnoptosis). Unilateral prolapse of the lower border of the lung can be caused by vicarious (replacement) emphysema of one lung when the other lung is turned off from the act of breathing (exudative pleurisy, hydrothorax, pneumothorax), with unilateral paralysis of the diaphragm.
Shift of the lower border of the lungs upward more often it is one-sided and depends on the following reasons: 1) from shrinkage of the lung as a result of the proliferation of connective tissue in it (pneumosclerosis, pulmonary fibrosis) or when the lower lobe bronchus is completely blocked by a tumor, which leads to a gradual collapse of the lung - atelectasis; 2) from the accumulation of fluid or air in the pleural cavity, which gradually pushes the lung upward and medially to its root; 3) from a sharp enlargement of the liver (cancer, sarcoma, echinococcus) or enlargement of the spleen, for example with chronic myeloid leukemia. A bilateral upward displacement of the lower border of the lungs can occur when a large amount of fluid (ascites) or air accumulates in the abdominal cavity due to acute perforation of a stomach or duodenal ulcer, as well as sudden flatulence.
