Percussion. Normal location of the lower borders of the lungs in normosthenics
tip right lung in front protrudes above the clavicle 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 top of the right lung, its anterior border goes down to the right sternoclavicular joint, then falls 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 turns sharply upwards and passes into its posterior border, which goes to the top 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. Borders 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 margin 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 - front edge of the right lung, 25 - front edge of the right pleura, 26 - upper lobe right lung, 27 - clavicle.
the sternum descends to the level of the cartilage of the 4th rib. Further, the anterior border of the left lung deviates to the left, goes 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 about half a rib lower than the lower border of the right lung (about half a rib). Along the paravertebral line, the lower border of the left lung passes into its posterior border, which runs along the spine on the left.
Lung innervation: branches vagus nerves and nerves sympathetic trunk, which are in the area lung root form a pulmonary plexus.
blood supply lung has features. arterial blood enters the lungs through the bronchial branches of the thoracic aorta. Blood from the walls of the bronchi through the bronchial veins flows into the tributaries of the pulmonary veins. The left and right pulmonary arteries supply the lungs with deoxygenated blood, which, as a result of gas exchange, is enriched with oxygen, gives off carbon dioxide and becomes arterial. Arterial blood from the lungs flows through the pulmonary veins into the left atrium.
Lymphatic vessels lungs flow into the bronchopulmonary, lower and upper tracheobronchial lymph nodes.
Pleura and pleural cavity
Allocate percussion of the lungs. This method It consists in tapping certain parts of the body. With such tapping, there are certain sounds, according to the features of which the sizes and boundaries of organs are established and the existing pathologies are revealed.
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. Experienced Specialist often able to deliver accurate diagnosis without application technological means so that treatment can be started much earlier. However, percussion may raise doubts about the proposed diagnosis, and then other diagnostic tools are used.
Percussion chest may be different. For example:
- Direct (direct). It is carried out with the help of fingers directly on the patient's body.
- mediated. Done with a mallet. In this case, it is necessary to strike on a plate attached to the body, which is called a plessimeter.
- Finger-finger. With this method of percussion of the lungs, 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 by them that one can determine the boundaries of the respiratory organs and establish the properties of internal tissues.
There are the following types of sounds detected during percussion:
- Dull sound. It can occur when a compacted area is found in the lungs.
- Box sound. This type of sound appears in case of excessive airiness of the examined organ. The name comes from the resemblance to how an empty cardboard box sounds when it is lightly hit.
- Tympanic sound. It is typical for percussion of areas of the lungs with smooth-walled cavities.
According to the characteristics of sounds, the main 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 found, a diagnosis characteristic of the patient can be assumed.
The most commonly used percussion technique is the finger-finger technique.
It is performed according to the following rules:
To this way diagnostics turned out to be the most effective, the doctor must follow the technique of execution. It's impossible without special knowledge. In addition, experience is necessary, since in its absence 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 occur when tapping in the area above the lungs. It is carried out on symmetrical sections, while the blows must have the same force. In the course of its implementation, the order of actions is very important and correct position fingers.
Such percussion can be deep (if pathological areas are supposed to be deep inside), superficial (when pathological foci are close) and normal. Percussion is carried out on the anterior, posterior and lateral surfaces of the chest.
Topographic percussion lung is designed to determine the upper and lower bounds organ. The results obtained are compared with the norm (a special table has been developed for this). According to the existing deviations, the doctor may suggest a particular diagnosis.
This type of percussion of the respiratory organs is performed only in a superficial way. The boundaries are determined by the tone of the sounds. The doctor must necessarily observe the technique of performing the procedure and be careful not to miss important details examinations.
Normal performance
This method of studying the respiratory system allows you to detect pathological phenomena without the use of more complex diagnostic procedures. Most often, X-ray or MRI is 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 the organs during the 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 the borders of the lungs in children and adults is almost the same. An exception may be the indicators of the child preschool age, but only in relation to the tops of the body. Therefore, in children of preschool age, this boundary is not defined.
Measurement of indicators of the upper border of the lungs is performed both in front of the chest and behind it. On both sides there are landmarks on which doctors rely. The reference point on the front of the body is the clavicle. IN normal condition the upper border of the lungs lies 3-4 cm above the clavicle.
Definition upper bounds lungs
From the back, this border is determined by the seventh cervical vertebra (it differs slightly from the others in 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 in an upward direction until a dull sound appears.
To identify the lower border of the lungs, it is necessary to take into account the location of the topographic lines of the chest. Tapping is performed along these lines from top to bottom. Each of these lines will receive different result because the lungs are cone-shaped.
In the normal state 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 lungs due to the heart located next to one of them.
It is also important to take into account the fact that the location of the lower boundaries is influenced by the characteristics of the physique of patients. With a lean physique, 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 in such an examination is the mobility of the lower boundaries. 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 move down; when you exhale, they return to their normal state. A normal indicator of mobility relative to the midclavicular and scapular lines is a value of 4-6 cm, relative to the middle axillary - 6-8 cm.
What do deviations mean?
The essence of this diagnostic procedure is the assumption of the disease by deviations from the norm. Deviations are most often associated with a displacement of the boundaries of the body up or down.
If the upper parts of the patient's lungs are displaced higher than they should be, this indicates that the lung tissues have excessive airiness.
Most often this is observed with emphysema, when the alveoli lose their elasticity. Below normal level the apices of the lungs are located if the patient develops diseases such as pneumonia, pulmonary tuberculosis and etc.
When the lower limit shifts, this is a sign of chest pathology or abdominal cavity. If the lower limit is below the normal level, this may mean the development of emphysema or the prolapse of internal organs.
With a downward displacement of only one lung, the development of pneumothorax can be assumed. The location of these boundaries above the prescribed level is observed in pneumosclerosis, bronchial obstruction, etc.
You also need to pay attention to the mobility of the lungs. Sometimes it may differ from normal, which indicates a problem. You can detect such changes that are characteristic of both lungs or for one - this must also be taken into account.
If the patient is characterized by a bilateral decrease in this value, one can assume the development of:
- emphysema;
- bronchial obstruction;
- formation of fibrotic 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 the features found in order to draw the right conclusions. If this fails, additional diagnostic methods to avoid mistakes.
The definition of the boundaries of the lungs has great importance for the diagnosis of many pathological conditions. The ability to percussion detect the 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 borders of the lungs?
Of course, you can use instrumental diagnostic methods, 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.
The determination of the boundaries of the lungs at the stage of examination is carried out by the method of topographic percussion. What it is? Percussion is a study based on the identification of sounds that occur when tapping on the surface of the human body. The sound changes depending on the area in which the study is taking place. Over parenchymal organs (liver) or muscles, it turns out to be deaf, over hollow organs(intestine) - tympanic, and over filled air lungs acquires a special sound (pulmonary percussion sound).
Performed this study in the following way. One hand is placed with the palm on the area of study, two or one finger of the second hand hits the middle finger of the first (plessimeter), like a hammer on an anvil. As a result, you can hear one of the options for percussion sound, which was already mentioned above. Percussion is comparative (sound is evaluated in symmetrical areas of the chest) and topographic. The latter is just designed to determine the boundaries of the lungs.
How to conduct topographic percussion?
The finger-plessimeter is set to the point from which the study begins (for example, when determining the upper borders of the lung along the front surface, it starts over middle part clavicle) and then shifts to the point where this measurement should approximately end. The limit is determined in the area where the pulmonary percussion sound becomes dull.
The finger-plesimeter for the convenience of research should lie parallel to the desired border. The displacement step is approximately 1 cm. Topographic percussion, in contrast to comparative, is performed by gentle (quiet) tapping.
Upper limit
The position of the tops of the lungs is assessed both anteriorly and posteriorly. On the front surface of the chest, the clavicle serves as a guide, 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 borders of the lungs are normally located as follows:
Research should be done like this:
Displacement of the upper borders of the lungs
The upward displacement of the boundaries occurs due to excessive airiness of the lung tissue. This condition is typical for emphysema - a disease in which the walls of the alveoli are overstretched, and in some cases their destruction with the formation of cavities (bulls). Changes in the lungs with emphysema are irreversible, the alveoli swell, the ability to collapse is lost, elasticity is sharply reduced. The boundaries of the human lungs (in this case, the limits of the apex) can move 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 (proliferation of connective tissue and wrinkling of the lung). The borders of the lungs (upper), located below the normal level, - diagnostic feature pathologies such as tuberculosis, pneumonia, pneumosclerosis.
Bottom line
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 specified lines from top to bottom until the percussion pulmonary sound changes into a dull one. 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.
From the front, the lower borders of the lungs are determined along the line passing along the lateral surface of the sternum, as well as along the line descending down from the middle of the clavicle. From the side, three axillary lines are important landmarks - anterior, middle and posterior, which start from the anterior edge, center and posterior edge of the armpit, respectively. Behind the edge of the lungs is determined relative to the line that descends from the angle of the scapula, and the line located on the side of the spine.
Displacement of the lower borders of the lungs
It should be noted that in the process of breathing, the volume of this organ changes. Therefore, the lower borders of the lungs are normally displaced by 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 are excessively enlarged in emphysema, which leads to a bilateral downward displacement of the borders. Other causes may be hypotension of the diaphragm and pronounced prolapse of the abdominal organs. Lower limit shifts 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 a total pneumothorax, hydrothorax, etc.
The borders of the lungs usually move upward due to wrinkling of the latter (pneumosclerosis), a decrease in the lobe as a result of bronchial obstruction, accumulation in pleural cavity exudate (as a result of which the lung collapses and is pressed against the root). Pathological conditions in the abdominal cavity can also shift the pulmonary boundaries upward: for example, the accumulation of fluid (ascites) or air (with perforation of a hollow organ).
The borders of the lungs are normal: table
Lower limits in an adult
Field of study
Right lung
Left lung
Line at the lateral surface of the sternum
5 intercostal space
-
Line descending from the middle of the clavicle
6 rib
-
Line originating from the anterior margin of the armpit
7 rib
7 rib
A line from the center of the armpit
8 rib
8 rib
Line from the posterior edge of the armpit
9 rib
9 rib
Line descending from the angle of the scapula
10 rib
10 rib
Line to the side of the spine
11 thoracic vertebrae
11 thoracic vertebrae
The location of the upper pulmonary borders is described above.
The change in the indicator depending on the physique
In asthenics, the lungs are elongated in the longitudinal direction, so they often fall slightly below the generally accepted norm, ending not on the ribs, but in the intercostal spaces. For hypersthenics, on the contrary, a higher position of the lower border is characteristic. Their lungs are broad and flattened in shape.
How are the lung borders located in a child?
Strictly speaking, the borders of the lungs in children practically correspond to those in an adult. The tops of this organ in guys who have not yet reached preschool age, which are not determined. Later they are in front 20-40 mm above the middle of the clavicle, behind - at the level of the seventh cervical vertebra.
The location of the lower bounds are discussed in the table below.
Borders of the lungs (table)
Field of study
Age up to 10 years
Age over 10 years old
A line from the middle of the clavicle
Right: 6 rib
Right: 6 rib
Line originating 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
Causes of displacement of the pulmonary borders 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 has already been said above that during breathing, the lower boundaries shift relative to normal indicators due to expansion of the lungs on inspiration and decrease on expiration. Normally, such a shift is possible within 20-40 mm up from the lower border and the same amount down. The definition of mobility is carried out by three main lines, starting from the middle of the clavicle, the center of the armpit and the angle of the scapula. Research is carried out as follows. First, the position of the lower border is determined and a mark is made on the skin (you can use a pen). Then the patient is 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, the position of the lung during maximum expiration is determined. Now, focusing on the estimates, we can judge how the lung is shifting along its lower border. In some diseases, lung mobility is markedly reduced. For example, this occurs with adhesions or a large amount of exudate in the pleural cavities, loss of light elasticity in emphysema, etc.
Difficulties in conducting topographic percussion
This research method is not easy and requires certain skills, and even better - experience. Complications arising from its use are usually associated with improper execution technique. Concerning 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 builds self-confidence.
Summarize
Percussion is a very important diagnostic method of research. It makes many suspect 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 are important for full treatment.
The location of the lower boundaries of the lungs is normal - section Mechanics, Methods of examination of 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 emphysema.
The displacement of the lower border of the lungs upward is more often unilateral. And it occurs when:
1) Wrinkling of the lung as a result of pneumosclerosis.
2) Atelectasis.
3) The accumulation of fluid or air in the pleural cavity, which pushes the lung up.
4) With a sharp increase in the liver or spleen.
Bilateral elevation of the lower border of the lungs is possible with large cluster in the abdominal cavity fluid (ascites) or air.
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. During auscultation of the lungs, first compare the breath sounds in different phases breathing (on inhalation and exhalation), their nature, duration, loudness are assessed, and then these noises are compared with respiratory noises at a similar point in the other half of the chest (comparative auscultation).
The main respiratory sounds are 2 of them: vesicular breathing and bronchial breathing. Basic breath sounds are best heard when breathing through the nose.
Vesicular respiration is auscultated above the lung tissue, it occurs as a result of the vibration of the walls of the alveoli at the moment they are filled with air in the inhalation phase. This noise resembles the sound that is formed when the letter "F" is pronounced. at the moment of inhalation of 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 respiration, which is heard only in the first third of the exhalation phase. Vesicular breathing is heard on the anterior surface of the chest, below the second rib, lateral to the parasternal line, in the axial regions and below the angles of the shoulder blades.
Change in vesicular respiration.
May be physiological or pathological. It can change in the direction of both weakening and strengthening.
Physiological weakening is observed when the chest wall is thickened due to excessive development of its muscles or obesity.
Physiological enhancement of vesicular respiration. It is noted in persons with a thin chest and pancreas. Increased vesicular breathing is always heard in children - it is called puerile. Increases with hard physical work.
Physiological change vesicular respiration always occurs simultaneously in both halves and in its symmetrical areas, respiration is the same.
Pathological weakening:
1) Emphysema of the lungs.
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 sheets, or accumulation of fluid or air in the pleural cavity. When accumulating a large number 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, exhalation lengthens, becomes equal to inhalation; saccadic breathing is also a vesicle-breathing, the inhalation phase of which consists of separate, short, intermittent breaths with slight pauses between them, the exhalation usually does not change, it is observed with an uneven contraction of the respiratory muscles or inflammatory process in the bronchi of various calibers).
Bronchial breathing. Occurs in the larynx and trachea during the passage of air through the glottis, the sounds resulting from the sound “x”, when exhaled, it becomes stronger, rougher and longer, normally bronchial breathing is heard over the larynx, trachea, and in places of projection on chest, bifurcation (division into 2 bronchi) of the trachea. In front in the area of the sternum handle, and behind in the interscapular space, at the level of 3 and 4 thoracic vertebrae.
If bronchial breathing is heard above other parts of the lungs, then it is called pathological bronchial breathing.
The cause of the appearance of pathological bronchial breathing is a seal lung tissue, which may be due to:
1) Accumulation of exudate in the alveoli (croupous pneumonia, TBC, pulmonary infarction).
2) Compression of the lung, with the 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) The formation in the lung of a cavity free of contents and communicating with the bronchus.
Varieties of bronchial breathing:
1) Amphoric breathing - occurs when there is 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 strongly blow 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 heard with an open pneumothorax.
3) Stenotic breathing - characterized by increased bronchial breathing. Occurs with narrowing of the trachea or large bronchus tumor. And it is found mainly in places of listening to physiological breathing.
4) Vesicle-bronchial respiration - mixed respiration. Heard at focal pneumonia or infiltrative tbc of the lungs, 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) Rubbing noise of the pleura.
Side noises are heard only in pathology. They are best heard with deep breathing through an open mouth.
Wheezing:
1) Dry wheezing - formed when the bronchial lumen narrows or thick, viscous sputum accumulates in the bronchi. Auscultated during inhalation and exhalation. Narrowing of the lumen of small bronchi causes wheezing, and bronchi of medium and large caliber - buzzing. If wheezing is caused by the accumulation of viscous viscous sputum in the lumen of the bronchi, then they are during deep breathing or after coughing may in some cases increase, in others decrease or disappear for a while.
2) Wet rales - are formed when liquid sputum accumulates in the lumen of the bronchi. When 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 in the phase of inhalation and exhalation. 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 in the exhalation phase the alveolar walls stick together, and in the inhalation phase they come apart with great difficulty. It is heard in the form of a light crackle and resembles the sound that is obtained by rubbing a small tuft of hair over the ear. It is observed with inflammation of the lung tissue with lobar pneumonia, infiltrative TBC of the lungs, pulmonary infarction, with congestion in the lungs. Crepitus is heard ONLY at the height of inspiration and does not change after coughing.
Rubbing noise of the pleura. The visceral and parietal pleura under physiological conditions have a smooth surface and a constant "wet lubricant" in the form of a capillary layer. pleural fluid. Therefore, their sliding during breathing occurs silently. When the pleura becomes inflamed, it thickens, becomes uneven, and therefore additional noise is formed during breathing - the noise of pleural friction. It is heard in the phase of inhalation and exhalation and is more often detected in the lower-lateral sections 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 during retraction and subsequent protrusion of the sick 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 jitter, words containing the sound "p" or "h" in the study of bronchophony are pronounced in a whisper (a cup of tea). Increased voice trembling appears in the presence of compaction of the lung tissue.
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- 14. Determining the type of breathing, symmetry, frequency, depth of breathing, respiratory excursion of the chest.
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- 73. X-ray examination of the gallbladder (cholecystography, intravenous cholegraphy, cholangiography, the concept of retrograde cholangiography).
- 74. Methods of examination of the pancreas (questioning, examination, palpation and percussion of the abdomen, laboratory and instrumental research methods).
- 75. General ideas about endoscopic, X-ray, ultrasound methods for examining the gastrointestinal tract. (Stupid question - stupid answer).
- 89. Methods for diagnosing diabetes mellitus (questioning, examination, laboratory and instrumental methods of research).
- 90. Determination of glucose in blood, urine, acetone in urine. Glycemic curve or sugar profile.
- 91. Diabetic coma (ketoacidotic), symptoms and emergency care.
- 92. Signs of hypoglycemia and first aid in hypoglycemic conditions.
- 93. Clinical signs of acute adrenal insufficiency. Principles of emergency care.
- 94. Rules for the collection of biological materials (urine, feces, sputum) for laboratory research.
- 1. Urine examination
- 2.Sputum examination
- 3. Examination of feces
- 96. Methods of examination of patients with pathology of the hematopoietic organs (questioning, examination, palpation, percussion, laboratory and instrumental methods of research).
- 1. Inquiry, complaints of the patient:
- 2.Inspection:
- B. Enlarged lymph nodes
- D. Enlargement of the 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. Leukocyte count and leukocyte formula.
- 99. Methodology for determining the blood group, the concept of the Rh factor.
- II (a) groups.
- III (c) groups.
- 100. Diagnostic value of a clinical study of a complete blood count
- 101. The concept of sternal puncture, lymph node and trepanobiopsy, interpretation of the results of the study of bone marrow punctate.
- 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 the coagulogram.
- 108. Examination of the musculoskeletal system, joints
- 109. Ultrasound in the clinic of internal diseases
- 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, bladder catheterization.
The upper border of the lungs from behind is always determined in relation to their position in relation to the spinous process of the VII cervical vertebra. To do this, the finger-plessimeter is placed in the supraspinatus fossa parallel to the spine of the scapula and percussion is performed from its middle; at the same time, the plessimeter finger 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 position of the tops behind is approximately at the level of the spinous process of the VII cervical vertebra.
The so-called Krenig fields are zones of clear lung sound above the tops of the lungs. The width of the Krenig fields is determined along 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
an anterior part, extending to the clavicle, and a posterior part, expanding towards the supraspinatus fossa. To determine the width of the apex of the lung is usually used quiet or subthreshold, percussion. At the same time, the plessimeter finger is placed in the middle of the trapezius muscle perpendicular to its front edge and percussed first medially and then laterally until a dull sound appears. The distance between the transition points of a clear lung sound to a dull one is measured in centimeters.
The position of the upper border of the lungs, as well as the width of the Krenig fields, may vary depending on the amount of air in the tops of the lungs. With increased airiness of the lungs, which can be caused by acute or chronic emphysema, the tops of the lung increase in volume and move upward. Correspondingly, the Krenig field also expands. The presence of connective tissue in the apex of the lung, which is usually formed as a result of inflammation (tuberculosis, pneumonia) or inflammatory infiltrate in it, is the cause of a decrease in the airiness of the lung tissue, and, consequently, the cause of a 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 altered lung is somewhat lower than that of 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 by percussion from top to bottom along conditionally drawn vertical topographic lines. First, the lower border of the right lung is determined in front along the parasternal and midclavicular lines, laterally (on the side) - along the anterior, middle and posterior axillary lines (Fig. 18), 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 (the lower border of the left lung is not determined from the front due to the adherence of the heart to the anterior chest wall).
The finger-plessimeter during percussion 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 to be performed along the anterior surface from the second and third intercostal spaces (when the patient is in a horizontal or vertical position); on the lateral surface - from the axillary fossa (in the position of the patient sitting or standing with hands raised up on his head) and along the back 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 point of transition of a clear pulmonary sound to a dull one (lung-hepatic border). As an exception, in the presence of 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, a clear pulmonary sound will turn into a tympanic one. 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 one. 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 features of the organism. In persons of asthenic constitution, it is somewhat lower than in persons of normosthenic constitution, and is located not on the rib, but in the intercostal space corresponding to this rib, in persons of hypersthenic constitution it is somewhat 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 that develop both in the lungs and in the pleura, diaphragm, and abdominal organs. This change can occur both due to the displacement or lowering of the boundary, and due to its rise; it can be either unilateral or bilateral.
Bilateral descent of the lower border of the lungs observed in acute (attack of bronchial asthma) or chronic (emphysema) expansion of the lungs, as well as a sharp weakening of the tone of the abdominal muscles and prolapse of the abdominal organs (splanchnoptosis). Unilateral descent 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 unilateral and depends on the following reasons: 1) from wrinkling of the lung as a result of the growth of connective tissue in it (pneumosclerosis, lung fibrosis) or with complete blockage of the lower lobe bronchus 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 push the lung up and medially to its root; 3) from a sharp increase in the liver (cancer, sarcoma, echinococcus) or an increase in the spleen, for example, with chronic myeloid leukemia. Bilateral displacement of the lower border of the lungs upward may be due to the accumulation of a large amount of fluid (ascites) or air in the abdominal cavity due to acute perforation of a gastric or duodenal ulcer, as well as with severe flatulence.
