General examination: physique. The doctrine of normal and pathological constitutions Epigastric angle in normosthenic women

An acute angle will indicate an asthenic physique, a narrow chest. Normosthenics have a right angle, but hypersthenics have a wide chest, and hypersthenics have a wide chest.

To determine it yourself, stand in front of a mirror, place the edges of your palms against your costal arches, with your fingertips meeting at the top of the angle. Looking at the angle of the palms, it is not difficult to assess the type of angle formed. In degrees with a protractor, it is not determined.

How to determine your body type

There are several approaches to determining your somatotype. The methods for determining physique described in the article are suitable for men and women. Find out who you are by simply measuring your wrist circumference.

In the article “Body types: how does genetics affect your figure?” I talked in detail about characteristic features ectomorph, mesomorph and endomorph. In this article I will talk about how you can determine which somatotype you belong to.

There are several ways.

Wrist measurement

It is necessary to measure your wrist at the narrowest point with a measuring tape and compare it with the data in the table.

This method is the simplest, but its accuracy is very relative and today, some studies generally question the possibility of determining the somatotype using such parameters.

Determination of the epigastric angle

Epigastric angle- this is the angle that is formed between the 12th pair of ribs (the lowest pair). To determine it, go to the mirror, take a deep breath and hold your breath. Take two pencils and arrange them so that their ends on one side meet at the junction of the lower edges, and the pencils themselves are located along each of the edges. The location of the pencils will clearly show you the size of the intercostal angle. By its value you can determine your body type.

Determination of anthropometric indicators

Anthropometric indicators are age, gender, race and other characteristics of the physical structure that can be expressed quantitatively.

This method is the most accurate, but you cannot use it yourself. Such measurements can be carried out in medical centers or in fitness rooms where there is special equipment.

Determination of body type based on visual assessment

You can also roughly determine your body type simply by analyzing your appearance. And the best way to do this is to remember what kind of child you were as a child. If you are thin and tall, then most likely you are an ectomorph. If you were overweight as a child, then it is more likely that you are an endomorph. But do not forget about the objective factors that could influence this. So, if you were “fed for three” as a child, then the reason excess weight most likely in this, and not in the somatotype.

Why do you need to know your body type?

In order to rely on this data when compiling your diet and training regimen. For different body types, nutrition recommendations and training strategies can be very different, even if the goals are the same.

Epigastric angle

1. Undress to the waist, go to the mirror, take a deep breath and hold your breath for a while. The pair of lower ribs form the epigastric angle (highlighted in gray in the figure), the meaning of which we need to find out. Determine its value by eye.

You are asthenic if you have an epigastric angle< 90°

a normosthenic has an angle = 90°

in hypersthenic > 90°

Sorry for the scary picture, there are others on the Internet, but this one is visual.

That's all I'm talking about.

By all indications and by all descriptions, I am a normosthenic.

I tried to look at my ribs, the angle looks about 90.

I recently took an x-ray of the lumbar spine - clearly, clearly an acute angle!

no, it’s not very spicy, it’s close to 90, but clearly less than 90))

what is this?? can I be really slim?? Am I thin-boned??

• How to determine your body type
• how to determine your body type

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The diagnosis of obesity is established when the body mass index (BMI) is more than 30 kg/m². Hormonal background, metabolism and heredity influence the distribution of excess adipose tissue. Women and men, young and old, gain weight differently. There are two main types of obesity:

How to determine the type of obesity

In order to determine the type of obesity, it is necessary to measure the circumference of the waist and hips with a measuring tape. The waist is assessed along a horizontal line midway between the edges of the costal arch and the iliac crests. Hips are measured at the fullest point of the buttocks. Next, the resulting waist circumference is divided by the hip circumference. If the result is more than one in a man or more than 0.85 in a woman, then it is legitimate to talk about the abdominal type of obesity. If the numbers are lower, then the patient has the femorogluteal type.

Type of obesity and metabolism

The abdominal type of obesity indicates insulin resistance. This condition is caused by hereditary receptor deficiency. Very often, abdominal obesity is accompanied by arterial hypertension, diabetes mellitus, hypercholesterolemia, and polycystic ovary syndrome. To normalize metabolism it is required low calorie diet, physical activity and drug therapy. The drug of choice is metformin.

Femoral and gluteal obesity is common in women of reproductive age. Lipid and carbohydrate metabolism are most often not affected in this type of disease. Patients experience osteoporosis, venous insufficiency, and arthrosis. Treatment is primarily aimed at correcting eating behavior. Medications that may be recommended include orlistat and sibutramine.

Body weight and reproductive health

Many conversations about how obesity or thinness affects the likelihood of getting pregnant do not contain any useful information. This is due to the fact that even determining the percentage of fat is a rather complicated task, and there’s nothing to say about interpreting the results, so first let’s define the concepts.

About body mass index and body types

The range of a person's body weight can vary from underweight (hypotrophy) to obesity. How to determine what body weight can be considered normal?

There is not an ideal, but the most optimal solution - body mass index (BMI), this is the ratio of weight in kilograms to the square of height in meters. The normal range is based on age.

On average, a range from 20 to 24.9 is considered normal. This ratio works in a large percentage of cases, but as always there are exceptions.

Body tissues have different properties, bones and muscles give weight gain, but adipose tissue is quite light and first gives an increase in volume, and then weight. Each person's bones have their own thickness and width.

Based on the type of bone structure, there are 3 body types:

1. Asthenic ( thin bone, epigastric angle less than 90º),
2. Normosthenic (normal bone thickness, epigastric angle 90º, the most common body type),
3. Hypertensive (big-boned, stocky people, epigastric angle more than 90º).

The epigastric angle is the angle formed by the costal edges in the sternum area, open downwards.

Accordingly, in people with an asthenic physique, the BMI may be insufficient, and in hypersthenics it may be excessive, with a normal ratio between lean mass and fat.

Another body type can be determined by the volume ratio index chest at rest to height in centimeters.

For asthenics this ratio is less than 50%, for normosthenics it is from 50 to 55%, for hypersthenics it is more than 55%.

How to determine your body fat percentage?

In order to determine the percentage of fat contained in the body and the weight of lean mass, there is a special method. A direct method for determining body composition is weighing in water, the fatty tissue floats up, and you press the lean mass onto the scales, i.e. everything except fat. Accordingly, the difference in indicators will be the amount of fat. This is the simplest and most accurate method. There are also indirect methods based on the principle of impedance (special devices), as well as indices calculated by the sum of the thickness of fat folds (caliperometry). But these methods are less accurate and produce errors.

The optimal range for health is the % body fat range for women from 18 to 33 (for men from 12 to 25). The critical level of % fat tissue for women is 12% (for men 5%).

We present the norms of adipose tissue as a percentage by age for women and men. Keep in mind that the upper and lower limits of the range are actually no longer the norm, but also not a reason to talk about being overweight or underweight. They can be compared to a lottery and count on luck.

Adipose tissue and women's reproductive health

Adipose tissue is not only a storage site fatty acids, it performs an endocrine function and is the site of extraovarian estrogen synthesis.

When planning pregnancy, gynecologists recommend being within the normal range for health by age, both in weight and in % of fat tissue.

What happens if you lose a lot of weight?

With a sharp decrease in weight, when the percentage of body fat is less than 12%, a sharp hormonal change occurs - menstruation stops, i.e. secondary amenorrhea occurs. The mechanism of development of this condition is associated with a violation of the neuroendocrine control of the synthesis and release of gonadotropin-releasing hormone (aka gonadorelin, gonadoliberin, or GnrH for short) in the hypothalamus. A decrease in its entry into the pituitary gland leads to a decrease in the synthesis and disruption of the rhythm of synthesis of gonadotropins: FSH, ACTH, TSH, LH, Prolactin, STH. With a decrease in the synthesis of FSH and LH, the growth of follicles slows down, and accordingly, underdeveloped follicles will synthesize less estrogens - secondary hypoestrogenism develops, against the background of which full ovulation does not occur. When treating this pathology, with weight gain, the menstrual cycle is usually restored, but ovulation is very difficult to restore.

How will excess body weight affect?

With obesity, secondary amenorrhea also often occurs, but the reasons for its development are different: polycystic ovary syndrome, hyperprolactinemia, hyperandrogenism, dysfunction thyroid gland. As a rule, these disorders develop with early childhood, they are associated with the pathology of neuroendocrine regulation, and obesity in such cases develops secondarily, from puberty.

The development of obesity after puberty, due to insufficient physical activity and poor nutrition can also lead to a number of endocrine disorders that negatively affect a woman’s reproductive health.

Estrogen is found in the ovaries and adrenal glands. The ovaries produce estrogen constantly, and the adrenal glands produce the hormone androstenedione, which is converted in fat cells to folliculin, which is very close to estrogen. This will disrupt the natural ovulation cycle and can lead to infertility.

Excess weight can cause:

1. Menstrual irregularities;
2. Increased risk of developing infertility;
3. Low probability of successful infertility treatment;
4. Increased risk of spontaneous abortion.

But there is also diabetes, cardiovascular diseases, arterial hypertension, etc. All these diseases, including infertility, are extremely difficult to treat, since excess fat in the body makes it difficult to absorb drugs.

Let's name the numbers. According to research, the likelihood of becoming pregnant in obese women is on average 45% lower than in women with normal body weight. And this is subject to regular menstrual cycles. As soon as problems with ovulation begin, the picture becomes much worse. We would like to emphasize once again that even with a normal ovulatory cycle, excess body weight reduces the likelihood of getting pregnant.

Conclusion

Nature does not like extremes and the mechanism of natural selection will not work at this stage of development of medical science. Developed countries are literally groaning at the rate at which obesity is affecting the population. Your weight and your reproductive health depend only on you. This is not a loud phrase, but a simple statement of fact, as obvious as the phrase that smoking kills. By making your choices today you influence your future.

Respiratory system. Basic research methods for subjective sensations

RESPIRATORY SYSTEM. BASIC RESEARCH METHODS

1. Subjective sensations

Healthy people sometimes notice physiological shortness of breath, dry reflex cough and muscle pain in the chest. Untrained individuals may experience dizziness when breathing frequently and deeply.

Physiological shortness of breath, as a rule, appears during significant physical and neuropsychic stress, staying in a stuffy and smoky room, or in high altitude conditions.

Dry reflex cough is a protective reaction when mucus accumulates in the larynx, when a foreign body, dust, smoke particles, etc. enter the upper respiratory tract. A reflex cough can be caused by irritation of the receptors in the ear canal or esophagus.

Chest pain often occurs in poorly trained individuals when they perform significant physical activity (for example, long running) and is explained by overstrain of the intercostal muscles and diaphragm.

In practically healthy people, the skin has a uniform pale pink color over the entire surface of the body. Exposed skin may be tanned. In some cases, a pale color of the skin is observed, due to the reduced transparency of its upper layers and the depletion of blood vessels in the skin. Visible mucous membranes are pink, moderately moist.

When examining the chest, the doctor determines its shape, symmetry, the participation of both halves in the act of breathing, the type of breathing, its frequency, depth and rhythm. The patient should sit or stand completely straight with the torso bare to the waist, evenly illuminated from all sides.

2.1. Determining the shape of the chest

To determine the shape of the chest it is necessary to examine:

chest diameters;

supra- and subclavian fossae;

angle of connection between the body and the manubrium of the sternum;

epigastric (epigastric) angle;

direction of the ribs in the lateral parts of the chest;

adhesion of the shoulder blades to the chest.

2.1.1. Study of chest diameters

There are two diameters:

costal (transverse or lateral).

They are determined using a special compass, the legs of which are installed in certain places of the chest. So, to determine the first diameter, one leg of the compass is placed on the sternum area, and the other on the spine at the same level. To measure the second diameter, the legs of the compass are placed on symmetrical points along the middle axillary lines. In practice, most often, to determine the diameters of the chest, a centimeter tape is used, with which the doctor measures both diameters, projecting them onto the patient’s chest. Normally, in adults, the sternovertebral diameter is smaller than the costal diameter.

2.1.2. Study of the supraclavicular and subclavian fossae

The supraclavicular and subclavian fossae may be of varying degrees of severity or absent (“smoothed”), for example, in obese people or in people with a hypersthenic physique. Along with a visual assessment of the condition of the supraclavicular and subclavian fossae, they must be palpated.

2.1.3. Study of the angle of connection between the body and the manubrium of the sternum

This angle is determined visually and is called the Louis angle. It serves as an identification point for the P edge, from which edges are usually counted. The degree of its severity can vary - from significant to complete smoothness.

2.1.4. Study of the epigastric (epigastric) angle

This angle is formed by the costal arches. To determine the size of the epigastric angle, the palmar surfaces thumbs they are pressed tightly against the costal arches, and their ends rest against the xiphoid process. The epigastric angle can be acute, straight or obtuse.

2.1.5. Study of the direction of the ribs in the lateral parts of the chest

The direction of the ribs in the lateral parts of the chest in thin people can be determined visually, in overweight people - by palpation. The ribs in the lateral sections have an oblique, vertical or horizontal direction.

2.1.6. Study of intercostal spaces

Intercostal spaces are determined both visually and by palpation. Palpation is performed simultaneously on both sides of the chest or alternately on each side. The researcher's fingers are placed only in one intercostal space, then in the next intercostal space, etc. The intercostal spaces can be widened or reduced, drawn inward, smoothed or bulging.

2.1.7. The fit of the shoulder blades to the chest

It is determined both visually and by palpation. The shoulder blades can fit tightly to the chest and be located at the same level, wing-shaped behind the chest and be at different levels.

Shapes of the chest in a healthy person

Normal forms of the chest, depending on the constitutional type, include normosthenic (conical), hypersthenic and asthenic.

1.Normosthenic (conical) chest in persons of normosthenic physique. The anteroposterior (sternovertebral) size is smaller than the lateral (transverse) size. The ratio of anteroposterior to transverse dimensions is in the range of 0.65 - 0.75. The supraclavicular and subclavian fossae are poorly marked. The angle formed by the body of the sternum and its manubrium is clearly visible; the epigastric angle approaches 90°. The ribs in the lateral sections have a moderately oblique direction; the shoulder blades fit snugly to the chest and are located at the same level; The thoracic section of the body is approximately equal in height to the abdominal section.

2. Hypersthenic chest in persons with a hypersthenic physique. Its anteroposterior size approaches the lateral one; the ratio of the anteroposterior to transverse dimensions is greater than 0.75. The hypersthenic chest is characterized by a predominance of the transverse size over the longitudinal; it is wide but short. The supraclavicular and subclavian fossae are not visible, “smoothed out.” The angle of connection between the body and the manubrium of the sternum is pronounced; the epigastric angle is obtuse (more than 90°). The ribs have an almost horizontal direction, the intercostal spaces are narrow. The shoulder blades fit snugly to the back of the chest.

3. Asthenic chest in persons of asthenic physique. It is elongated, narrow and flat, i.e. has the shape of a cylinder flattened in the anteroposterior direction. The longitudinal size of the asthenic chest significantly prevails over the transverse one, as a result of which it looks long. The absolute values ​​of the anteroposterior and lateral dimensions are reduced, the lateral dimension prevails over the anteroposterior, and therefore the chest of an asthenic is flat. The ratio of anteroposterior to lateral dimensions is less than 0.65. The supraclavicular and subclavian fossae stand out sharply. The ribs have an oblique direction and approach vertical. There is no angle of connection between the sternum and its manubrium - the sternum and its manubrium form a straight “plate”. Epigastric angle less than 90°. The tenth ribs are not attached to the costal arch, the intercostal spaces are widened, the shoulder blades are wing-shaped behind the chest.

2.2. Determination of the symmetry of the right and left halves of the chest and their participation in the act of breathing

After a general examination of the chest, you should determine whether both halves are symmetrical. Normally, both halves of the chest are almost the same size. A slight predominance of the right half over the left is normal and is associated with greater development of the muscles of the right shoulder girdle. In left-handed people, both halves of the chest are equal or the left half may be slightly dominant.

The symmetry or asymmetry of the halves of the chest can be objectified through comparative measurements. To do this, with the patient’s arms raised, a measuring tape is placed on the chest from the middle of the sternum to the spinous process of the vertebra lying at the same level, after which the patient lowers his arms. In order not to miss the increase or decrease of any part of one of the halves of the chest, it is necessary to take measurements at several levels either during inhalation or during exhalation. During the measurement, the subject should hold his breath as much as possible.

A static examination of the chest does not always allow one to decide which of the two halves, unequal in volume, is normal and which is pathological. That is why a static examination of the chest should always be supplemented by a dynamic one, in which the degree of participation of each half in the act of breathing is determined. Normally, in healthy people, both halves of the chest are equally involved in the act of breathing. To judge the synchronicity of movement of the right and left halves of the chest, the patient is asked to breathe deeply and monitor the angles of the shoulder blades. If during deep breathing they rise to the same level, it means that both halves are equally involved in the act of breathing; if one of the shoulder blades remains lower, this indicates a lag in the corresponding half of the chest. The half that lags behind in the act of breathing is pathological. In order to obtain more accurate data, inspection is combined with palpation. To do this, hands are placed on the chest in such a way that the end phalanges of the thumbs are at the corners of the shoulder blades, and the remaining fingers, slightly apart, are placed along the lateral surfaces of the chest. With normal mobility of both halves of the chest, the thumbs rise to the same level on the right and left, and the remaining fingers, due to the expansion of the chest in the lateral directions, move slightly apart. When one of the halves lags thumb on the corresponding side will stand lower.

To study the mobility of the chest, its circumference is measured in the position of inhalation and exhalation. The difference between these figures reflects her excursion. With quiet breathing, the chest excursion does not exceed 2 - 3 cm. The maximum chest excursion ranges from 7.0 to 8.5 cm (the position of maximum inhalation and maximum exhalation). The chest circumference is measured with a measuring tape, preferably with the patient standing and arms down. The patient should not change his position. You need to make sure that the tape runs at the angle of the shoulder blades at the back and at the level of the 4th rib at the front.

When examining the chest, it is necessary to pay attention to the participation of auxiliary respiratory muscles in the act of breathing. Normally, these muscles, like muscles abdominals, do not participate in the act of breathing.

2.3. Determination of the type, frequency, depth and rhythm of breathing

The following types of breathing are distinguished: chest, abdominal and mixed. If the expansion of the chest during breathing occurs mainly due to the contraction of the intercostal muscles, then this type of breathing is called thoracic, or costal. In this case, the chest during inhalation noticeably expands and rises slightly, and during exhalation it narrows and falls slightly. To better understand the chest type of breathing, we can say that this is “chest” breathing. The chest type of breathing is characteristic mainly of women.

When the diaphragm takes the main part in expanding the chest, this type of breathing is called diaphragmatic, or abdominal, since during inhalation the protrusion of the upper abdomen is noticeable. The abdominal type of breathing, or “belly” breathing, is more common in men.

If breathing movements are performed simultaneously due to contraction of the intercostal muscles and the diaphragm, then this type of breathing is called mixed. Breathing involves the lower parts of the chest and top part belly. Mixed breathing is observed in older people.

Respiratory rate is determined by monitoring breathing. For this purpose, a palm is placed on the epigastric region of the subject and the number of complete respiratory cycles (breathing movements) per minute is calculated by lifting the subclavian region with each inhalation. Inhalation corresponds to the raising of the palm, and exhalation corresponds to its lowering. With noisy breathing, its frequency can be determined at a distance from the patient. It is best if he does not realize that his breathing is being counted, otherwise he may unwittingly change its frequency. To distract the subject's attention, you can simultaneously place the fingers of the other hand on the radial artery to simulate palpating the pulse or simulate determining the pulse rate and at the same time follow the respiratory movements of the chest with your eyes. For an accurate determination, you should count your breathing rate for at least one minute.

The number of breaths per minute in a healthy person at rest ranges from 12 to 18, averaging 16 respiratory movements. Significant changes in respiratory rate can be expressed either by an increase in frequency (tachypnea) or a decrease in frequency (bradypnea). Under physiological conditions, a sharp increase in breathing occurs during nervous excitement, during and immediately after physical stress. However, such an increase is usually short-lived and quickly passes after the cause that caused it is eliminated.

During the study, it is necessary to pay attention to the relationship between respiratory rate and pulse rate. Usually it is 1:4.

In addition to determining the frequency of breathing, during examination you can establish its depth and rhythm.

The depth of breathing is determined by the volume of inhaled and exhaled air in a calm state. In adults, under physiological conditions, the volume of respiratory air ranges from 300 to 900 ml, averaging 500 ml. A change in breathing rate is usually combined with a change in its depth. Rapid breathing is usually shallow, as inhalation and exhalation become shorter. Slow breathing, on the contrary, is usually deep.

The breathing rhythm of a healthy person is correct, which is expressed in the same duration and the same depth of each respiratory movement - inhalation and exhalation. The pause is practically not defined. An exception may be a slight respiratory arrhythmia in healthy people during sleep.

3. Palpation of the chest

3.1. Techniques and rules of palpation

Palpation (feeling) of the chest as a research method consists of independent methodological techniques that allow:

clarify the examination data regarding the shape of the chest and the nature of breathing (see section “Inspection of the chest”);

if there is pain in the chest, determine its location and severity;

determine the resistance (elasticity) of the chest;

if the pleura is affected, detect the pleural friction noise and the sound of liquid splashing.

When palpating the chest, it is necessary to follow the general rules: carry it out in a warm room with the palmar surfaces of the fingers of one or both hands in symmetrical areas; the examiner’s hands should be sufficiently warm, nails should be cut short; if palpation causes pain, it should be done with extreme caution.

To accurately indicate the localization of changes in the chest area, it is conventionally divided by generally accepted horizontal and vertical identification lines. Horizontal lines are located along the ribs and intercostal spaces. Vertical lines - anterior median, sternal right and left, midclavicular right and left; anterior, middle and posterior axillary, scapular, paravertebral, posterior median.

Palpation is carried out methodically, starting from the upper sections in front. The skin and subcutaneous fat, muscles, ribs, sternum, shoulder blades, spine, intercostal spaces are palpated.

The thickness of the skin fold in symmetrically located areas of the chest is determined by palpation. To do this, take the skin fold with the index and thumb of both hands at the same time.

3.2. Determination of resistance (elasticity) of the chest

The study of the resistance (elasticity) of the chest is carried out by squeezing it in the anteroposterior and lateral directions, as well as palpating the intercostal spaces.

When compressing in the anteroposterior direction, the palm of the right hand is applied to the area of ​​the middle of the sternum, left hand- to the interscapular space at the same level. Compression of the chest in the lateral direction is performed along the axillary lines closer to the armpits. When palpating the intercostal spaces, the researcher's fingers are placed only in one intercostal space, both on the right and on the left. Normally, in young people, when palpating the chest and intercostal spaces, a feeling is created of their elasticity, pliability, they seem to be springing. With age, the elasticity of the chest decreases, it becomes less pliable and rigid (rigidity is increased resistance).

3.3. Definition of the phenomenon of vocal tremors

The phenomenon of vocal tremor is a palpable sensation of vibration in the patient’s chest when speaking or pronouncing individual words containing the letter “P”. Vibration vocal cords, which occurs when pronouncing these words, is transmitted through the bronchi to the chest.

The palms of the hands are placed on symmetrical areas of the chest, and then the patient is asked to loudly pronounce several words that contain the letter “P” (for example, “thirty-three”, “three hundred thirty-three”, “forty three”, “forty four”). Voice tremor is studied on symmetrical areas of the chest, starting from the top in front. In this case, the degree of vibration of the chest on the right and left is assessed. Normally, vocal tremor is better felt over the upper parts of the chest, and weaker over its lower parts. Increased vocal fremitus in the upper chest is explained by a shorter distance from the glottis to this area. Moreover, on the right side in the upper section, vocal tremor in healthy people is slightly stronger than on the left, which is due to the shorter and straighter right bronchus. Voice tremors are better detected in men with low voices and in people with thin chests, less so in women and children with high-pitched voices, as well as in obese people.

4.1. Rules

Percussion of the lungs as a research method consists of tapping on the surface of the chest in order to judge the physical properties of the respiratory organs by the nature of the resulting sound. Percussion of the lungs allows you to identify pathological changes in any part of the lung, determine the boundaries of the lungs and the mobility of their lower edge.

The patient's position during lung percussion should be vertical: standing or sitting. Doctor percussing the anterior and side walls chest, is located in front of the subject, and when percussing the posterior surface - behind him. When percussing the front surface, the patient stands with his arms down, the side surfaces with his hands behind his head, the back surface with his head down, slightly bent forward, with his arms crossed, with his hands on his shoulders so as to move the shoulder blades away from the spine as much as possible. The muscles of the upper shoulder girdle should be relaxed, since even slight muscle tension can change the percussion sound.

Possible pathological changes in the lungs or pleura can be detected using comparative percussion, i.e. percussion strictly on symmetrical areas of the chest. In this case, the percussion sound obtained in this area is compared with that in a symmetrical area of ​​the other half of the chest.

4.2. Method of comparative lung percussion

Comparative percussion of the lungs begins in the front in the supraclavicular fossae (above the apices of the lungs). The pessimeter finger is first placed parallel to the collarbone, then directly along the collarbones. Using a hammer finger, apply uniform blows first on the collarbones (direct percussion according to Yanovsky F.G.), then below the collarbones (in the first and second intercostal spaces). The pessimeter finger is placed in the intercostal spaces parallel to the ribs in strictly symmetrical areas of the right and left halves of the chest.

In the 3rd and lower intercostal spaces in front, comparative percussion is not performed, since from the 3rd intercostal space on the left, dullness of the percussion sound from the adjacent heart begins. You can only percuss below, along the parasternal line, comparing the sounds obtained by percussion in the 3rd, 4th and 5th intercostal spaces.

In the lateral areas of the chest, percussion is performed in the axillary fossa and along the 4th and 5th intercostal spaces. The pessimeter finger in the axillary areas is placed in the intercostal spaces parallel to the rib. In the 6th intercostal space, comparative percussion along the axillary lines is not carried out, since on the right in this intercostal space the dullness of sound from the adjacent liver begins, and on the left the sound acquires a tympanic hue due to the proximity of the gas bubble of the stomach.

From behind, comparative percussion is carried out in the suprascapular areas, in the upper, middle and lower parts of the interscapular spaces and under the shoulder blades - in the 8th and 9th intercostal spaces. The pessimeter finger is installed horizontally in the suprascapular region, and vertically in the interscapular spaces, parallel to the spine; under the shoulder blades - horizontally, parallel to the ribs.

4.3. Types of percussion sound and conditions for its appearance during comparative percussion of the lungs

Over the lungs of a healthy person, during percussion, a clear pulmonary sound is heard, which is mainly due to vibrations of the dense elements of the alveoli and the air contained in them. A clear pulmonary sound is a clear (loud), full (long-lasting), rather low and non-tympanic percussion sound.

During comparative percussion of the lungs of a healthy person, the percussion sound in symmetrical areas may not be exactly the same. This depends on the mass or thickness of the pulmonary layer, muscle development, and the effect on the percussion sound of neighboring organs.

A quieter and shorter percussion sound is determined by:

above the right apex - due to the shorter right upper bronchus, which reduces its airiness, and greater development of the muscles of the right shoulder girdle;

in the 2nd and 3rd intercostal spaces on the left due to the closer location of the heart;

over the upper lobes of the lungs compared to the lower lobes as a result of different thicknesses of air-containing lung tissue;

in the right axillary region compared to the left due to the proximity of the liver.

The difference in percussion sound in the latter case is also due to the fact that the stomach is adjacent to the diaphragm and lung on the left, the bottom of which is filled with air and, upon percussion, gives a loud tympanic sound (Traube's semilunar space). Therefore, percussion sound in the left axillary region due to resonance with “ air bubble The sound of the stomach becomes louder and higher-pitched, with a tympanic tone. Traube's space is limited on the right by the edge of the left lobe of the liver, on the left by the spleen, above by the lower border of the heart and the lower edge of the left lung, below by the left costal arch. When fluid accumulates in the left pleural cavity, Traube's space disappears, since the pleural sinus is filled with exudate and the percussion blow does not reach the gas bubble of the stomach.

4.4. Determination of the boundaries of the lungs and mobility of the lower edge of the lungs

Determination of the boundaries of the lungs and the mobility of their lower edge is carried out by the method of topographic percussion, which is based on determining the line of transition of one sound to another.

Topographic percussion allows you to establish:

the upper borders of the lungs or the height of the apexes and their width (the width of the Krenig fields);

lower borders of the lungs;

mobility of the lower edge of the lungs.

4.4.1. Determination of the upper boundaries of the lungs or the height of the apexes

The height of the tops is determined from the front and back. On this day, the front finger-pessimeter is installed in the supraclavicular fossa. Percussion is carried out in an oblique direction from the middle of the collarbone upward to a dull sound. A mark is made on the side of the pessimeter finger that faces the clear pulmonary sound, the collarbone. Normally, the height of the apex ranges from 3 to 4 cm. The right apex is 1 cm lower than the left.

To determine the posterior height of the apex, a finger-pessimeter is installed in the middle of the suprascapular fossa at the scapular crest, and then moved in the direction of the 7th cervical vertebra until a dull sound occurs. The mark is made on the side of the clear pulmonary sound. Normally, the height of the apex on the back right and left corresponds to the level of the spinous process of the 7th cervical vertebra.

4.4.2. Determining the width of the Krenig margins

The Kroenig field is a band of clear pulmonary sound that extends in front from the clavicle back to the scapula. The width of the Krenig field is determined in the following way: the pessimeter finger is installed in the middle of the upper edge trapezius muscle. Then percussion is carried out from the middle of this muscle along its upper edge to the shoulder until there is a dull sound. A mark is made on the side of the clear pulmonary sound. Next, percussion is carried out again from the middle of the trapezius muscle along its upper edge to the neck until a dull sound occurs. The mark is placed on the side of the clear pulmonary sound. The distance in centimeters between two marks is the width of the Kroenig field. Normally it ranges from 5 to 8 cm.

4.4.3. Determination of the lower border of the lungs

First, the lower border of the right lung is determined, i.e. establish the hepatopulmonary boundary. For this purpose, tap from above, going down along the intercostal spaces (starting from the 2nd intercostal space) along the periosternal, midclavicular, axillary and scapular lines. On the left, it is customary to begin determining the lower border from the anterior axillary line. To determine the lower border of the lungs, quiet percussion is used. The pessimeter finger is installed on the corresponding line parallel to the desired boundary and gradually moves towards it. The displacement of the pessimeter finger down to the expected border should not exceed its width. Percussion is carried out both along the ribs and intercostal spaces until a dull sound occurs. The mark is placed on the side of the pessimeter finger that faces the clear pulmonary sound. The boundaries along all lines, excluding the paravertebral line, are assigned to the corresponding ribs. The border along the paravertebral line is referred to as the spinous process of the corresponding vertebra, since palpation of the ribs near the spine is due to powerful muscles back is impossible. The location of the lower border of the lungs in people of different builds is not entirely the same. In typical hypersthenics it is one rib higher, and in asthenics it is one rib lower.

Table 1.1. Lower limit of the lungs in normosthenics

How to determine your body type?

Determine your body type! Training mode!

Good day to everyone who visited the site about Natural Bodybuilding! From this post you will get information on how to determine your body type. I think this article will be very useful for beginning bodybuilders, as well as girls and women. I ask smart people to walk by. So.

From a physiological point of view, there are three fundamental types of human physique - asthenic (ectomorph), normosthenic (mesomorph) and hypersthenic (endomorph). Each specific type has individual characteristics of muscle development and requires appropriate training and nutrition.

In order to find out your body type, it is enough to use a simple and accessible method - measure the thickness of the wrist of your right (or left - if you are left-handed) hand. An ectomorph has a circumferential wrist thickness of no more than 17.5 cm, a mesomorph has 17.5-20 cm, and for an endomorph this figure exceeds 20 cm.

In general, I believe that the most accurate way to find out your type is to determine the epigastric angle of the chest. The epigastric angle is measured between the costal arches, see the figure below.

a. Hypersthenic-Endomorph, obtuse epigastric angle.

b. Normosthenic-Mesomorph, right epigastric angle.

V. Asthenic-ectomorph, acute epigastric angle.

This applies to both men and women.

So, let's determine your body type, diet and training regimen.

1. Who is an ectomorph, type of training and nutrition?

Ectomorphs or Asthenics have a body type characterized by tall stature, elongated long limbs, thin bones, long and thin muscle fibers. People with this type of build have a low rate of muscle development, however, the percentage of body fat is low - this is their noticeable advantage when gaining lean body mass. muscle mass. How to gain weight for an asthenic person?

For ectomorphs, the most important factor in body building is proper high-calorie nutrition. Hyposthenics, in order to get their body weight off the ground, need to increase the calorie content of their diet to more than 3.5-4 thousand calories per day. To increase the calorie content in the diet, it is recommended to use gainers as a source of essential carbohydrates.

Ectomorph workouts are designed with an emphasis on heavy compound exercises, such as deadlift, squats with a barbell, bench press with a barbell, - three, two hard training in Week. Taking this into account, isolation exercises and cardio training are kept to a minimum, and the average training duration is no more than an hour.

For each basic exercise a separate training day is allocated, the optimal option for such training is 2-3 exercises of 3-4 sets of 6-10 repetitions. It is important to maintain a sufficiently long rest between sets (from two to three minutes) and limit the use of auxiliary exercises after the basic one - 1-2 “auxiliary” exercises will be enough for ectomorphs.

2. Who is a mesomorph, type of training and nutrition?

Mesomorphs or Normosthenics differ from nature in having a developed muscular skeleton, strong bones of moderate size, their muscle mass initially occupies a significant part of the body weight. Body fat content is relatively average.

Such people have beautiful correct proportions of limbs, wide rounded shoulders, and a massive chest. The mesomorph's metabolism is ideally suited to convert nutrients into growth muscle fibers. Mesomorphs have the greatest tendency to gain muscle mass and, with proper training, can as soon as possible get good results in bodybuilding.

The diet of a mesomorph bodybuilder should consist of high-quality healthy food. It is important to limit the consumption of fast carbohydrates – foods that lead to a gain of “fat” mass.

Mesomorph training should combine aerobic and strength components. You can dedicate one training day a week purely to aerobic and cardio exercises. The principle of strength training is generally similar to training ectomorphs - the heaviest working weights, short training duration - 3-4 exercises of 4 sets of 8-12 repetitions.

However, unlike asthenics, mesomorphs can expand the arsenal of auxiliary and isolating exercises, since it is easier for them to recover after heavy strength training.

3. Who is an endomorph, type of training and nutrition?

Endomorphs or Hypersthenics are people who tend to be overweight, characterized by short stature (in relation to weight) and wide bones. Hypersthenics have a fairly high body fat content and have a slow metabolism.

For good results In terms of body structure, an endomorph must follow a strict diet and almost completely abandon fast carbohydrates and saturated fats. It is also important to consume starchy foods such as rice or potatoes in moderation. The diet of an endomorph should include a large amount of foods containing fiber and protein. The most preferred food for this is various vegetables, boiled meat and fish.

The optimal training regimen for an endomorph or hypersthenic is alternating cross-fit and cardio training with heavy strength training, in an approximate ratio of 65/35%. Cross-Fit program and aerobic exercise allow hypersthenics to work in the mode of maximum elimination of adipose tissue, and heavy power loads will give an additional signal to the body aimed at overall muscle growth.

It is worth noting the required frequency of training for an endomorph - the more regularly he trains, the better he gets fat layer. Naturally, you shouldn’t force yourself into daily cardio training; it’s important to think through a program with 4-5 training days a week, 3-5 exercises of 4 sets of repetitions.

For more information about training for each body type, its intensity, approaches and repetitions, you can find information in the “PROGRAMS” section.

My name is Alex, I am the author of this site, I have been involved in amateur bodybuilding since 1992. I will give anyone a FREE consultation and write a competent individual program workouts taking into account your body type, both a beginner and an intermediate level athlete. You can write to me on this page.

/ proped_atastatsia

The hypersthenic chest (in persons with a hypersthenic physique) has the shape of a cylinder. Its anteroposterior size approaches the lateral one; supraclavicular fossae are absent, “smoothed out”. The angle of connection between the body and the manubrium of the sternum is pronounced; epigastric angle is greater than 90°. The direction of the ribs in the lateral sections of the chest approaches horizontal, the intercostal spaces are reduced, the shoulder blades fit tightly to the chest, the thoracic region is smaller than the abdominal region.

The asthenic chest (in persons of asthenic build) is elongated, narrow (both the anteroposterior and lateral dimensions are reduced), flat. The supraclavicular and subclavian fossae are clearly defined. There is no angle of connection between the sternum and its manubrium: the sternum and its manubrium form a straight “plate”. Epigastric angle less than 90°. The ribs in the lateral sections acquire a more vertical direction, the X ribs are not attached to the costal arch (costa decima fluctuans), the intercostal spaces are widened, the shoulder blades are wing-shaped behind the chest, the muscles of the shoulder girdle are poorly developed, the shoulders are lowered, the thoracic region is larger than the abdominal region.

The pathological forms of the chest are as follows: 1. Emphysematous (barrel-shaped) chest in its shape resembles a hypersthenic one. It differs from the latter in its barrel-shaped shape, bulging of the chest wall, especially in the posterolateral sections, and an increase in the intercostal spaces. Such a chest develops as a result of chronic emphysema of the lungs, in which their elasticity decreases and their volume increases; the lungs are as if in the inhalation phase. Therefore, natural exhalation during breathing is significantly difficult, and the patient experiences expiratory shortness of breath not only when moving, but often at rest. When examining the chest of patients with pulmonary emphysema, one can see the active participation in the act of breathing of the auxiliary respiratory muscles, especially the sternocleidomastoid and trapezius, retraction into the intercostal spaces, upward lifting of the entire chest during inhalation, and relaxation of the respiratory muscles during exhalation muscles and lowering the chest to its original position.

2. The paralytic chest resembles an asthenic one in its characteristics. It occurs in severely malnourished people, with general asthenia and poor constitutional development, for example in those suffering from Marfan's disease, often with severe chronic diseases, more often with pulmonary tuberculosis. Due to the progression of chronic inflammation, fibrous tissue developing in the lungs and pleura leads to their shrinkage and a decrease in the total surface of the lungs. When examining patients with a paralytic chest, along with signs typical of an asthenic chest, one often notices pronounced atrophy of the chest muscles, asymmetrical arrangement of the clavicles, and unequal retraction of the supraclavicular fossae. The shoulder blades are located at different levels and during the act of breathing they shift asynchronously (not simultaneously).

3. Rachitic (keel-shaped, chicken) chest - pectus carinatum (from Latin pectus - chest, carina - keel of a boat) is characterized by a pronounced increase in anteroposterior size due to the sternum protruding forward in the form of a keel. In this case, the anterolateral surfaces of the chest wall seem to be compressed on both sides and, as a result, connect to the sternum at an acute angle, and the costal cartilages at the site of their transition into the bone thicken clearly (“rachitic rosary”). In persons who previously suffered from rickets, these “rosaries” can usually be palpated only in childhood and adolescence.

4. The funnel-shaped chest in its shape can resemble normosthenic, hypersthenic or asthenic and is also characterized by a funnel-shaped depression in the lower part of the sternum. This deformity is considered as a result of an abnormal development of the sternum or long-term compression on it. Previously, such deformation was observed in teenage shoemakers; the mechanism of formation of the “funnel” was explained by the daily long-term pressure of the shoe last: one end of it rested on bottom part sternum, and on the other the shoe blank was stretched. Therefore, the funnel-shaped chest was also called the “shoemaker's chest.”

5. The scaphoid chest is distinguished by the fact that the depression here is located mainly in the upper and middle parts of the anterior surface of the sternum and is similar in shape to the depression of a boat (rook). This anomaly has been described in a rather rare disease of the spinal cord - syringomyelia.

6. Deformation of the chest is also observed in spinal curvatures that occur after injury, spinal tuberculosis, ankylosing spondylitis (Bechterew's disease), etc. There are four variants of spinal curvature: 1) curvature in lateral directions - scoliosis (scoliosis); 2) backward curvature with the formation of a hump (gibbus) - kyphosis; 3) forward curvature - lordosis; 4) a combination of sideways and posterior curvature of the spine - kyphoscoliosis.

Scoliosis is the most common. It develops mainly in school-age children when sitting incorrectly at a desk, especially if it does not correspond to the student’s height. Spinal kyphoscoliosis and very rare lordosis are much less common. Curvatures of the spine, especially kyphosis, lordosis and kyphoscoliosis, cause a sharp deformation of the chest and thereby change the physiological position of the lungs and heart in it, creating unfavorable conditions for their activity.

7. The shape of the chest can also change due to an increase or decrease in the volume of only one half of the chest (chest asymmetry). These changes in its volume can be temporary or permanent.

An increase in the volume of one half of the chest is observed when a significant amount of inflammatory fluid, exudate, or non-inflammatory fluid - transudate effusions into the pleural cavity, as well as as a result of the penetration of air from the lungs during injury. During examination, on the enlarged half of the chest, one can see smoothness and bulging of the intercostal spaces, an asymmetrical arrangement of the clavicles and shoulder blades, and a lag in the movement of this half of the chest during the act of breathing from the movement of the unchanged half. After resorption of air or fluid from the pleural cavity, the chest in most patients acquires a normal symmetrical shape.

A decrease in the volume of one half of the chest occurs in the following cases:

due to the development of pleural adhesions or complete fusion of the pleural fissure after resorption of exudate that has been in the pleural cavity for a long time;

when a significant part of the lung shrinks due to the proliferation of connective tissue (pneumosclerosis), after acute or chronic inflammatory processes (lobar pneumonia with subsequent development of lung carnification, pulmonary infarction, abscess, tuberculosis, pulmonary syphilis, etc.);

after surgical removal of part or the whole lung;

in the case of atelectasis (collapse of the lung or its lobe), which can occur as a result of blockage of the lumen of a large bronchus by a foreign body or tumor growing in the lumen of the bronchus and gradually leading to its obstruction. In this case, the cessation of air flow into the lung and the subsequent resorption of air from the alveoli lead to a decrease in the volume of the lung and the corresponding half of the chest.

Due to the reduction of one half, the chest becomes asymmetrical: the shoulder on the side of the reduced half is lowered, the collarbone and scapula are located lower, their movements during deep inhalation and exhalation are slow and limited; the supraclavicular and subclavian fossae sink more deeply, the intercostal spaces are sharply reduced or not expressed at all.

13. Inspiratory and expiratory dyspnea. Various forms of breathing rhythm disturbances. The concept of respiratory failure. Graphic recording of breathing rhythm disturbances. Shortness of breath (dyspnea) is a violation of the frequency and depth of breathing, accompanied by a feeling of lack of air.

By its nature, pulmonary dyspnea can be: inspiratory, in which it is mainly difficult to inhale; characteristic of a mechanical obstruction in the upper respiratory tract (nose, pharynx, larynx, trachea). In this case, breathing is slowed down, and with a pronounced narrowing of the airways, the inhalation becomes loud (stridor breathing). expiratory shortness of breath - with difficulty exhaling, observed with a decrease in the elasticity of the lung tissue (emphysema) and with narrowing of the small bronchi (bronchiolitis, bronchial asthma). mixed shortness of breath - both phases of respiratory movements are difficult, the reason is a decrease in the area of ​​the respiratory surface (with inflammation of the lung, pulmonary edema, compression of the lung from the outside - hydrothorax, pneumothorax).

Breathing rhythm. The breathing of a healthy person is rhythmic, with the same depth and duration of the inhalation and exhalation phases. In some types of shortness of breath, the rhythm of respiratory movements may be disrupted due to changes in the depth of breathing (Kussmaul breathing is pathological breathing, characterized by uniform, rare, regular respiratory cycles: deep noisy inhalation and intense exhalation. Usually observed with metabolic acidosis due to uncontrolled diabetes mellitus or chronic renal failure in patients in serious condition due to dysfunction of the hypothalamic part of the brain, in particular in diabetic coma.This type of breathing was described by the German doctor A. Kussmaul), the duration of inhalation (inspiratory dyspnea), exhalation (expiratory dyspnea) and the respiratory pause.

A dysfunction of the respiratory center can cause a type of shortness of breath in which, after a certain number of respiratory movements, a visible (from several seconds to 1 minute) prolongation of the respiratory pause or short-term breath holding (apnea) occurs. This type of breathing is called periodic breathing. There are two types of dyspnea with periodic breathing:

Biot's breathing is characterized by rhythmic but deep respiratory movements, which alternate at approximately equal intervals with long (from several seconds to half a minute) respiratory pauses. It can be observed in patients with meningitis and in an agonal state with deep cerebrovascular accident. Cheyne-Stokes breathing (from a few seconds to 1 minute) respiratory pause (apnea) first appears silent shallow breathing, which quickly increases in depth, becomes noisy and reaches a maximum on the 5-7th breath, and then decreases in the same sequence and ends with the next regular short pause. Sometimes during a pause, patients are poorly oriented in their surroundings or completely lose consciousness, which is restored when breathing movements are resumed. This kind of breathing rhythm disorder occurs in diseases that cause acute or chronic failure cerebral circulation and brain hypoxia, as well as in severe intoxication. It often manifests itself during sleep and often occurs in older people with severe atherosclerosis of the cerebral arteries. Periodic breathing also includes the so-called wave breathing, or Grocco breathing. In its form, it is somewhat reminiscent of Cheyne-Stokes breathing, with the only difference that instead of a respiratory pause, weak shallow breathing is observed, followed by an increase in the depth of respiratory movements, and then its decrease. This type of arrhythmic shortness of breath, apparently, can be considered as a manifestation of an earlier stages of the same pathological processes that cause Cheyne-Stokes respiration. Currently, it is customary to define respiratory failure as a condition of the body in which the maintenance of normal blood gas composition is not ensured or it is achieved through more intensive operation of the apparatus external respiration and heart, which leads to a decrease in the functionality of the body. It should be borne in mind that the function of the external respiration apparatus is very closely related to the function of the circulatory system: with insufficient external respiration, increased work of the heart is one of the important elements her compensation. Clinically, respiratory failure is manifested by shortness of breath, cyanosis, and in the late stage - in the case of the addition of heart failure - by edema.

14. Determination of the type of breathing, symmetry, frequency, depth of breathing, respiratory excursion of the chest.

When starting to study the respiratory system, first visually determine the shape and symmetry of the chest, then the frequency of breathing, its rhythm, depth and uniformity of participation of both halves of the chest in the act of breathing. In addition, pay attention to the ratio of the duration of the inhalation and exhalation phases, as well as which muscles are involved in breathing.

The chest is examined from all sides using direct and lateral lighting. Its shape is judged by the ratio of the anteroposterior and transverse dimensions (determined visually or measured with a special compass), the severity of the supra- and subclavian fossae, the width of the intercostal spaces, the direction of the ribs in the inferolateral sections, and the size of the epigastric angle. In the case when the epigastric angle is not outlined, in order to determine its size, it is necessary to press the palmar surfaces of the thumbs to the costal arches, resting their tips on the xiphoid process (Fig. 35).

When measuring chest circumference, it is advisable to compare the distance from the middle of the sternum to the spinous process of the vertebra on both sides.

The respiratory rate is usually determined by visual observation of the respiratory excursions of the chest, however, if the patient is breathing shallowly, you should place your palm on the epigastric region and count the respiratory movements by lifting the hand as you inhale. Respiratory movements are counted over one or more minutes, and this must be done unnoticed by the patient, since breathing is a voluntary act. The rhythm of breathing is judged by the uniformity of respiratory pauses, and the depth of breathing is determined by the amplitude of respiratory excursions of the ribs. In addition, by comparing the amplitude of movements of the ribs, collarbones, angles of the shoulder blades and shoulder girdles on both sides, one gets an idea of ​​the uniformity of participation of both halves of the chest in the act of breathing.

When comparing the duration of inhalation and exhalation, it is necessary to pay attention to the intensity of the noise created by the air flow in both phases of breathing.

Normally, the chest has a regular, symmetrical shape. In normosthenics, it has the shape of a truncated cone, with its apex facing downwards, its anteroposterior size is 2/3-3/4 of the transverse size, the intercostal spaces, supra- and subclavian fossae are not clearly expressed, the direction of the ribs in the inferolateral sections is moderately oblique, the epigastric angle approaches direct

In asthenics, the chest is narrow and flattened due to a uniform decrease in its anteroposterior and transverse dimensions, the supra- and subclavian fossae are deep, the intercostal spaces are wide, the ribs go steeply down, the epigastric angle is acute.

In hypersthenics, the anteroposterior and transverse dimensions of the chest, on the contrary, are uniformly increased, so it appears wide and deep, the supra- and subclavian fossae are barely outlined, the intercostal spaces are narrowed, the direction of the ribs approaches horizontal, the epigastric angle is obtuse.

Changes in the shape of the chest may be due to pathology of the lung tissue or improper formation of the skeleton during development.

Patients with tuberculosis of both lungs with cicatricial wrinkling of the lung tissue are characterized by the so-called paralytic chest, reminiscent of an extreme version of the chest of asthenics: it is significantly flattened and is constantly in a position of complete exhalation, the ribs are drawn closer together, the intercostal spaces are retracted, supra- and subclavian fossa, atrophy of the pectoral muscles.

With emphysema (bloating) of the lungs, a barrel-shaped chest is formed, which resembles an extreme version of the chest of hypersthenics: both of its diameters, especially the anteroposterior one, are significantly increased, the ribs are directed horizontally, the intercostal spaces are widened, the supra- and subclavian fossae are smoothed out or even bulge in the form of so-called "emphysematous pillows". At the same time, the amplitude of respiratory excursions is significantly reduced and the chest is constantly in a position of deep inspiration. A similar shape of the chest, but with sharply thickened collarbones, sternum and ribs, can be observed in patients with acromegaly. It should also be taken into account that the smoothness of both supraclavicular fossae due to myxedematous edema is sometimes detected in hypothyroidism.

Congenital abnormalities of the chest sometimes result in a funnel-shaped depression in the lower part of the sternum (funnel chest, or cobbler's chest) or, less commonly, an elongated depression running along the upper and middle parts of the sternum (scaphoid chest). The scaphoid shape of the chest is usually combined with a congenital disease spinal cord characterized by impaired pain and temperature sensitivity (syringomyelia).

In patients who suffered from rickets in early childhood, in some cases a characteristic deformation of the chest is observed: it is as if compressed on both sides, while the sternum sharply protrudes forward in the form of a keel (rachitic, or keeled, chest, “chicken breast”). A keeled chest shape can also be detected with Marfan syndrome.

15. Palpation of the chest. Determination of pain, elasticity of the chest. Determination of vocal tremors, the reasons for its strengthening or weakening.

First, determine the degree of resistance of the chest, then palpate the ribs, intercostal spaces and pectoral muscles. After this, the phenomenon of vocal tremors is examined. The patient is examined in a standing or sitting position. The resistance (elasticity) of the chest is determined by its resistance to compression in various directions. First, the doctor places the palm of one hand on the sternum, and the palm of the other on the interscapular space, while both palms should be parallel to each other and at the same level. With jerking movements it compresses the chest in the direction from back to front (Fig. 36a).

Then, in a similar way, alternately compresses both halves of the chest in the anteroposterior direction in symmetrical areas. After this, place your palms on symmetrical areas of the lateral sections of the chest and compress it in the transverse direction (Fig. 36b). Next, placing your palms on symmetrical areas of the right and left halves of the chest, sequentially palpate the ribs and intercostal spaces in front, from the sides and from behind. The integrity and smoothness of the surface of the ribs are determined, and painful areas are identified. If there is pain in any intercostal space, the entire intercostal space from the sternum to the spine is felt, determining the extent of the area of ​​pain. It is noted whether the pain changes when breathing and bending the body to the sides. The pectoral muscles are felt by grasping them in the fold between the thumb and forefinger.

Normally, when compressed, the chest is elastic and pliable, especially in the lateral sections. When feeling the ribs, their integrity is not broken, the surface is smooth. Palpation of the chest is painless.

The presence of increased resistance (rigidity) of the chest to the pressure exerted on it is observed with significant pleural effusion, large tumors of the lungs and pleura, emphysema, as well as with ossification of the costal cartilages in old age. Pain in the ribs in a limited area may be due to their fracture or inflammation of the periosteum (periostitis). When a rib is fractured, a characteristic crunch appears at the site of palpable pain when breathing, due to the displacement of bone fragments. With periostitis, in the area of ​​the painful area of ​​the rib, its thickening and uneven surface are felt. Periostitis of the III-V ribs to the left of the sternum (Tietze syndrome) can mimic cardialgia. In patients who have suffered rickets, in the places where the bony part of the ribs passes into the cartilaginous part, thickenings are often determined by palpation - “rickets rosaries”. Diffuse pain in all ribs and sternum upon palpation and tapping on them often occurs with bone marrow diseases.

Pain that occurs on palpation of the intercostal spaces may be caused by damage to the pleura, intercostal muscles or nerves. Pain caused by dry (fibrinous) pleurisy is often detected in more than one intercostal space, but not throughout the entire intercostal space. This local pain intensifies during inhalation and when the torso is tilted to the healthy side, but it weakens if the mobility of the chest is limited by squeezing it on both sides with the palms. In some cases, in patients with dry pleurisy, when palpating the chest over the affected area, a rough pleural friction noise can be felt.

In case of damage to the intercostal spaces, pain on palpation is detected throughout the entire corresponding intercostal space, and with intercostal neuralgia, three pain points in places where the nerve is located superficially: at the spine, on the lateral surface of the chest and at the sternum.

Intercostal neuralgia and myositis of the intercostal muscles are also characterized by a connection between pain and breathing, but it intensifies when bending to the painful side. Detection of pain when palpating the pectoral muscles indicates their damage (myositis), which may be the cause of the patient’s complaints of pain in the precordial region.

In patients with significant effusion into the pleural cavity, in some cases it is possible to palpate thickening of the skin and pastosity over the lower parts of the corresponding half of the chest (Wintrich's sign). If the lung tissue is damaged, subcutaneous emphysema of the chest may develop. In this case, areas of swelling of the subcutaneous tissue are visually identified, upon palpation of which crepitus occurs.

Vocal tremors are vibrations of the chest that occur during conversation and are palpably felt, which are transmitted to it from the vibrating vocal cords along the column of air in the trachea and bronchi.

When determining vocal tremor, the patient repeats in a loud, low voice (bass) words containing the sound “r”, for example: “thirty-three”, “forty-three”, “tractor” or “Ararat”. At this time, the doctor places his palms flat on symmetrical areas of the chest, lightly presses his fingers against them and determines the severity of vibrating tremors of the chest wall under each of the palms, comparing the sensations received on both sides with each other, as well as with the vocal tremor in adjacent areas of the chest. If unequal severity of vocal tremor is detected in symmetrical areas and in doubtful cases, the position of the hands should be changed: the right hand should be placed in place of the left, and the left hand in place of the right, and the study should be repeated.

When determining vocal tremor on the anterior surface of the chest, the patient stands with his arms down, and the doctor stands in front of him and places his palms under the collarbones so that the bases of the palms lie on the sternum and the ends of the fingers are directed outward (Fig. 37a).

Then the doctor asks the patient to raise his hands behind his head and places his palms on the lateral surfaces of the chest so that the fingers are parallel to the ribs and the little fingers are at the level of the 5th rib (Fig. 37b).

After this, he invites the patient to lean forward slightly, lowering his head, and cross his arms over his chest, placing his palms on his shoulders. At the same time, the shoulder blades diverge, expanding the interscapular space, which the doctor palpates by placing his palms longitudinally on both sides of the spine (Fig. 37d). Then he places his palms in the transverse direction on the subscapular areas directly under the lower angles of the shoulder blades so that the bases of the palms are at the spine, and the fingers are directed outward and located along the intercostal spaces (Fig. 37e).

Normally, vocal tremor is moderately expressed, generally the same in symmetrical areas of the chest. However, due to the anatomical features of the right bronchus, vocal tremor over the right apex may be slightly stronger than over the left. With some pathological processes in the respiratory system, vocal tremors over the affected areas may increase, weaken, or disappear completely.

An increase in vocal tremors occurs when the conduction of sound in the lung tissue improves and is usually determined locally over the affected area of ​​the lung. The reasons for increased vocal tremors may be a large focus of compaction and decreased airiness of the lung tissue, for example, with lobar pneumonia, pulmonary infarction, or incomplete compression atelectasis. In addition, vocal trembling can be intensified over a cavity formation in the lung (abscess, tuberculous cavity), but only if the cavity is large, located superficially, communicates with the bronchus and is surrounded by compacted lung tissue.

A uniformly weakened, barely perceptible vocal tremor over the entire surface of both halves of the chest is observed in patients with pulmonary emphysema. It should, however, be taken into account that vocal tremor may be slightly pronounced over both lungs and in the absence of any pathology in the respiratory system, for example, in patients with a high or quiet voice, a thickened chest wall.

The weakening or even disappearance of vocal tremors may also be due to the displacement of the lung from the chest wall, in particular, the accumulation of air or fluid in the pleural cavity. In the case of pneumothorax, weakening or disappearance of vocal tremor is observed over the entire surface of the air-pressed lung, and in the case of effusion into the pleural cavity, usually in the lower parts of the chest above the place of fluid accumulation.

When the lumen of the bronchus is completely closed, for example, due to its obstruction by a tumor or compression from the outside by enlarged lymph nodes, there is no vocal tremor over the collapsed part of the lung corresponding to the given bronchus (complete atelectasis).

16. Percussion of the lungs. Physical justification of the method. Percussion methods. Types of percussion sound.

Percussion (percussio) - tapping, one of the main methods of objective examination of the patient, which consists in tapping areas of the body and determining, by the nature of the sound that arises, the physical properties located under the percussed area of ​​organs and tissues. The nature of the sound depends on the density of the organ, its airiness and elasticity. Based on the properties of the sounds generated during percussion, the physical properties of the organs lying under the tapped area are determined.

Direct percussion - Auenbrugger percussion - is now rarely used; sometimes when determining the boundaries of the heart, during comparative percussion of the lower parts of the lungs, during percussion along the collarbones, although in the latter case we already have a transition from direct to mediocre percussion, since the collarbone plays the role of a plessimeter. With direct percussion, we have a very low intensity of percussion sound and the difficulty of distinguishing sounds from each other, but here we can fully use the sense of touch and the sensation of resistance of the percussed tissues. The development of direct percussion in this direction led to the development of methods that can be called silent percussion methods: this can, for example, to a certain extent include Obraztsov’s clicking method and the stroking or sliding method. For percussion, Obraztsov used a click (strike) with the flesh of the index finger of his right hand as it slipped from the back surface of the middle finger. Stroking or sliding percussion is performed with the flesh of three or four fingers on the exposed surface of the chest. In this way, it is possible, as our own experience convinces us, to determine the boundaries of organs with sufficient accuracy. Mediocre percussion in its various forms, due to the influence of the plessimeter (by which the percussed area is compressed, made denser and more elastic, and therefore more capable of vibration and sound transmission), has two main advantages: the percussion sound becomes louder and more distinct. In addition, with mediocre percussion, there is a much greater possibility of adapting percussion sound for various purposes pursued by percussion. The finger-finger method of percussion has a number of advantages: 1) with it the doctor is independent of the instruments, 2) the finger plesimeter is convenient and easily adapts to any surface of the body , 3) with this method, both acoustic and tactile sensations are used to evaluate research data, 4) once you master this method of percussion, it is not difficult to master others. The middle or, less commonly, index finger of the left hand serves as a plessimeter. For this purpose, it is applied with its palmar surface to the percussed area tightly but easily (without much pressure). For percussion, use the middle or index finger of the right hand. The finger should be best bent so that its last two phalanges, or at least the end phalanx, are at right angles to the main one. In any case, the angle of its bending should always be the same. The remaining fingers should not touch it (they should be moved away from it). Movements for striking must be free and flexible and must be made at the wrist joint. A blow to the plessimeter finger (on its middle phalanx, less often on the nail) should be made with the flesh of the mallet finger and have a perpendicular direction to the percussed surface. This is very important condition to get a good, strong percussion sound. Further, the blow must have a number of other properties: it must be short, jerky, fast and elastic (it is best to remove the hammer finger from the plessimeter finger immediately after the blow, the blow must be rebounding). This achieves greater impact force and greater distribution in depth than on the surface. For a successful assessment of percussion sound and in the interests of a certain summation of auditory impressions, repeated blows should be used, that is, at each percussed place, make two or three identical blows at equal intervals. Deep and superficial percussion. A further division of percussion from the point of view of its methodology is its division into: 1) deep, strong or loud and 2) superficial, weak or quiet. The distribution of oscillatory movements across the surface and in depth, the amount of air brought into oscillation and the intensity of the percussion tone largely depend on the strength of the percussion blow. With deep (strong) percussion, vibrations of the percussed tissues spread over the surface to 4-6 cm and to a depth of 7 cm. With superficial (weak) percussion, vibrations spread over the surface to 2-3 cm and to a depth of 4 cm. In other words, acoustic the scope of action with strong percussion is approximately twice as large as with weak percussion. Depending on the circumstances - the greater or lesser size of the affected area, the greater or lesser depth of its location, and the purpose of the study - comparison of sound in different places or delimitation of two adjacent organs from each other - we use either stronger or less strong percussion. If the pathological focus in the lungs is small, its superficial location, or when determining the boundaries of organs, it is more advantageous to use weak (superficial) percussion. Conversely, for large-sized lesions, their deep location and for the purpose of sound comparison, it is better to use stronger (deep) percussion. A variation and further development of the principles of quiet (weak) percussion is the quietest (weakest), the so-called extreme or threshold percussion of Goldscheider. With this method of percussion, the strength of the percussion sound is reduced to the limits of the threshold for the perception of sound sensations (hence the name of the method), so that when we tap on airless parts of the body, we do not perceive any sound, but when moving to air-containing organs, a very light sound is heard. Goldscheider's method of extreme percussion is based on the idea that our hearing organ more easily notes the appearance of sound than its intensification. In practice, however, this method has not found general acceptance, and in any case, there is no doubt that stronger percussion, when used correctly, of course, does not give worst results. With the quietest or threshold percussion, you need to percussion only along the intercostal spaces in order to avoid intensifying the beetle on the ribs, and at the same time either finger on finger or finger on a special so-called stylus plessimeter. When percussing the finger, the latter should be held according to Plesch: the pessimeter finger is straightened at the second (distal) interphalangeal joint and bent at a right angle at the first; the dorsal surface of the second and third phalanges forms a concave surface. Tapping is done with the flesh of the middle finger of the right hand on the head of the main first phalanx of the plessimeter finger. The latter comes into contact with the percussed surface with its most sensitive part - the apex, which ensures the best perception of the difference in the feeling of resistance, which, undoubtedly, with this method of percussion plays a significant role, bringing it closer to tactile percussion. A slate plessimeter is a curved glass rod with a rubber cap at the end. Adjacent to the quietest (ultimate) percussion is the so-called tactile or palpatory percussion, although it is no longer based on sound perceptions, but on the sense of touch, on the sensation of resistance, which to a greater or lesser extent occurs with any percussion, but here it is placed, so say, in the eye of the corner. Tactile percussion can be, like percussion in general, direct and mediocre, and in the latter case not only finger-to-finger, but also instrumental (pessimeter - hammer). In any case, a percussion blow should not cause a sound. The blow should not be short and abrupt, as with ordinary percussion, but, on the contrary, slow, long and pressing. The position of the percussing hand corresponds to its position when writing, and the blow (or, perhaps, more accurately, pressure) is made by the soft part of the nail phalanx of the middle finger. Determination of the boundaries of organs by this method is carried out successfully, but it does not seem to have any significant advantages over conventional percussion. Comparative and topographical percussion. Depending on the goal we set for ourselves during percussion, we can distinguish two fundamentally various types percussion: 1) comparative percussion, aimed at comparing anatomically identical areas; 2) delimiting or topographical percussion, which has as its task the delimitation of anatomically different areas from each other and the projection of their boundaries onto the surface of the body. During comparative percussion, it is necessary to carefully monitor the equality (identity) of conditions when percussing symmetrical places: the same impact force, the same position and pressure of the plessimeter finger, the same breathing phase, etc. If in general during comparative percussion they usually use stronger percussion, then, if the data is unclear, doubtful, one should try successively strong, moderate, weak, and weakest percussion, and then it is often possible to obtain a completely clear result. In the interests of a more reliable comparison and for the purpose of self-control, the sequence of percussion strokes should be changed: for example, if we, comparing two symmetrical places, percussed first the right and then left side and at the same time you get some difference in sound, then you should percussion in the reverse order (first on the left, and then on the right). Often with this technique, the apparent difference in percussion tone disappears. Comparative percussion is, of course, applicable not only to comparing two symmetrical places, but also to comparing two places with a certain and known difference in their sound on the same side of the body. With comparative percussion, it is not enough to simply establish the fact of a change in sound, for example, dulling it, as with restrictive percussion, but detailed differentiation of the percussion tone according to all its basic properties is necessary: ​​intensity, tonality, timbre. This is extremely important for obtaining a clear picture of the physical state of the organ being percussed. Discriminating topographical percussion, as stated above, requires quiet percussion, a short impact and a possibly smaller surface area. The latter can be achieved by using the pessimeter in its edge position, and with a finger-pessimeter - by contacting only its apex with the percussed surface (conditions necessary to obtain intermittent oscillations of the percussed body). Very important point with delimiting percussion, there is the greatest possible elasticity, springy nature of both the percussing and percussed hands. The conditions necessary for this are difficult to describe, but they are easy to learn in practice. It is necessary to ensure that the pessimeter finger is applied to the percussion site, as indicated above, as easily as possible, without any pressure. For any strong pressure of the plessimeter already gives the percussion a strong character. When distinguishing air-containing parts of the body from airless ones, some recommend percussion in the direction from air-containing to airless, others - vice versa. In practice, this is not significant, and you need to percuss in both directions, crossing the desired boundary several times until its position is clearly determined. The organs of our body are located in such a way that they, as a rule, overlap one another, and the boundaries between them never go perpendicular to the surface of the body. Therefore, for most organs, when percussing them, we get two areas of dullness: 1) superficial or absolute in the part where the organ is directly adjacent to the outer wall of the body and where we get an absolutely dull percussion tone, and 2) deep or relative area of ​​dullness - there, where the airless organ is covered by the air-containing one and where we get a relatively dull percussion tone. The rule for determining superficial (absolute) dullness is superficial (weak) percussion, in which in the area of ​​absolute dullness the sound is inaudible or almost inaudible. In a word, there are general rules topographic percussion. To determine deep (relative) dullness, deeper, stronger percussion is also used. But the percussion blow should essentially be only slightly stronger than with superficial percussion (when determining absolute dullness), but the percussed finger should be pressed against the surface of the body much stronger, although again not too tightly. One thing to remember is that a common mistake for beginners is to use too much percussion. Of the special methods of percussion, two more need to be mentioned - the method of auscultatory percussion or, which is the same thing, percussion auscultation, i.e., the method of simultaneous use of percussion and auscultation, and then the method of rod-pleximeter percussion. The method of auscultatory percussion has been proposed for determining the boundaries of organs and consists in placing a stethoscope on the organ being examined and listening through it to hear the percussion tone, or better yet, the sound of friction (scratching) of the skin, which is produced in different directions or from the stethoscope to the periphery, or, conversely,” from the periphery to the stethoscope. In the first case, a percussion tone. or friction noises are heard clearly while they are produced within the organ being examined, and are sharply and suddenly muffled, weakened or disappear as soon as the border of the organ is crossed. In the second case, the change in sounds is the opposite: weak and dull at first, they intensify as they cross the border of the organ. This method has not found widespread use since, being more complex, it does not have any advantages over simple percussion. But in some cases it gives top scores, namely: when determining the boundaries of the stomach and the lower border of the liver. Rod-pleximeter percussion has been proposed to obtain a metallic shade of percussion tone, characteristic of air-containing cavities with smooth? walls and due to the sharp predominance of high overtones. You need to percussion on the plessimeter with some more or less sharp metal object (a metal stick, the end of a hammer handle, the edge of a coin, etc.). .

The position of the patient is distinguished: active, passive, forced.

Active position typical for patients with relatively mild illnesses or in the initial stages of severe illnesses. Patients actively move, at least within the hospital ward, although they experience various painful sensations.

Passive position- a condition when the patient cannot independently change the position given to him.

Forced position taken by the patient to alleviate his condition. During an attack bronchial asthma(suffocation, accompanied by a sharp difficulty in exhaling) the patient takes a forced sitting position. Resting your hands on the back of the chair, the edge of the bed, your knees. This allows you to fix the shoulder girdle and connect additional respiratory muscles, in particular the muscles of the neck, back and pectoral muscles, which help to exhale.

During an attack of cardiac asthma and pulmonary edema caused by blood overflow of the vessels of the pulmonary circulation, the patient tends to take a vertical position (sitting) with his legs down, which reduces the blood flow to the right side of the heart and makes it possible to somewhat relieve the pulmonary circulation (orthoptic position).

Patients with inflammation of the pleura and intense pleural pain often take a forced position lying on the affected side or sitting, pressing the chest on the affected side with their hands. This position limits the respiratory movements of the inflamed pleura, rubbing them against each other, which helps reduce pain.

Many patients with unilateral lung diseases (pneumonia) try to lie on the affected side. This position facilitates the respiratory excursion of a healthy lung, and also reduces the flow of sputum into the large bronchi, which reflexively causes a painful cough.

CONSTITUTION.

Different people have different body structure (physique) features. Although each person has his own constitution, certain types of people can be distinguished according to their most important constitutional characteristics - constitutional types.

There are three constitutional types:

Asthenic;

Normosthenic;

Hypersthenic.

Asthenic type.

The body structure (habitus) of asthenics is distinguished by the predominance of longitudinal dimensions over transverse ones. Growth is predominantly in length. The limbs are long and thin, the hands and fingers are narrow, the frame is light and slender. The skull is elongated in height and in anteroposterior size (dolichocephalic). The face is most often sharply defined, the profile is angular, and the nose is large and narrow. The chin is weakly expressed, the hairline is abundant, extending to the forehead and temples. The eyebrows are wide. The neck is long and thin, the shoulders are narrow.

The chest is long, narrow and flat, the intercostal spaces are wide. The epigastric angle is acute. The belly is small. The pelvis is small. The skin is thin, soft, dry, pale. The subcutaneous fat layer is slightly developed. Asthenics are thin. Their muscles are thin and relatively poorly developed.

Asthenics tend to have relatively lower blood pressure. Their intestinal absorption capacity is less intense. Metabolism is accelerated.

Hypersthenic type.

The structure of the hypersthenic body is distinguished by the predominance of transverse dimensions over longitudinal ones. These are massive, well-fed and strong people. He is tall, his body is large, his limbs are short, his fingers are short and blunt, his hands are wide. The head of a hypersthenic is round in shape and of considerable size. The face is wide, the features are soft, regular, the forehead is high. Well defined mouth with full lips and prominent chin. The hair is soft and there is a tendency to go bald. The neck is short and thick, the head sits deep in the shoulders, the shoulders are wide and straight. The chest is wide, short and deep. The ribs run almost horizontally, the intercostal spaces are narrow. Epigastric angle obtuse . The abdominal cavity and pelvis are capacious. The skin is dense and elastic, little pigmented. The bones of the skeleton are wide, heavy, strong.

This type of people tends to have higher blood pressure and red blood composition. Prone to obesity. Exchange is slow.

Normosthenic type.

Normosthenics have a right epigastric angle. Characterized by a correct physique with a proportional relationship between body parts, well-developed skeletal muscles, a regular chest shape with costal angle (epigastric), approaching the right angle .

SKIN CONDITION.

When examining the skin, attention is paid to its color, moisture, elasticity, condition of the hair, the presence of rashes, hemorrhages, vascular changes, scars, etc.

Skin coloring.

Normal skin has a physiological color.

Pallor skin can be explained by coldness, fear, anemia. Hyperemia(redness) is characteristic of feverish patients, occurs during neuropsychic excitement, overheating, after taking certain medications (nicotinic acid), etc. Cyanosis– bluish discoloration of the skin and visible mucous membranes. There are general and local cyanosis. General cyanosis is most noticeable in those places where the integument is thin (lips, cheeks, tip of the nose, ears) or where circulatory conditions are less favorable due to distance from the heart (tips of fingers and toes - acrocyanosis). Local (or limited) cyanosis has a different meaning and mostly depends on local circulatory disorders (for example, due to cessation of venous outflow in a particular part of the body). Jaundice the skin is observed when there is a violation of the outflow of bile from the liver into the intestines through the bile ducts; if there is a violation of the secretion of bile by liver cells; with excessive breakdown of red blood cells. Jaundice is noticeable first of all on the sclera, as well as on the mucous membranes.

Skin moisture.

When examining the skin, pay attention to sweating. In pathological conditions, increased sweating is caused by: fever, some nervous conditions (pain, fear), strong accumulation of carbon dioxide in the blood (toxic or acidic sweats due to suffocation, sudden shortness of breath). Last view sweat is usually observed not on hyperemic, but on pale skin.

Some infectious diseases are accompanied by a strong tendency to sweat (tuberculosis, brucellosis, influenza, rheumatism). Due to increased sweating, special rashes (prickly heat) sometimes appear in the form of matte white bubbles the size of a poppy seed, covering the skin like dew.

Skin elasticity (turgor).

Elasticity is determined by the fold in which the skin can be taken along with subcutaneous fat. Normal skin elasticity is characterized by rapid straightening of the skin fold after the doctor’s fingers are unclenched; when the elasticity of the skin decreases after the fingers are unclenched, the fold persists for some time. A decrease in skin elasticity is observed:

In elderly and senile patients,

When the body is dehydrated (uncontrollable vomiting, diarrhea),

An increase in skin turgor often indicates fluid retention in the body, which is often accompanied by some swelling of the skin.

Clean skin.

Skin pigmentation – the appearance of its dark color. Strong pigmentation occurs when exposed to sunlight ( Tan). Of the pathological forms, skin pigmentation is most pronounced when the adrenal glands are affected.

In addition to general disorders of pigmentation of the integument, there are local, focal disorders. Such, for example, are the well-known freckles, birthmarks ( nevi). During pregnancy, pigment deposition around the nipples and along the linea alba increases sharply, giving these areas a dark brown color. During pregnancy, as well as with diseases of the uterus and general exhaustion, rather large brown spots appear on the face - chloasma.

Reverse changes in the skin are also known: the skin loses its normal pigment. Complete absence of skin pigment - albinism It is extremely rare and represents an anomaly that is inherited. Loss of pigment in certain areas of the skin occurs in the form of vitiligo– white spots on the body, often located symmetrically.

When examining the external integument, scars may be discovered after wounds, abscesses, or operations. There are known scars on the face after smallpox or scar stripes on the abdomen after pregnancy ( striae).

Rash found in many acute infectious diseases. Of particular importance are roseola, i.e. round pink small spots, on average 2 mm in diameter, not sharply demarcated from the surrounding skin. When pressed, roseola disappears. Roseola often turns into petechiae, i.e. the same formations in the center of which hemorrhage occurs.

There are also large spotted redness of the skin - erythema.

Often found on the skin rash(for urticaria). After the rash on the skin is noticeable peeling.

Hemorrhages in the skin and mucous membranes it occurs with bruises, wounds, infectious and toxic lesions of blood vessels, and with a lack of vitamin C in the body.

Examination of the skin can reveal various types of ulceration - ulcers

Traumatic, infectious or trophic order, in particular bedsores, formed in bedridden patients.

Figure 3 – Scheme of constitutional types according to V.G. Shtefko and A.D. Ostrovsky

Thoracic(thoracic) type - the chest is cylindrical or slightly flattened, highly developed in length, the abdomen is straight, the epigastric angle is acute or straight. The muscle and fat components are moderately expressed. The muscle tone is quite high, although their mass may be small. The legs are often straight, but there are O- and X-shaped legs.

Digestive(digestive) type - short neck, short chest, widened towards the bottom (conical), strongly developed belly, which protrudes and forms folds above the pubic bone. The epigastric angle is obtuse. The back is normal or flattened. The skeleton is large and massive. Due to abundant fat deposition, the bone relief is smoothed. Skeletal muscles can be well or poorly developed with good or weak tone. Legs are usually X-shaped or normal, O-shaped is extremely rare.

Abdominal(abdominal) type – slight development of the chest, significant development of the abdomen, the fat layer is moderately developed.

Muscle type– massive skeleton with clearly defined distal epiphyses of the upper and upper bones lower limbs. Strong muscle development, especially on the limbs, the chest is cylindrical, round, of the same diameter along the entire length, the shoulders are wide, the fat deposition is insignificant, the epigastric angle is straight. The back is normal with normally pronounced curves. The legs are often straight, but there are O- and X-shaped legs.

Asthenoid type– characterized by thin and delicate bones, long limbs. The chest is flattened, elongated, and often narrows downward. The epigastric angle is acute. The abdomen is sunken or straight. The back is stooped with sharply protruding shoulder blades.

Undefined type– based on the set of characteristics, it cannot be attributed to any of the types listed above.

Scheme of V.V.Bunak(1925). It is based on the following characteristics: the degree of fat deposition and muscle development, the shape of the chest, abdomen and back. There are 3 main body types: pectoral, muscular, abdominal and 4 subtypes: pectoral-muscular, muscular-pectoral, muscular-abdominal, abdominal-muscular. An indeterminate type is often isolated (up to 30%).

Figure 4 – Body types of men according to V.V. Bunaku: 1 – thoracic, 2 – muscular, 3 – abdominal.

Chest type– flat chest, acute epigastric angle, sunken abdomen, poorly developed muscles, slight fat deposits, thin skin, stooped or normal back.

Muscular type– cylindrical chest, straight stomach, well-developed muscles, straight back, moderate fat deposits, thick or medium-thick skin.

Abdominal type– conical chest, convex belly, average muscle development, highly developed fat deposits, thick or medium-thick skin, stooped or normal back.

Subtypes are characterized by a combination of properties inherent in different types, often located nearby.

When describing the female constitution, a diagram is often used I.B. Galant (1927), which takes into account body length, the degree of fat deposition and muscle mass, as well as the shape of the chest and abdominal region. It is proposed to distinguish 7 types of constitution in women, grouped into 3 categories.

A. Leptosomal constitutions

1. Asthenic type - Long pale face, thin body, flat, narrow and long chest, stooped back, sunken belly, narrow pelvis, long legs; When closed, there is free space between the thighs; the muscles are poorly developed.
2. Stenoplastic type - has a significant part of the signs of the asthenic type. This is a narrowly built type, but thanks to the qualitatively and quantitatively better development of all tissues of the body, this type approaches the ideal of female beauty: moderate fat deposition, muscles are elastic in tone, but small in volume, the chest is flattened. The back is normal.

B. Mesosomal constitutions.

1. Pyknic type - moderate or slightly increased fat deposition, shortened limbs compared to the stenoplastic type, rounded head and face, full shortened neck, wide and round shoulders. Cylindrical chest, round belly, wide pelvis with characteristic fat deposits, rounded hips, complete closure of legs.
2. Mesoplastic type - moderately developed muscles, a weak fat layer compared to the pyknic type, a wide, rounded face, strong development of the cheekbones.

B. Megalosomal constitutions.

The general trend is the same growth in length and width, in contrast to the trend of growth in length in leptosomal types and growth in width in mesosomal types.

1. Athletic type - highly developed muscles, poor fat development. Male terminal hair type, male pelvis, male facial features, etc.
2. Subathletic type - tall, slender women of strong build, moderate development of muscles and fat.
3. Euriplastic type - strong development of fat with pronounced features of the athletic type in the structure of the skeleton and muscles.

Figure 5 – Body types of women according to I.B. Galant: 1 – asthenic,

2 – stenoplastic, 3 – picnic, 4 – mesoplastic,

5 – athletic, 6 – sub-athletic, 7 – euryplastic

There are approaches to classification that are based on the characteristics of systems that unite a set of organs into a single physiological type. Yes, y I.P. Pavlova this is the central nervous system. When dividing into types, he proceeded from the fact that the internal unity of all parts of the body, its reactivity and balance with the external environment are ensured by the central nervous system. Higher nervous activity is characterized by the following basic properties - the strength of the processes of irritation and inhibition, mobility and balance. From this point of view, I.P. Pavlov identified the following constitutional types:

• strong unbalanced excitable , or unrestrained (with strong processes of excitation and inhibition, but with a relative predominance of the first);
• strong balanced agile , or fast;
• strong balanced calm , or slow (inertia of basic nervous processes);
• weak (weakness of both processes with a relative predominance of inhibition).

For humans, I.P. Pavlov proposed another classification, c. the basis of which was the predominance of the I or II signaling system. Depending on this, I distinguished mental And art types.

Constitutional types according to V.P. Kaznacheev:

• individuals resistant to short-term and large loads (sprinters),
• individuals who are resistant to long-term and light loads (stayers),
• individuals with response traits of the first and second types (mixers)

Analysis of associations of constitutional features allowed B.A. Nikityuk identify systems that are interconnected at the statistical and functional levels and have the following extreme manifestations in the human constitution.

1. Ectomorphy system – leptosomal (dolichomorphic, asthenic) body proportions (the chest is flattened, the epigastric angle is sharp, the limbs are elongated, the back is slightly stooped or straightened), reduced fat deposition, muscles of the “dry” type, with high specific strength (stomach straight or sunken); more often they have a simplified nature of finger patterns (arch, loop) with a low total ridge count, an increased occurrence of the serological factor “O” is assumed; at the chromosomal level, an incomplete set (45,XO) or a superset (47,XXY or 47,XYY) of sex chromosomes is possible.

2. Endomorphy system – eirisomal (brachymorphic, hypersthenic) body proportions (conical chest, obtuse epigastric angle, normal back, stooped or arched anteriorly), increased fat deposition, massive muscles with a lower specific strength (the abdomen is rounded-convex); complexity of the pattern (relative predominance of curls and loops with a high total ridge count).

Studying the weakest, most vulnerable aspects of constitutional types in people allows us to prevent their injury, identify a tendency to disease in time, predict the course of the disease, individualize treatment and a pedagogical approach. Based on this, we can recommend the most favorable living and activity conditions for representatives of each constitutional type.

Question 3 . Anomalous constitutions.

The concept of diathesis is closely related to the doctrine of constitutional affiliation. Diathesis are constitutional variants bordering on pathology . The concept of diathesis is essential for pediatrics. Numerous evidence of the dependence of the state of health and psychomotor development of children on the presence of certain constitutional anomalies has made the doctrine of diathesis an important part of pediatric medicine.

In the presence of diathesis, individuals are not sick, but are in a state of minimal resistance or maximum risk of developing certain diseases. The state of diathesis can be characterized as prenosological in relation to a certain range of diseases united by common links of pathogenesis.

Diathesis - this is a kind of anomaly of constitutional characteristics, characterized by a pathological reaction of the body to physiological and pathological stimuli.

Diathesis most often manifests itself in childhood when the mechanisms of homeostasis are not yet mature enough.

Ideas about diathesis were formulated at the end of the 19th - beginning of the 20th centuries.

Currently there are:

• exudative-catarrhal diathesis;
• lymphatic-hypoplastic diathesis;
• neuro-arthritic diathesis

Exudative diathesis . The appearance is normal or pasty, inflammatory processes easily occur with the formation of exudate, with a tendency to protracted course and allergic manifestations. Characterized by increased irritability of the skin and mucous membranes, modified by adaptation to the external environment, and reduced resistance to infections. In the first year of life, exudative diathesis is manifested by skin itching, increased irritability, sweating, mild occurrence and persistent progression of diaper rash, gneiss, and milk crusts. After a year, such children develop itchy blistering nodular rashes. Frequent and prolonged runny noses, pharyngitis, tonsillitis, sinusitis, conjunctivitis and bronchitis are noted.

Classics of pediatrics considered geographic tongue, enlarged peripheral lymph nodes, a tendency toward dyspepsia, loose and pale skin, a tendency toward hyperglycemia, and eosinophilia to be characteristic of this diathesis.

These individuals easily develop immediate allergic reactions and hyperergic inflammation, which affects the nature and spectrum of pathology and the course of psychomotor development of individuals. Clinically observed are bronchial asthma, urticaria, Quincke's edema, false croup, and anaphylactic shock.

Such children are characterized by a tendency to atopic allergies, and eczematous phenomena on the skin are frequent.

Lymphatic-hypoplastic diathesis. Various authors estimate the frequency of this constitutional anomaly at 3-7%. The appearance is characterized by pastiness and pallor, muscle tissue is poorly developed, and the lymph nodes are enlarged. The symptoms of disorders are very diverse. On the one hand, these are the phenomena of hyperplasia and at the same time insufficiency of lymphoid tissue. Sore throat and pharyngitis are common, there is lymphocytosis in the blood, and the spleen is enlarged. Predisposition to autoallergic diseases. On the other hand, there are phenomena of a hypoplastic nature, somatic and mental infantilism. Early hypoplasia of organs and depletion of the reparative and immunological properties of the mesenchyme, premature wear and tear of the body, early atherosclerosis. This condition is explained by a delay in the involution of the thymus gland, which in turn is caused by a violation of the regulatory effects of adrenal hormones on it. This diathesis is characterized by reduced adaptive capabilities of the body, low resistance to stress, easy development of the phase of exhaustion and non-adaptation (“distress”) during stress reactions, which is explained by reduced functionality of the adrenal glands. Factors that are low pathogenic for the average individual can seriously affect the health of carriers of lymphatic-hypoplastic constitutional anomaly.

Normally, depending on the constitution of a person, all chest cells are divided into normo-, hyper- and asthenic. In addition, against the background of certain diseases, injuries, etc. pathological variants may develop. For example: emphysematous, rachitic, funnel-shaped, etc.

Normosthenic, or conical, in shape resemble a truncated cone with an upward-facing base (shoulder girdle area). The epigastric (epigastric) angle, measured between the costal arches (to do this, the examiner presses the palmar surfaces of his thumbs tightly against the costal arches so that their ends rest against the xiphoid process), is 90°.

Hypersthenic chests are wide and shaped like a cylinder. The anteroposterior size here is approximately equal to the lateral one, and all absolute values ​​of diameters are greater than similar indicators in normosthenics. The epigastric angle is more than 90°, the muscles of the chest are well developed, and the shoulder blades fit tightly to it.

The asthenic chest is outwardly flat and narrow - due to the reduced anteroposterior and lateral dimensions, it looks somewhat elongated. The epigastric angle is acute (less than 90°). The shoulders are lowered, the shoulder blades are noticeably behind the back, and the muscles of the shoulder girdle are usually poorly developed.

In people who have been suffering from pulmonary emphysema for a long time, which is a complication of such quite common somatic problems today as chronic obstructive pulmonary diseases and bronchial asthma, an emphysematous (“barrel-shaped”) chest is formed. It, in fact, has the same basic features as hypersthenic, but in this case the anteroposterior size is more sharply increased, the supraclavicular fossae protrude, the horizontal course of the ribs is noted and the spaces between them are widened. On physical examination of patients, it is usually clearly visible active work accessory respiratory muscles, especially the sternocleidomastoid and trapezius muscles.

Rachitic (keeled) chest, or the so-called “chicken breast”, occurs in people who suffered from rickets in childhood. Its anteroposterior size is elongated, the anterolateral surfaces seem to be pressed inward, connecting at an acute angle with the sternum protruding forward like a keel. In addition, at the level of the attachment of the diaphragm, retraction of the lower part of the chest occurs.

The funnel-shaped form in its appearance resembles normo-, hyper- or asthenic, but has a funnel-shaped depression in the lower part of the sternum and in the area of ​​the xiphoid process, which is not characteristic of normal variants. Due to the fact that similar chest deformation was previously observed in teenage shoemakers, it has another name: “shoemaker’s chest.” It looks like the result of abnormal development of the sternum or very prolonged external pressure, although in most cases the exact cause cannot be determined.

In the case of the scaphoid chest, there is a depression in the upper and middle third of the sternum that visually resembles a boat. This option occurs in syringomyelia, a rare disease of the spinal cord.

The kyphoscoliotic chest is formed due to severe curvature of the spine against the background of a pathological process such as tuberculosis, rheumatoid arthritis, etc.

11.Physiological curves of the spine.

The beginning of the formation of physiological curves of the spine dates back to infancy.

Around 3 months During life, a child develops cervical lordosis under the influence of developing muscles neck and back while lifting the head while lying on your back and maintaining this position for a certain time.

By 6 months Thoracic kyphosis begins to form. The child develops the ability to move from a lying position to a sitting position and independently maintain this position.

By 9-12 months Lumbar lordosis begins to form under the action of the muscles that ensure the vertical position of the torso and limbs during standing and walking.

By 3 years a child has all the curves of the spine characteristic of an adult, but they are less pronounced, or rather, smoothed out.

Up to 5-7 years old With age, the shape of the spine is not fixed.

In a 6 year old a child lying on his back, all the curves of the spine disappear.

By age 7 The cervical and thoracic curves are firmly fixed, and the lumbar - at puberty. In younger schoolchildren, the formation of physiological curves is completed, which are supported by the appropriate balance of traction of the muscles attached to the spine.

The most stable posture is observed in children aged 10 years.

12. Determination of muscle tone and strength.

13. Determination of skin properties.

The total surface area of ​​the skin in newborns is approximately 0.25 m4, by the year it increases to 0.43 m2. With age, there is a further increase in the surface area of ​​the skin, calculated using the formulas: 29 years S=0.43+0.06x(n 1); 1017 yearsS=(n 1)+10, where: S - skin surface (m2); n - age (years). The thickness of the various layers of skin in children under 3 years of age is 1.5-3 times less than in adults, and only by the age of 7 does it reach the level of an adult. The thickness of the epidermis in newborns ranges from 0.15 to 0.25 mm, and in an adult - in the range of 0.25-0.36 mm. Epidermal cells in children are relatively far apart and contain a lot of water. The structure of the epidermis is loose, which gives the impression of a greater thickness of this layer. The stratum corneum in newborns is thin and consists of 2-3 layers of easily exfoliated cells. The granular layer is poorly developed, which determines the significant transparency of the skin of newborns and its pink color. The basal layer is well developed, however, due to insufficient production of melanocortin in the first months (sometimes years) of life, the function of melanocytes is reduced, and they produce relatively little melanin, which determines a lighter skin color. Features of the skin of newborns The skin itself in newborns and young children has a number of features. From the age of 4 months, the first elements of elastic fibers appear in the baby’s skin. They grow especially actively between the ages of 8 and 16 years. Only by the age of 6 years does the histological structure of the dermis approach that of adults, although the collagen fibers remain thin and the elastic fibers are relatively poorly developed. A distinctive feature of the skin of children, especially newborns, is the weak connection of the epidermis with the dermis, which is primarily caused by the insufficient number and poor development of anchor fibers. The border between the epidermis and dermis is uneven and tortuous. In various diseases, the epidermis easily peels off from the dermis, which leads to the formation of blisters. The surface of a newborn's skin is covered with a secretion that is close to neutral, which determines its weak bactericidal activity, but by the end of the first month of life the pH decreases significantly. The skin of infants contains up to 80-82% water. With age, the amount of water in the skin gradually decreases, primarily due to extracellular fluid. In adults, the skin contains only 62% water. The nerve endings of the skin are not sufficiently developed at the time of birth, but are functionally sound and cause pain, tactile and temperature sensitivity. The skin of newborns and children of the first year of life has a well-developed network of capillaries. After a year, the network of wide capillaries gradually decreases, and the number of long, narrow ones increases. The development of capillary structures ends by 14-16 years. The skin of a child in the first year of life, due to the peculiarities of its morphological structure, biochemical composition, and rich vascularization, is distinguished by its tenderness, velvety, and elasticity. In general, it is thin, smooth, its surface is drier than that of adults, and there is a tendency to peeling. The entire surface of the skin and hair is covered with a water-lipid layer, or mantle, consisting of water and fatty substances. The mantle protects the skin from the influence of environmental factors, excessive moisture and drying, sudden temperature changes, slows down and prevents absorption and exposure chemical substances, serves as a carrier of provitamin D. In addition, it has an antibacterial effect and increases the strength of the epithelium. The water-lipid layer in children contains 3 times less lipids. Copied from the site:

14.Determination of body weight deficiency.

One of the most important factors included in a comprehensive assessment of a child’s health status is physical development. Body weight deficiency reflects existing trophic disorders in the child’s body and is a risk factor for the occurrence of frequent morbidity, background pathology, changes in neurological status, functional disorders of the cardiovascular and autonomic nervous system, and, consequently, deviations in the formation of adaptive-compensatory reactions

Factors influencing the formation of underweight at various stages of child development include: national traditions, territorial and climatic conditions, health status of the mother and father, occupational hazards, working and living conditions, lifestyle. A number of works talk about the influence of a woman’s malnutrition during pregnancy on the development of dystrophic processes in the fetus and lag physical development in the first year of life

Every month in the first half of the year the weight increases by 800g, in the second half of the year by 400g. For example, a child’s body weight at birth is 3500g, now he is 9 months old, at this age his proper body weight is: 3500+ 800 *6+400*3=9500g.

15.Definition and norms of respiratory rate depending on age.

Respiratory rate the best way reflects lung function in young children,
More details: http://nawideti.info/zdorove-rebenka/375.html but significantly depends on the child’s activity during wakefulness. The most reliable and reproducible results are obtained when determining respiratory rate during sleep. The younger the child, the greater the impact on the respiratory system of various toxic substances. However, children in the first days of life are adapted to hypoxia.

16.Types of shortness of breath in children.

Dyspnea is one of the common signs of respiratory system disease; it is difficulty breathing with a violation of its frequency, depth and rhythm. There are 3 types of shortness of breath: inspiratory, expiratory and mixed.

Inspiratory dyspnea is the result of impaired air movement during inspiration through the upper respiratory tract. Signs:

Prolonged difficulty breathing

Difficulty breathing, often wheezing

In a serious condition noisy breath

Bradypnea develops

Retraction of intercostal muscles

Inspiratory dyspnea is one of the main signs of stenosing laryngotracheitis and foreign body diphtheria in the larynx and trachea.

Expiratory shortness of breath is the result of impaired passage of air during exhalation through the lower respiratory tract (bronchioles and small bronchi). Signs:

Extended exhalation

Difficulty exhaling

Tachypnea during a protracted process can turn into an attack of suffocation

protrusion of intercostal muscles

Expiratory shortness of breath is one of the main signs of obstructive bronchitis and bronchial asthma, in which narrowing of the terminal bronchi occurs.

Mixed dyspnea is difficulty in inhaling and exhaling, often against the background of tachypnea. It occurs in many diseases of the respiratory system (pneumonia, bronchitis, pleurisy) as well as other systems (flatulence, circulatory failure)

17. Features of comparative percussion of the lungs in children.

Percussion is a method of objective examination of the condition internal organs by assessing the sound produced by tapping fingers on a specific area of ​​the body.

It is carried out sequentially on the anterior, lateral and posterior surfaces of the chest. In this case, they alternately percussion on symmetrical areas of both halves of the chest. The nature of the sound at each point of percussion is determined and compared with the percussion sound on the opposite side, as well as with the sound in adjacent areas of the lungs.

The reliability of the results of comparative percussion largely depends on the identity of the conditions for its implementation in symmetrical areas. Such conditions, in particular, include the position of the pessimeter finger on the chest wall, the pressure it exerts on the percussed surface, and the force of percussion blows. Usually, percussion blows of medium strength are used first, however, in necessary cases, percussion blows of different strengths can be applied alternately. In particular, to detect pathological areas lying deep in the lung tissue, strong percussion blows should be used, while lesions lying superficially and having a small size are detected by quiet percussion. If a change in the nature of the percussion sound is detected in any area, as well as in doubtful cases, it is advisable to repeat the percussion, while changing the order of percussion strikes in symmetrical areas.

First, the doctor stands in front of the patient and percusses alternately in both supraclavicular fossae. To do this, the pessimeter finger is placed directly above the collarbone and parallel to it. Then he percusses the collarbones with a hammer finger, using them as a plessimeter. Next, it percusses in the 1st and 2nd intercostal spaces along the midclavicular lines, placing the pleximeter finger along the intercostal spaces (Fig. 39a). In the underlying parts of the anterior surface of the chest, comparative percussion is not performed, since cardiac dullness is located on the left below the second intercostal space, and on the right, the nature of the percussion sound was determined before examining the right border of the heart.

On the lateral surfaces of the chest, comparative percussion is sequentially carried out along the anterior, middle and posterior axillary lines. The doctor asks the patient to raise his hands behind his head and percusses alternately on both sides, first at axillary fossae, and then in the IV and V intercostal spaces, placing the finger-pessimeter along the intercostal spaces (Fig. 39b). In the underlying intercostal spaces along the axillary lines, comparative percussion is usually not performed, due to the fact that the area of ​​the tympanic sound of Traube's space is located close to the left, and the area of ​​hepatic dullness is located on the right.

To conduct comparative percussion on the back surface of the chest (Fig. 39c), the doctor stands behind the patient and asks him to lean forward slightly, lowering his head and crossing his arms over his chest, placing his palms on his shoulders. At the same time, the blades diverge to the sides, expanding the interscapular space. Initially, it percusses in the suprascapular areas. For this purpose, the pessimeter finger is placed above the spine of the scapula and parallel to it.

Then he percusses sequentially on symmetrical areas of the upper, middle and lower sections of the interscapular space, placing the pessimeter finger alternately to the right and left of the spine and parallel to it (percussion is not carried out along the shoulder blades). After this, it percusses on both sides in the subscapular areas, in particular in the VII, VIII and IX intercostal spaces, first along the paravertebral and then along the scapular lines. In this case, the finger-pessimeter is installed in the transverse direction along the intercostal spaces.

Normally, comparative percussion over the entire surface of both lungs reveals a clear pulmonary sound, basically the same in symmetrical areas of the chest. At the same time, it must be borne in mind that over the left apex the percussion sound may be slightly more “clear” than over the right, which is mainly due to the greater thickness of the muscles of the shoulder girdle on the right (in a left-handed patient, a clearer percussion sound may revealed by the right apex).

If you find an area over which, during percussion, instead of a clear pulmonary sound, a change in the percussion sound is noted, you should indicate the coordinates of this area, and also approximately determine in which lobe of the lung it is located.

As you know, both lungs have an upper and lower lobe, and the right lung, in addition, has a middle lobe. On back surface The upper and lower lobes are projected on both sides of the chest, the border between which runs along the line connecting the point of intersection of the IV rib with the posterior axillary line and the spinous process of the III thoracic vertebra. On the lateral and anterior surfaces of the left half of the chest, the border between the upper and lower lobes of the left lung runs along the line connecting the indicated point with the place of attachment of the VI rib to the sternum. A similar line on the lateral and anterior surfaces of the right half of the chest corresponds to the border between the middle and lower lobes of the right lung, while the border between its upper and middle lobes runs horizontally along the IV rib from the posterior axillary line to the right edge of the sternum.

Local dullness of percussion sound indicates compaction and decreased airiness of the area of ​​lung tissue in the percussion zone (pneumonia, tuberculosis, tumor, atelectasis, pulmonary infarction). Dullness of percussion sound in the interscapular space at the level of the IV-VI thoracic vertebrae can be caused by an expansion of the mediastinum, for example, due to an enlargement of the lymph nodes in it.

In contrast to the clear pulmonary sound, the dull sound is quieter, higher in pitch and shorter in duration, but in the above pathological processes it does not reach the character of the dull sound obtained by percussion over dense airless organs. At the same time, when fluid accumulates in the pleural cavities (exudative pleurisy, hydrothorax, hemothorax), percussion over the effusion reveals a dull sound, reminiscent of the sound obtained by percussion over the thigh muscles ("femoral dullness"). Usually in this case, a dull percussion sound is detected above the lower part of the pleural cavity, where fluid accumulates. However, with encysted pleurisy, the dull sound zone may be located atypically.

In patients with pulmonary emphysema, a box sound is detected over all parts of the chest during percussion due to increased airiness of the lung tissue. When cicatricial wrinkling or resection of one lung occurs, compensatory vicarious (replacement) emphysema of the healthy lung occurs, over which a tympanic sound will be detected by percussion.

The accumulation of air in the pleural cavity (pneumothorax) also leads to the appearance of a box sound over the entire surface of the corresponding half of the chest. The detection of a box sound in a limited area usually indicates the presence in the lung of a superficial, large, air-filled, smooth-walled cavity, for example, an abscess or a tuberculous cavity. In this case, an increase in the pitch of the sound can be noted if the patient opens his mouth during percussion (Wintrich phenomenon) or takes a deep breath (Friedreich phenomenon). If the cavity communicates with the bronchus through a narrow slit-like opening, then upon percussion over it a peculiar intermittent rattling tympanic sound appears, as when hitting a closed empty vessel with a cracked wall (“the sound of a cracked pot”). This sound can be reproduced by hitting the knee with your hands, folding them into a “lock”, but without pressing your palms tightly together.

18. Determination of the lower boundaries of the lungs.

When examining the lower border, percussion is carried out from above, going down along the intercostal spaces, on the right - along the midclavicular, axillary and scapular lines, on the left - along the axillary and scapular lines. The upper border of the lungs in infants and young children is not determined, since the tops do not extend beyond the collarbones due to the high position of the upper aperture of the chest and the relatively short neck. In children school age Determination of the standing height of the apexes of the lungs begins from the front. Percussion is carried out from the collarbone upward, touching the outer edge of the sternocleidomastoid muscle with the end phalanx of the pessimeter finger, until a shortened percussion sound appears. In healthy children, this area is located at a distance of 2-4 cm from the middle of the collarbone.

19.What kind of breathing is heard in children depending on age?

20.Types of cyanosis.

Cyanosis (blueness) of the skin is one of the main external manifestations of pathology of the respiratory organs and cardiovascular system, in which hypoxemia develops (the amount of oxyhemoglobin in the bloodstream decreases by 5% or more).

Based on localization, cyanosis is divided into general (total and generalized), when the skin of the entire body becomes bluish, and regional (local).
Local includes:

Acrocyanosis – cyanosis of the tips of the fingers, toes, nose, lips and earlobes

Perioral - around the lips

Periorbital - around the eyes

Cyanosis of the nasolabial triangle

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Many conversations about how obesity or thinness affects the likelihood of getting pregnant do not contain any useful information. This is due to the fact that even determining the percentage of fat is a rather complicated task, and there’s nothing to say about interpreting the results, so first let’s define the concepts.

About body mass index and body types

The range of a person's body weight can vary from underweight (hypotrophy) to obesity. How to determine what body weight can be considered normal?

There is not an ideal, but the most optimal solution - body mass index (BMI), this is the ratio of weight in kilograms to the square of height in meters. The normal range is based on age.

On average, a range from 20 to 24.9 is considered normal. This ratio works in a large percentage of cases, but as always there are exceptions.

Body tissues have different properties, bones and muscles give weight gain, but adipose tissue is quite light and first gives an increase in volume, and then weight. Each person's bones have their own thickness and width.

Based on the type of bone structure, there are 3 body types:

1. Adynamic(thin bone, epigastric angle less than 90º),
2. Normosthenic(normal bone thickness, epigastric angle 90º, most common body type),
3. Hypertensive(broad-boned, stocky people, epigastric angle more than 90º).

Epigastric angle- this is the angle formed by the costal edges in the sternum area, open downwards.

Accordingly, in people with an asthenic physique, the BMI may be insufficient, and in hypersthenics it may be excessive, with a normal ratio between lean mass and fat.

Another body type can be determined by the index of the ratio of chest volume at rest to height in centimeters.

For asthenics this ratio is less than 50%, for normosthenics it is from 50 to 55%, for hypersthenics it is more than 55%.

How to determine your body fat percentage?

In order to determine the percentage of fat contained in the body and the weight of lean mass, there is a special method. A direct method for determining body composition is weighing in water, the fatty tissue floats up, and you press the lean mass onto the scales, i.e. everything except fat. Accordingly, the difference in indicators will be the amount of fat. This is the simplest and most accurate method. There are also indirect methods based on the principle of impedance (special devices), as well as indices calculated by the sum of the thickness of fat folds (caliperometry). But these methods are less accurate and produce errors.

The optimal range for health is the % body fat range for women from 18 to 33 (for men from 12 to 25). The critical level of % fat tissue for women is 12% (for men 5%).

We present the norms of adipose tissue as a percentage by age for women and men. Keep in mind that the upper and lower limits of the range are actually no longer the norm, but also not a reason to talk about being overweight or underweight. They can be compared to a lottery and count on luck.

Adipose tissue and women's reproductive health

Adipose tissue is not only a site for the deposition of fatty acids, it performs an endocrine function and is the site of extraovarian synthesis of estrogens.

When planning pregnancy, gynecologists recommend being within the normal range for health by age, both in weight and in % of fat tissue.

What happens if you lose a lot of weight?

With a sharp decrease in weight, when the percentage of body fat is less than 12%, a sharp hormonal change occurs - menstruation stops, i.e. secondary amenorrhea occurs. The mechanism of development of this condition is associated with a violation of the neuroendocrine control of the synthesis and release of gonadotropin-releasing hormone (aka gonadorelin, gonadoliberin, or GnrH for short) in the hypothalamus. A decrease in its entry into the pituitary gland leads to a decrease in the synthesis and disruption of the rhythm of synthesis of gonadotropins: FSH, ACTH, TSH, LH, Prolactin, STH. With a decrease in the synthesis of FSH and LH, the growth of follicles slows down, and accordingly, underdeveloped follicles will synthesize less estrogens - secondary hypoestrogenism develops, against the background of which full ovulation does not occur. When treating this pathology, with weight gain, the menstrual cycle is usually restored, but ovulation is very difficult to restore.

How will excess body weight affect?

With obesity, secondary amenorrhea also often occurs, but the reasons for its development are different: polycystic ovary syndrome, hyperprolactinemia, hyperandrogenism, dysfunction of the thyroid gland. As a rule, these disorders develop from early childhood, they are associated with pathology of neuroendocrine regulation, and obesity in such cases develops secondarily, from puberty.

The development of obesity after puberty, due to insufficient physical activity and poor nutrition, can also lead to a number of endocrine disorders that negatively affect a woman’s reproductive health.

Estrogen is found in the ovaries and adrenal glands. The ovaries produce estrogen constantly, and the adrenal glands produce the hormone androstenedione, which is converted in fat cells to folliculin, which is very close to estrogen. This will disrupt the natural ovulation cycle and can lead to infertility.

Excess weight can cause:

1. Menstrual irregularities;
2. Increased risk of developing infertility;
3. Low probability of successful infertility treatment;
4. Increased risk of spontaneous abortion.

But there are also diabetes, cardiovascular diseases, arterial hypertension, etc. All these diseases, including infertility, are extremely difficult to treat, since excess fat in the body makes it difficult to absorb drugs.

Let's name the numbers. According to research, the likelihood of becoming pregnant in obese women is on average 45% lower than in women with normal body weight. And this is subject to regular menstrual cycles. As soon as problems with ovulation begin, the picture becomes much worse. We would like to emphasize once again that even with a normal ovulatory cycle, excess body weight reduces the likelihood of getting pregnant.

Conclusion

Nature does not like extremes and the mechanism of natural selection will not work at this stage of development of medical science. Developed countries are literally groaning at the rate at which obesity is affecting the population. Your weight and your reproductive health depend only on you. This is not a loud phrase, but a simple statement of fact, as obvious as the phrase that smoking kills. By making your choices today you influence your future.

2. The palmar surfaces of the thumbs are pressed tightly against the costal arch, and their ends rest against the xiphoid process.

3. The epigastric angle can be:

· normosthenic chest - 90 degrees;

· hypersthenic - more than 90 degrees;

· asthenic - less than 90 degrees;

2. The palms of the hands are placed on symmetrical areas of the chest: supraclavicular areas, infraclavicular areas, the anterior surface of the chest on the right, lateral surfaces of the chest, suprascapular region, interscapular space, subscapular region.

3. Ask the patient to loudly pronounce several words that contain the letter “P” (for example: thirty-three)

Standard “Technique for comparative lung percussion”.

Comparative percussion is used to determine the nature of pathological changes in the lungs and pleural cavity and is used to diagnose a number of bronchopulmonary syndromes.

The comparative percussion technique has a number of features.

1. Comparative percussion of the lungs is carried out in a certain sequence: in front, on the sides, behind in strictly symmetrical areas of the right and left halves of the chest.

2. Apply percussion blows of medium strength or use loud percussion.

3. Percussion is carried out along the intercostal spaces.

4. Compare the nature of percussion sounds obtained in symmetrical areas of the chest

I. Front:

1. Ask the patient to undress to the waist.

2. Place the pessimeter finger alternately on the right and left halves
chest parallel to the collarbone above the apices of the lungs and
make 2-3 blows of equal force. Compare percussion sound.

3. Strike the collarbone with the second finger of your right hand.

4. Below the collarbones, place the pessimeter finger in the intercostal space
spaces parallel to the ribs along the midclavicular lines.
Percuss to the level of the fourth rib on the left. Percuss on the right until there is a dull sound.

P. Side

1. The pessimeter finger is located parallel to the course of the ribs.

2. The patient’s arms are raised to the head, elbows apart.

3. Conduct comparative percussion on the middle axillary
lines. W. Rear:

1. First, the suprascapular areas are percussed, for which the plessimeter finger is placed slightly above the spine of the scapula and parallel to it, and percussion blows are applied sequentially to the right and left.

2. In this case, the patient stands with his arms down along the body, the muscles are not tense.

3. Then the interscapular areas are percussed. The pessimeter finger is located parallel to the spine at the edge of the shoulder blades, sequentially on the right and left. The patient's arms are asked to be crossed on the chest, with the palms on the shoulders, this causes the shoulder blades to diverge, expanding the scapular space.

12. Examination of the chest. Signs that determine the shape of the chest. Physiological and pathological forms of the chest.

Inspection

Examination of the chest should always be carried out in strict sequence. First, you need to assess the shape of the chest, the location of the clavicles, supraclavicular and subclavian fossae, and shoulder blades, then characterize the type of breathing, its rhythm and frequency, and monitor the movements of the right and left shoulder blades, shoulder girdle and the participation of auxiliary respiratory muscles in the act of breathing during breathing. The examination is best carried out with the patient standing or sitting with the torso naked to the waist, which should be evenly illuminated from all sides.

Assessment of chest shape. The shape of the chest can be normal or pathological. A normal chest is observed in all healthy people of regular physique. Its right and left halves are symmetrical, the clavicles and shoulder blades are at the same level, the supraclavicular fossae are equally pronounced on both sides. But since all people of correct physique are conventionally divided into three constitutional types, the chest of different body types has a different shape, characteristic of its constitutional type. The pathological shape of the chest can arise as a result of both congenital bone abnormalities and various chronic diseases (emphysema, rickets, tuberculosis).

The normal shapes of the chest are as follows:

The normosthenic (conical) chest (in people of normosthenic physique) in its shape resembles a truncated cone, the base of which is formed by well-developed muscles of the shoulder girdle and is directed upward. The anteroposterior (sternovertebral) size is smaller than the lateral (transverse) size, the supraclavicular fossa is slightly pronounced. The angle formed by the body of the sternum and its manubrium (angulus Ludovici) is clearly visible; the epigastric angle approaches 90°. The ribs in the lateral sections have a moderately oblique direction; the shoulder blades fit snugly to the chest and are located at the same level; The thoracic section of the body is approximately equal in height to the abdominal section.

The hypersthenic chest (in persons with a hypersthenic physique) has the shape of a cylinder. Its anteroposterior size approaches the lateral one; supraclavicular fossae are absent, “smoothed out”. The angle of connection between the body and the manubrium of the sternum is pronounced; the epigastric angle is greater than 90 e. The direction of the ribs in the lateral parts of the chest approaches horizontal, the intercostal spaces are reduced, the shoulder blades fit tightly to the chest, the thoracic region is smaller than the abdominal region.

The asthenic chest (in persons of asthenic build) is elongated, narrow (both the anteroposterior and lateral dimensions are reduced), flat. The supraclavicular and subclavian fossae are clearly defined. There is no angle of connection between the sternum and its manubrium: the sternum and its manubrium form a straight “plate”. Epigastric angle less than 90°. The ribs in the lateral sections acquire a more vertical direction, the X ribs are not attached to the costal arch (costadecima fluctuans), the intercostal spaces are widened, the shoulder blades are wing-shaped behind the chest, the muscles of the shoulder girdle are poorly developed, the shoulders are lowered, the thoracic region is larger than the abdominal region.

The pathological forms of the chest are as follows:1. Emphysematous (barrel-shaped) The chest in its shape resembles a hypersthenic one. It differs from the latter in its barrel-shaped shape, bulging of the chest wall, especially in the posterolateral sections, and an increase in the intercostal spaces. Such a chest develops as a result of chronic emphysema of the lungs, in which their elasticity decreases and their volume increases; the lungs are as if in the inhalation phase. Therefore, natural exhalation during breathing is significantly difficult, and the patient experiences expiratory shortness of breath not only when moving, but often at rest. When examining the chest of patients with pulmonary emphysema, one can see the active participation in the act of breathing of the auxiliary respiratory muscles, especially the sternocleidomastoid and trapezius, retraction into the intercostal spaces, upward lifting of the entire chest during inhalation, and relaxation of the respiratory muscles during exhalation muscles and lowering the chest to its original position.

2. Paralytic The chest in its characteristics resembles an asthenic one. It occurs in severely malnourished people, with general asthenia and poor constitutional development, for example in those suffering from Marfan's disease, often with severe chronic diseases, more often with pulmonary tuberculosis. Due to the progression of chronic inflammation, fibrous tissue developing in the lungs and pleura leads to their shrinkage and a decrease in the total surface of the lungs. When examining patients with a paralytic chest, along with signs typical of an asthenic chest, one often notices pronounced atrophy of the chest muscles, asymmetrical arrangement of the clavicles, and unequal retraction of the supraclavicular fossae. The shoulder blades are located at different levels and during the act of breathing they shift asynchronously (not simultaneously).

3. Rachitic (keeled, chicken) chest -pectuscarinatum (from Latin pectus - chest, carina - keel of a boat) is characterized by a pronounced increase in anteroposterior size due to the sternum protruding forward in the form of a keel. In this case, the anterolateral surfaces of the chest wall seem to be compressed on both sides and, as a result, connect to the sternum at an acute angle, and the costal cartilages at the site of their transition into the bone thicken clearly (“rachitic rosary”). In persons who previously suffered from rickets, these “rosaries” can usually be palpated only in childhood and adolescence.

4. Funnel-shaped The shape of the chest can resemble normosthenic, hypersthenic or asthenic and is also characterized by a funnel-shaped depression in the lower part of the sternum. This deformity is considered as a result of an abnormal development of the sternum or long-term compression on it. Previously, such deformation was observed in teenage shoemakers; the mechanism of formation of the “funnel” was explained by the daily long-term pressure of the shoe last: one end of it rested on the lower part of the sternum, and the shoe blank was pulled on the other. Therefore, the funnel-shaped chest was also called the “shoemaker's chest.”

5. Scaphoid The chest is different in that the depression here is located mainly in the upper and middle parts of the anterior surface of the sternum and is similar in shape to the depression of a boat (rook). This anomaly has been described in a rather rare disease of the spinal cord - syringomyelia.

6. Chest deformity It is also observed with curvatures of the spine that occur after injury, spinal tuberculosis, ankylosing spondylitis (Bechterew's disease), etc. There are four options curvature of the spine: 1) curvature in lateral directions - scoliosis; 2) backward curvature with the formation of a hump (gibbus) - kyphosis; 3) forward curvature - lordosis; 4) a combination of sideways and posterior curvature of the spine - kyphoscoliosis.

Scoliosis is the most common. It develops mainly in school-age children when sitting incorrectly at a desk, especially if it does not correspond to the student’s height. Spinal kyphoscoliosis and very rare lordosis are much less common. Curvatures of the spine, especially kyphosis, lordosis and kyphoscoliosis, cause a sharp deformation of the chest and thereby change the physiological position of the lungs and heart in it, creating unfavorable conditions for their activity.

7. The shape of the chest can also change due to an increase or decrease in the volume of only one half of the chest (chest asymmetry). These changes in its volume can be temporary or permanent.

Increase in the volume of one half of the chest observed when there is effusion into the pleural cavity of a significant amount of inflammatory fluid, exudate, or non-inflammatory fluid - transudate, as well as as a result of the penetration of air from the lungs during injury. During examination, on the enlarged half of the chest, one can see smoothness and bulging of the intercostal spaces, an asymmetrical arrangement of the clavicles and shoulder blades, and a lag in the movement of this half of the chest during the act of breathing from the movement of the unchanged half. After resorption of air or fluid from the pleural cavity, the chest in most patients acquires a normal symmetrical shape.

Reduction in the volume of one half of the chest occurs in the following cases:

due to the development of pleural adhesions or complete fusion of the pleural fissure after resorption of exudate that has been in the pleural cavity for a long time;

when a significant part of the lung shrinks due to the proliferation of connective tissue (pneumosclerosis), after acute or chronic inflammatory processes (lobar pneumonia with subsequent development of lung carnification, pulmonary infarction, abscess, tuberculosis, pulmonary syphilis, etc.);

after surgical removal of part or the whole lung;

in the case of atelectasis (collapse of the lung or its lobe), which can occur as a result of blockage of the lumen of a large bronchus by a foreign body or tumor growing in the lumen of the bronchus and gradually leading to its obstruction. In this case, the cessation of air flow into the lung and the subsequent resorption of air from the alveoli lead to a decrease in the volume of the lung and the corresponding half of the chest.

Due to the reduction of one half, the chest becomes asymmetrical: the shoulder on the side of the reduced half is lowered, the collarbone and scapula are located lower, their movements during deep inhalation and exhalation are slow and limited; the supraclavicular and subclavian fossae sink more deeply, the intercostal spaces are sharply reduced or not expressed at all.

13. Inspiratory and expiratory dyspnea. Various forms of breathing rhythm disturbances. The concept of respiratory failure. Graphic recording of breathing rhythm disturbances. Shortness of breath (dyspnea) is a violation of the frequency and depth of breathing, accompanied by a feeling of lack of air.

By its nature, pulmonary dyspnea can be: inspiratory, in which it is mainly difficult to inhale; characteristic of a mechanical obstruction in the upper respiratory tract (nose, pharynx, larynx, trachea). In this case, breathing is slowed down, and with a pronounced narrowing of the airways, the inhalation becomes loud (stridor breathing). expiratory shortness of breath - with difficulty exhaling, observed with a decrease in the elasticity of the lung tissue (emphysema) and with narrowing of the small bronchi (bronchiolitis, bronchial asthma). mixed shortness of breath - both phases of respiratory movements are difficult, the reason is a decrease in the area of ​​the respiratory surface (with inflammation of the lung, pulmonary edema, compression of the lung from the outside - hydrothorax, pneumothorax).

Breathing rhythm. The breathing of a healthy person is rhythmic, with the same depth and duration of the inhalation and exhalation phases. In some types of shortness of breath, the rhythm of respiratory movements may be disrupted due to changes in the depth of breathing (Kussmaul breathing is pathological breathing, characterized by uniform, rare, regular respiratory cycles: deep noisy inhalation and intense exhalation. Usually observed with metabolic acidosis due to uncontrolled diabetes mellitus or chronic renal failure in patients in serious condition due to dysfunction of the hypothalamic part of the brain, in particular in diabetic coma.This type of breathing was described by the German doctor A. Kussmaul), the duration of inhalation (inspiratory dyspnea), exhalation (expiratory dyspnea) and the respiratory pause.

A dysfunction of the respiratory center can cause a type of shortness of breath in which, after a certain number of respiratory movements, a visible (from several seconds to 1 minute) prolongation of the respiratory pause or short-term breath holding (apnea) occurs. This kind of breathing is called periodic. There are two types of dyspnea with periodic breathing:

Breath Biota characterized by rhythmic but deep breathing movements, which alternate at approximately equal intervals with long (from several seconds to half a minute) breathing pauses. It can be observed in patients with meningitis and in an agonal state with deep cerebrovascular accident. Cheyne-Stokes breathing(from several seconds to 1 minute) of a respiratory pause (apnea), first silent shallow breathing appears, which quickly increases in depth, becomes noisy and reaches a maximum on the 5-7th breath, and then decreases in the same sequence and ends with the next regular short pause. Sometimes during a pause, patients are poorly oriented in their surroundings or completely lose consciousness, which is restored when breathing movements are resumed. This kind of breathing rhythm disturbance occurs in diseases that cause acute or chronic cerebral circulatory failure and brain hypoxia, as well as in severe intoxication. It often manifests itself during sleep and often occurs in older people with severe atherosclerosis of the cerebral arteries. Periodic breathing also includes the so-called wave-like breathing, or Grocco's breath. In its form, it is somewhat reminiscent of Cheyne-Stokes breathing, with the only difference that instead of a respiratory pause, weak shallow breathing is observed, followed by an increase in the depth of respiratory movements, and then its decrease. This type of arrhythmic shortness of breath, apparently, can be considered as a manifestation of an earlier stages of the same pathological processes that cause Cheyne-Stokes respiration. It is currently customary to define respiratory failure as a condition of the body in which the maintenance of normal blood gas composition is not ensured or it is achieved due to more intensive work of the external respiration apparatus and heart, which leads to a decrease in the functional capabilities of the body. It should be borne in mind that the function of the external respiration apparatus is very closely related to the function of the circulatory system: in case of insufficient external respiration, increased work of the heart is one of the important elements of its compensation. Clinically, respiratory failure is manifested by shortness of breath, cyanosis, and in the late stage - in the case of the addition of heart failure - by edema.

The rib cage is a natural internal shell designed to protect vital organs from damage, bruises or injury. IN chest cavity hidden are the heart, lungs, pulmonary arteries and veins, thymus, bronchi, esophagus, and liver. The respiratory muscles and muscles of the upper limbs are attached to it.

Structure of the human chest

The chest is formed by:

• 12 pairs of arched ribs, connected at the back to the thoracic spine, and at the front connected to the sternum using costal cartilages.
• The sternum is an unpaired bone with an elongated shape. It is characterized by a convexity on the front surface and a concavity on the back. Includes three parts: handle, body and
• Muscles.

It is flexible, meaning it expands and contracts as you breathe.

Types of chest

The size and shape of the chest are variable and may change depending on the degree of development of the muscles and lungs. And the degree of development of the latter is closely related to a person’s life activity, his activity and profession. The normal shape of the chest has three types:

• flat;
• cylindrical;
• conical.

Flat chest shape

It is often found in people with weak muscles and leading a passive lifestyle. It is long and flattened in anteroposterior diameter, the anterior wall is almost vertical, the clavicles are clearly visible, and the intercostal spaces are wide.

Conical chest shape

This wide and short chest shape is characteristic of people with a well-developed shoulder girdle muscle group. Its lower part is wider than the upper. The inclination of the ribs and intercostal spaces are small.

Cylindrical chest shape

This chest shape is normally found in short people. It is round, the same along its entire length. The horizontal arrangement of the ribs explains the unclear intercostal spaces. The inframammary angle is obtuse. People, professionally, have exactly this breast shape.

Age and physiological characteristics

The shape of a person's chest changes significantly with age. Newborns are characterized by a narrow and shortened shape of a truncated pyramid. It is slightly compressed from the sides. The transverse size is smaller than the anteroposterior one. teaching him to crawl and stand up, the development of the musculoskeletal system and the growth of the internal organs determine the rapid growth of the chest. The shape of the chest in children in the third year of life becomes cone-shaped. At 6-7 years of age, growth slows down slightly, and an increase in the angle of inclination of the ribs is observed. School-age children have more convex chest shapes than adults, and the slope of the ribs is also less. This is associated with the more frequent and shallow breathing of younger schoolchildren. In boys, the chest begins to grow rapidly at the age of 12, in girls - 11 years. In the period up to 18 years, the middle section of the chest changes the most.

The shape of the chest in children largely depends on the position of the body during landing. Physical activity and regular exercise will help increase the volume and width of the chest. The expiratory form will be the result of weak muscles and poorly developed lungs. Incorrect sitting, resting on the edge of the table, can lead to changes in the shape of the chest, which will negatively affect the development and function of the heart, lungs and large vessels.

Reducing the size, lowering and changing the shape of the chest in older people is associated with a decrease in the elasticity of the costal cartilages, frequent illnesses airways and kyphotic curvature.

The male chest is larger than the female and has a more pronounced rib curve at the angle. In women, the spiral-shaped twisting of the ribs is more pronounced. Due to this, a flatter shape and the predominance of chest breathing are obtained. Men have an abdominal type of breathing, which is accompanied by a displacement of the diaphragm.

The chest and its movements

The respiratory muscles play an active role in the process of inhalation and exhalation.
Inhalation is carried out by contracting the diaphragm and external intercostal muscles, which, lifting the ribs, move them slightly to the sides, increasing the volume of the chest. Exhalation of air is accompanied by relaxation of the respiratory muscles, lowering of the ribs, and raising of the dome of the diaphragm. The lungs perform a passive function in this process, following the moving walls.

Types of breathing

Depending on the age and development of the chest, there are:

• This is the name for the breathing of newborns who do not yet have a good bend of the ribs, and they are in a horizontal position, the intercostal muscles are weak.
• Thoracic breathing with a predominance of diaphragmatic breathing is observed in children in the second half of the first year of life, when the intercostal muscles begin to strengthen and the ore cell begins to descend downwards.
• The pectoral girdle begins to predominate in children from 3 to 7 years of age, when the shoulder girdle is actively developing.
• After seven years, gender differences in breathing patterns appear. Abdominal will predominate in boys, thoracic in girls.

Pathological forms of the chest

Pathologies are most often noticed by patients. They can be congenital (associated with impaired bone development during pregnancy) or acquired (a consequence of injuries and diseases of the lungs, bones, and spine). Deformations and distortions are usually revealed by a simple examination of the chest. The shape and its changes, asymmetry, and irregular breathing allow an experienced doctor to make a preliminary diagnosis. The shape of the chest becomes irregular under the influence of pathological processes in the organs of the chest cavity and with curvature of the spine. Pathological forms of the chest can be:

• Barrel-shaped. This deviation is found in people whose lung tissue has increased airiness, that is, its elasticity and strength are impaired. This is accompanied by an increased air content in the alveoli. The barrel-shaped chest has an expanded transverse and, especially, anteroposterior diameter, with horizontally located ribs and wide intercostal spaces.
• Paralytic. This chest looks flat and narrow. The collarbones are pronounced and located asymmetrically. The shoulder blades clearly lag behind the chest, their location is at different levels and during the breathing process they shift asynchronously. The location of the ribs is oblique downwards. Paralytic forms of the chest occur in emaciated people, in people with poor constitutional development, and in people with severe chronic diseases, such as tuberculosis.
• Rachitic. This shape is also called keel-shaped or chicken-shaped. It is characterized by a significant increase in anteroposterior size, which is a consequence of rickets suffered in childhood. The keel-shaped form also occurs as a result of a genetic deviation in development skeletal system. Bone protrusion may or may not be significant. The severity of the pathology affects the secondary symptoms of the disease that arise due to compression of the heart and lungs.

• Funnel-shaped. This type of pathology is expressed in a noticeable retraction of individual zones: ribs, cartilage, sternum. The depth of the funnel can reach 8 cm. A pronounced funnel-shaped deformity is accompanied by displacement of the heart, curvature of the spine, problems in lung function, and changes in arterial and venous pressure. In infants, the pathology is little noticeable, only when inhaling is there a slight depression in the chest area. It becomes more pronounced as it grows.
• Scaphoid. Characteristic of this pathology is the presence of an elongated depression in the middle and upper part of the sternum. Develops in children suffering from diseases of the nervous system, in which motor functions and sensitivity are impaired. Severe deformation is accompanied by shortness of breath, fatigue, intolerance physical activity, rapid heartbeat.
• Kyphoscoliotic. Develops against the background of spinal diseases, namely thoracic, or is a consequence of traumatic injury.

Evolution has provided protection for the most important organs human body chest. The chest cavity contains organs without which we cannot survive for even a few minutes. A rigid bone frame not only protects, but also fixes them in a constant position, ensuring stable operation and our satisfactory condition.

1. Subjective method of examining the patient

a) auscultation

c) inspection

d) palpation

2. The main objective method of examining the patient

a) auscultation

b) bronchography

c) spirometry

d) tomography

3. The normal number of respiratory movements in an adult is (per 1 minute)

4. Men have a predominant breathing type

a) abdominal

b) chest

c) mixed

5. Right epigastric angle (90 degrees) corresponds to the shape of the chest

a) asthenic

b) hypersthenic

c) normosthenic

a) auscultation

b) inspection

c) palpation

d) percussion

7. The upper border of the lungs in front is determined by

a) 1-2 cm below the collarbone

b) 1-2 cm above the collarbone

c) 3-4 cm below the collarbone

d) 3-4 cm above the collarbone

8. The lower border of the lungs along the anterior axillary line corresponds to the rib

9. The normal excursion of the lungs along the midaxillary line is (cm)

10. With vesicular breathing it is determined

a) inhale and exhale briefly

b) inhale equal to exhale

c) just inhale

d) just exhale

11. Breathing is normally heard above the lungs

a) amphoric

b) bronchial

c) vesicular

d) hard

12. Breathing is normally heard above the trachea and large bronchi

a) amphoric

b) bronchial

c) vesicular

d) stenotic

13. Pathological shape of the chest

a) asthenic

b) barrel-shaped

c) hypersthenic

d) normosthenic

14. Deep, noisy, rare breathing is breathing

b) Grokka

c) Kussmaul

d) Cheyne-Stokes

15. A gradual increase in the depth of respiratory movements followed by a decrease until breathing stops completely - this is breathing

b) Grokka

c) Kussmaul

d) Cheyne-Stokes

16. Dry wheezing occurs when

a) unsticking of the alveoli

b) gluing of alveoli

c) narrowing of the bronchi

d) friction of the pleura

17. Crepitus indicates defeat

a) alveoli

b) bronchi

c) pleura

d) trachea

18. Pleural friction noise is heard

a) on inhalation and exhalation

b) only on inspiration

c) only on exhalation

19. Layered X-ray examination of the lungs

a) bronchography

b) spirography

c) tomography

d) fluorography

20. In case of focal compaction syndrome of pulmonary tissue, vocal tremor over this area

a) strengthened

b) weakened

c) not changed

21. With the syndrome of focal compaction of the lung tissue, percussion sound above it

a) boxed

b) dull

c) tympanic

22. With the syndrome of cavity formation in the lung, percussion sound above it

a) boxed

b) tympanic

23. Breathing is detected above the large cavity in the lung, communicating with the bronchus.

a) amphoric

b) bronchial

c) vesicular

d) hard

24. With the syndrome of fluid accumulation in the pleural cavity, percussion sound

a) boxed

b) tympanic

25. With the syndrome of fluid accumulation in the pleural cavity, mediastinal organs

a) do not move

b) shift to the healthy side

c) shift to the painful side

26. With the syndrome of air accumulation in the pleural cavity, percussion sound

a) boxed

b) tympanic

27. Increased airiness of the lungs is

a) atelectasis

b) pneumonia

c) pneumosclerosis

d) emphysema

28. The proliferation of connective tissue in the lungs is

a) atelectasis

b) pneumonia

c) pneumosclerosis

d) emphysema

29. The accumulation of fluid in the pleural cavity is

a) atelectasis

b) hydrothorax

c) pneumothorax

d) emphysema

30. Accumulation of air in the pleural cavity is

a) hemothorax

b) hydrothorax

c) pneumothorax

d) emphysema

31. The normal number of heartbeats in an adult is (per 1 minute)

32. A 30-year-old man’s normal blood pressure is (in mmHg)

33. Examination of the cardiac region can reveal

a) pulsation of the apex beat

b) heart size

c) dimensions of the vascular bundle

d) symptom of “cat purring”

34. The apical impulse is normally located in the 5th intercostal space

a) along the left midclavicular line

b) 1-1.5 cm medially from the left midclavicular line

c) 1-1.5 cm outward from the left midclavicular line

d) 2 - 3 cm outward from the left midclavicular line

35. Cardiac percussion is performed to determine

a) apical impulse

b) borders of the heart

c) Musset's symptom

d) heart sounds and murmurs

36. The width of the vascular bundle in the 2nd intercostal space is (in cm)

37. The boundaries of relative cardiac dullness are determined by the method

a) auscultation

b) inspection

c) palpation

d) percussion

38. The left border of the heart is formed

a) apex of the right ventricle

b) apex of the left ventricle

c) left atrium

d) left atrium and ventricle

39. Normal area of ​​relative cardiac dullness

a) equal to the area of ​​absolute cardiac dullness

b) less area of ​​absolute cardiac dullness

V) more area absolute cardiac dullness

40. The right border of relative cardiac dullness is

a) along the right edge of the sternum

b) 1-1.5 cm medially from the right edge of the sternum

c) 1-1.5 cm outward from the right edge of the sternum

d) along the left edge of the sternum

41. The upper limit of absolute cardiac dullness is at the level of the rib

42. The first heart sound is formed by clapping

b) pulmonary valve

c) aortic and pulmonary valves

d) bicuspid and tricuspid valves

43. Sound phenomena from the valve are heard in the area of ​​the apex beat

a) aortic

b) mitral

c) pulmonary

d) tricuspid

44. In the 2nd intercostal space near the sternum on the right, sounds from the valve are heard

a) aortic

b) mitral

c) pulmonary

d) tricuspid

45. Quality of the pulse, characterizing the state of the vascular wall

a) filling

b) voltage

d) frequency

46. ​​Sound phenomena arising during the work of the heart are recorded

a) bicycle ergometry

b) phonocardiography

c) electrocardiography

d) echocardiography

47. The condition of the heart valve apparatus is better reflected

b) X-ray examination

c) ultrasound examination

d) electrocardiography

48. The appearance of a murmur at the apex of the heart indicates valve damage

a) aortic

b) mitral

c) pulmonary

d) tricuspid

49. When recording an ECG, an electrode (color) is placed on the right arm

a) yellow

b) green

c) red

d) black

50. In arterial hypertension syndrome, it hypertrophies

a) right ventricle

b) left ventricle

c) left and right atrium

d) interventricular septum

51. When the pressure in the pulmonary circulation increases,

a) accent of the second tone on the aorta

b) emphasis of the second tone on the pulmonary artery

c) weakening of the second tone on the pulmonary artery

d) weakening of the first tone at the apex

52. Examination of the abdomen reveals

a) the size of internal organs

b) position of internal organs

c) the presence of asymmetry

d) presence of pain

53. Palpation of the abdomen is carried out in a lying position

a) a soft bed without a pillow

b) a soft bed with a pillow

c) a hard bed without a pillow

d) a hard bed with a pillow

54. Superficial palpation of the abdomen is carried out to determine

a) tension in the muscles of the anterior abdominal wall

b) positions of internal organs

c) the size of internal organs

d) “Medusa’s head” symptom

55. Deep palpation abdomen is carried out to determine

a) presence of abdominal asymmetry

b) muscle tension in the anterior abdominal wall

c) positions of internal organs

d) divergence of the muscles of the anterior abdominal wall

56. The acid-forming function of the stomach is examined when

a) duodenal intubation

b) fractional gastric intubation

c) endoscopic examination

d) X-ray examination

57. The cecum is palpated in the area

a) left iliac

b) right iliac

c) epigastric

d) mesogastric

58. The sigmoid colon is palpated in the area

a) left iliac

b) right iliac

c) epigastric

d) mesogastric

59. Normal lower edge of the liver upon palpation

a) hard, smooth

b) hard, lumpy

c) soft, smooth

d) soft, lumpy

60. Percussion sound is normally detected above the stomach area

a) boxed

b) tympanic

61. Pain when tapping on the right costal arch is a positive symptom

b) Ortner

c) frenicus

d) Shchetkin-Blumberg

62. The upper limit of absolute hepatic dullness along the right midclavicular line corresponds to the rib

63. The lower border of the liver along the right midclavicular line is determined

a) at the edge of the costal arch

b) 2 cm above the costal arch

c) 2 cm below the costal arch

d) 4 cm below the costal arch

64. Portion “B” of bile has color

b) olive

c) light yellow

d) dark yellow

65. Jaundice develops when

a) hypobilirubinemia

b) hyperbilirubinemia

c) hypoproteinemia

d) hyperproteinemia

66. Sign of portal hypertension

b) headache

c) jaundice

d) skin itching

67. Pasternatsky’s symptom is detected by the method

a) auscultation

b) inspection

c) palpation

d) effleurage

68. Edema of renal origin first appears on

b) lower back

69. Normal ratio of daytime and nighttime diuresis

70. The relative density of urine in the general analysis is

71. Number of red blood cells in urine analysis according to Nechiporenko (in 1 ml) up to

72. The number of red blood cells in a general urine test (in the field of view)

73. The functional capacity of the kidneys reflects

a) general urine test

b) Nechiporenko’s test

c) Zimnitsky test

d) Addis-Kakovsky test

74. The main manifestation of renal eclampsia

a) weakness

b) headache

c) convulsions

75. In case of renal failure syndrome, there is

a) increase in creatinine and urea

b) increase in creatinine

c) increase in urea

d) decrease in creatinine and urea

76. Frequent urge to urinate with the release of a small amount of urine is

a) anuria

b) dysuria

c) oliguria

d) pollakiuria

a) anuria

b) dysuria

c) oliguria

d) polyuria

78. Daily diuresis is 3 liters. This -

a) anuria

b) nocturia

c) oliguria

d) polyuria

79. Daily diuresis is 300 ml. This -

a) anuria

b) nocturia

c) oliguria

d) polyuria

80. Daily diuresis is 40 ml. This -

a) anuria

b) nocturia

c) oliguria

d) polyuria

81. Lymph nodes are normal

a) visible during general examination

b) not visible and not palpable

c) not visible, but the subclavian muscles are palpable

d) not visible, but the popliteal muscles are palpable

82. The spleen is normal

a) palpated in the left hypochondrium

b) palpated in the right hypochondrium

c) palpated in the left iliac region

d) not palpable

83. An enlarged liver is called

a) hypersplenism

b) hepatomegaly

c) gynecomastia

d) splenomegaly

84. An enlarged spleen is called

a) hypersplenism

b) hepatomegaly

c) splenomegaly

d) gynecomastia

85. The number of red blood cells is normal in men (per 1 l)

a) 4.5-5.0x1012

b) 4.5-5.0x109

86. The normal amount of hemoglobin in women is (g/l)

87. Color index reflects

a) the amount of hemoglobin

b) number of red blood cells

c) degree of saturation of erythrocytes with hemoglobin

d) degree of saturation of leukocytes with hemoglobin

88. Normal ESR value in men (mm/h)

89. The number of leukocytes is normal (in 1 l)

90. Normal platelet count (per 1 l)

c) 180-320x109

d) 180-320x1012

92. The degree of enlargement of the thyroid gland, at which the symptom of “thick neck” is determined during examination

93. Exophthalmos is observed in pathology

a) pituitary gland

b) adrenal glands

c) pancreas

d) thyroid gland

94. Bronze coloration of the skin is observed in pathology

a) pituitary gland

b) adrenal glands

c) pancreas

d) thyroid gland

95. To confirm the pathology of the pituitary gland, a

a) anthropometry

b) general blood test

c) general urine test

d) radiography of the skull bones

96. In thyrotoxicosis syndrome there are

a) drowsiness, lethargy

b) chilliness, decreased body temperature

c) bradycardia, constipation

d) exophthalmos, tachycardia

97. When hypothyroidism syndrome occurs

b) feeling of heat, increased body temperature

c) tachycardia, tremor

d) drowsiness, bradycardia

98. The appearance of glucose in the urine is called

a) hyperglucosuria

b) glucosuria

c) hyperglycemia

d) hyperproteinemia

100. Increased blood glucose is

a) hyperglycemia

b) glucosuria

c) hypoglycemia

d) hyperproteinemia

STANDARD ANSWERS

1 b, 2 a, 3 b, 4 a, 5 c, 6 c, 7 d, 8 c, 9 c, 10 a, 11 c, 12 b, 13 b, 14 c, 15 d, 16 c, 17 a , 18 a, 19 c, 20 a, 21 b, 22 b, 23 a, 24 c, 25 b, 26 b, 27 d, 28 c, 29 b, 30 c, 31 b, 32 b, 33 a, 34 b, 35 b, 36 b, 37 g, 38 g, 39 c, 40 c, 41 c, 42 g, 43 b, 44 a, 45 b, 46 b, 47 c, 48 b, 49 c, 50 b, 51 b, 52 c, 53 c, ​​54 a, 55 c, 56 b, 57 b, 58 a, 59 c, 60 b, 61 b, 62 b, 63 a, 64 b, 65 b, 66 a, 67 g , 68 g, 69 a, 70 a, 71 a, 72 a, 73 c, 74 c, 75 a, 76 g, 77 b, 78 g, 79 c, 80 a, 81 b, 82 g, 83 b, 84 c, 85 a, 86 c, 87 c, 88 b, 89 a, 90 c, 91 b, 92 c, 93 d, 94 b, 95 g, 96 g, 97 d, 98 b, 99 b, 100 a.