Apoplexic coma (due to cerebral hemorrhage). The face is red, breathing is slow, deep, and noisy, pulse is full and rare.
Hypoglycemic coma can develop during insulin therapy for diabetes. Diabetic (hyperglycemic) coma occurs in non-treated diabetes
mellitus.
Hepatic coma develops in acute and subacute dystrophy and necrosis of the liver parenchyma, and at the final stage of liver cirrhosis.
Uremic coma develops in acute toxic and terminal stages of various chronic diseases of the kidneys.
Epileptic coma. The face is cyanotic, there are clonic and tonic convulsions, the tongue is bitten. Uncontrolled urination and defecation. The pulse is frequent, the eye-balls are moved aside, the pupils are dilated, and breathing is hoarse.
4. Irritative disorders of consciousness may also develop. These are characterized by excitation of the central nervous system in the form of hallucinations, delirium (delirium furibundum due to alcoholism; in pneumonia, especially in alcoholics; quiet delirium in typhus, etc.).
General inspection can also give information on other psychic disorders that may occur in the patient (depression, apathy).
Posture (position) of the patient.
Position of the patient can be active, passive, or forced. The patient is active if the disease is relatively mild or at the initial stage of a grave disease. The patient readily changes his position depending on circumstances. But it should be remembered that excessively sensitive or alert patients would often lie in bed without prescription of the physician.
Passive posture is observed with unconscious patients or, in rare cases, with extreme asthenia. The patient is motionless, his head and the limbs hang down by gravity, and the body slips down from the pillows to the foot end of the bed.
Forced (compelled) posture is often assumed by the patient to relieve or remove pain, cough, dyspnea. For example, the sitting position relieves orthopnea: dyspnea becomes less aggravating in cases with circulatory insufficiency. The relief that the patient feels is associated with the decreased volume of circulating blood in the sitting position (some blood remains in the lower limbs and the cerebral circulation is thus improved).
Patients with dry pleurisy, lung abscess, or bronchiectasis prefer to lie on the affected side. Pain relief in dry pleurisy can be explained by the limited movement of the pleural membranes when the patient lies on the affected side. If a patient with lung abscess or bronchiectasis lies on the healthy side, coughing intensifies because the intracavitary contents penetrate the bronchial tree. And quite the reverse, the patient cannot lie on the affected side if the ribs are fractured because pain intensifies if the
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affected side is pressed against the bed.
The patient is also erecting (standing or sitting) during attacks of bronchial asthma. He would lean against the edge of the table or the chair back, with the upper part of the body slightly inclined forward. Auxiliary respiratory muscles are more active in this posture.
The supine posture is characteristic of strong pain in the abdomen (acute appendicitis, perforated ulcer of the stomach or duodenum). The prone position (lying with the face down) is characteristic of patients with tumours of the pancreas and gastric ulcer (if the posterior wall of the stomach is affected). Pressure of the pancreas on the solar plexus is lessened in this posture.
Habitus
The concept of habitus includes the body-build, i.e. constitution, height, and body weight.
Constitution is the combination of functional and morphological bodily features that are based on the inherited and acquired properties, and that account for the body response to endoand exogenic factors. The classification adopted by M. Chernorutsky differentiates between the following three main constitutional types: asthenic, hypersthenic, and normosthenic.
Asthenic constitution is characterized by a considerable predominance of the longitudinal over the transverse dimensions of the body by the dominance of the limbs over the trunk, of the chest over the abdomen. The heart and the parenchymatous organs are relatively small, the lungs are elongated, the intestine is short, the mesenterium long, and the diaphragm is low. Arterial pressure is lower than in hypersthenics; the vital capacity of the lungs is greater, the secretion and peristalsis of the stomach, and also the absorptive power of the stomach and intestine are decreased; the hemoglobin and red blood cells counts, the level of cholesterol, calcium, uric acid, and sugar in the blood are also decreased. Adrenal and sexual functions are often decreased along with thyroid and pituitary hyperfunction.
Hypersthenic constitution is characterized by the relative predominance of the transverse over the longitudinal dimensions of the body (compared with the normosthenic constitution). The trunk is relatively long, the limbs are short, the abdomen is large, and the diaphragm stands high. All internal organs except the lungs are larger than those in asthenics. The intestine is longer, the walls are thicker, and the capacity of the intestine is larger. The arterial pressure is higher; hemoglobin and red blood cell count and the content of cholesterol are also higher; hypermobility and hypersecretion of the stomach are more normal. The secretory and the absorptive function of the intestine are high. Thyroid hypofunction is common, while the function of the sex and adrenal
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glands is slightly increased.
Normosthenic constitution is characterized by a well proportioned makeup of the body and is intermediate between the asthenic and hypersthenic constitutions.
General state (general condition) of a patient can be estimated in the following degrees of assessment: grave (serious) condition of the patient, state of moderate severity (moderately grave condition), satisfactory state of the patient. The general condition of the patient can be only partly evaluated from the information given by the patient (psychic condition, asthenia, loss of weight, elevated temperature). State of patient's health and general condition of the patient are not the same.
Assessment of the general condition of patient is based on such objective criteria as the state of consciousness, a position of the patient, bearing, gait, a look, a state of a feeding, body temperature, parameters of activity of cardiovascular system (pulse, heart rate, BP), a respiratory organs (rate and character of respiration), functions of excretory system (especially daily urination).
Scheme of a case history
According to the plan of general examination the common schema of a case history includes such sections:
1.Passport data - surname, name, patronymic; sex, age, the home address, the place of employment, the diagnosis at entering a hospital, the clinical diagnosis.
2.Inquiry:
a)Present complaints of the patient;
b)Anamnesis morbi, or history of present illness;
c)Anamnesis vitae, or life history, or past history;
d)Status functionalis, review of systems, or general anamnesis;
3. Objective examination of the patient's condition at the present time (status praesens):
a)general survey, survey of the head and the neck;
b)respiratory system (survey, palpation, percussion of the chest, auscultation of the lungs);
c)circulatory system (survey; palpation, percussion and auscultation of the heart and the large blood vessels);
d)system of digestion (examination of an oral cavity, examination of an abdomen in vertical and horizontal position - survey, auscultation, percussion and palpation of the abdomen).
e)genitourinary system (survey of lumbar region and external genetalia, percussion and palpation of kidneys and urinary bladder, ureteric points).
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f)nervous system
4.Substantiation of the provisional diagnosis
5.Plan of additional examination and treatment of the patient
6.Results of laboratory and tool researches
7.Conclusions of consulting physician
8.The clinical diagnosis and its substantiation
9.Diaries.
A diary of a case history is filled every day and reflects dynamics of patients’ state during the running day and efficacy of prescribed medical actions. The diary of the serious patient is filled 2-4 times day on hours with a precise statement of all medical actions and their results, description of new symptoms and substantiation of new prescriptions. Body temperature, pulse rate, respirations rate, stool and diuresis are marked daily in the diary.
10. Epicrisis
The case history routinely is ended by an epicrisis. The epicrisis is a briefly described summary of the basic complaints of the patient, the history of his disease, objective data, basic laboratory and instrumental studies, the diagnostic resume, course of the disease during the observation, the treatment and its results, the further recommendations in attitude of the treatment and regimen, and a job placement.
Examination of patients with diseases of respiratory system: Subjective examination of patients with diseases of respiratory system. General survey. Static and dynamic survey of the chest. Palpation of the chest, definition of vocal fremitus (voice tremor)
Subjective examination (inquiry) of patients with diseases of respiratory system
Complaints
The main complaints typical for the respiratory system are dyspnea, cough, bloody expectorations, and pain in the chest.
Dyspnea (short breathlessness) can be subjective, objective, or subjective and objective simultaneously. By subjective dyspnea is understood the subjective feeling of difficult or laboured breathing. Objective dyspnea is determined by objective examination and is characterized by changes in the respiration rate, depth, or rhythm, and also the duration of the inspiration or expiration. Diseases of the respiratory system are often accompanied by mixed (i.e. subjective and objective)
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dyspnea. It is often associated with rapid breathing (tachypnea). These symptoms occur in pneumonia, bronchogenic cancer, and in tuberculosis. Cases with purely subjective dyspnea (in hysteria, thoracic radiculitis) or purely objective dyspnea (in pulmonary emphysema or pleural obliteration) occur less frequently. Dyspnea is possible with both normal and slow rate of breathing (bradypnea). Three types of dyspnea are differentiated by the prevalent breathing phase: inspiratory dyspnea, expiratory dyspnea and mixed dyspnea when both expiration and inspiration become difficult.
Dyspnea may be physiological (caused by heavy exercise) and pathological (associated with pathology of the respiratory organs, diseases of the cardiovascular and hemopoietic systems, and poisoning). Dyspnea associated with respiratory pathology may be of various etiology. It can be caused by obstruction of the respiratory ducts, contraction of the respiratory surface of the lungs due to their compression by liquid or air accumulated in the pleural cavity, decreased pneumatization of the lung in pneumonia, atelectasis, infarction or decreased elasticity of the lungs. These conditions are associated with decreased total (vital) lung capacity and ventilation, which causes increased carbon dioxide content of blood, and acidosis of tissues due to accumulation in them of incompletely oxidized metabolites (lactic acid, etc.).
Cough may indicate the presence of lung disease, but cough per se is not useful for the differential diagnosis. Cough may be dry, without sputum, and moist, during which various amounts of sputum of different quality are expectorated. The presence of sputum accompanying the cough often suggests airway disease and may be seen in asthma, chronic bronchitis, or bronchiectasis. Some diseases are attended only by dry cough, e.g. laryngitis, dry pleurisy or compression of the main bronchi by the bifurcation lymph nodes (tuberculosis, lymphogranulomatosis, cancer metastases, etc.). Bronchitis, pulmonary tuberculosis, pneumosclerosis, abscess, or bronchogenic cancer of the lungs can be first attended by dry cough, which will then turn into moist one with expectoration of the sputum.
Hemoptysis is expectoration of blood with sputum during cough. Hemoptysis can originate from disease of the airways, the pulmonary parenchyma, or the vasculature. Diseases of the airways can be inflammatory (acute or chronic bronchitis, bronchiectasis, or cystic fibrosis) or neoplastic (bronchogenic carcinoma or bronchial carcinoid tumors). Parenchymal diseases causing hemoptysis may be either localized (pneumonia, lung abscess, tuberculosis, or infection with Aspergillus) or diffuse (Goodpasture's syndrome, idiopathic pulmonary hemosiderosis). Vascular diseases potentially associated with hemoptysis include pulmonary thromboembolic disease and pulmonary arteriovenous malformations.
Chest pain caused by diseases of the respiratory system usually
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