originates from involvement of the parietal pleura. As a result, the pain is accentuated by respiratory motion and is often referred to as pleuritic. Common examples include primary pleural disorders, such as neoplasm or inflammatory disorders involving the pleura, or pulmonary parenchymal disorders that extend to the pleural surface, such as pneumonia or pulmonary infarction. Pain in the chest is classified by its location, origin, character, intensity, duration, and irradiation, by its connection with the respiratory movements, cough, and the posture. Pain may arise during the development of a pathological condition in the thoracic wall, the pleura, the heart, and the aorta, and in diseases of the abdominal organs (by irradiation).
Pain may develop in injury of the skin (trauma, erysipelas, herpes zoster, etc.), muscles (trauma, myositis), intervertebral nerves (thoracic radiculitis in spondylarthrosis), ribs and costal pleura (metastases of the tumour, fractured bones, periostitis).
Anamnesis
When questioning a patient the physician should determine the time the disease began. Acute onset is a characteristic of acute pneumonia, especially acute lobar pneumonia. Pleurisy begins more gradually. A nonmanifest onset and a prolonged course are the characteristic of pulmonary tuberculosis and cancer. The onset of many diseases may be provoked by chills (bronchitis, pleurisy, pneumonia).
Determining epidemiological conditions is very important for establishing the cause of the disease. Thus influenzal pneumonia often occurs during epidemic outbreaks of influenza. Establishing contacts with tuberculosis patients is also very important. Specific features of the course of the disease and the therapy given (and its efficacy) should then be established.
Information about risk factors for lung disease should be explicitly explored to assure a complete basis of historic data. A history of current and past smoking, especially of cigarettes, should be sought from all patients. The smoking history should include the number of years of smoking, the intensity (i.e., number of packs per day), and, if the patient no longer smokes, the interval since smoking cessation. The risk of lung cancer falls progressively with the interval following discontinuation of smoking, and loss of lung function above the expected age-related decline ceases with the discontinuation of smoking. The patient may have been exposed to other inhaled agents associated with lung disease, which act either via direct toxicity or through immune mechanisms. Important agents include the inorganic dusts associated with pneumoconiosis (especially asbestos and silica dusts) and organic antigens associated with hypersensitivity pneumonitis (especially antigens from molds and animal proteins). Bronchial asthma, which is more common in women than men, is often exacerbated by exposure to environmental allergens (dust mites, pet dander, or cockroach allergens in the home or allergens in the outdoor environment
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such as pollen and ragweed) or may be caused by occupational exposures (diisocyanates).
Collecting the life anamnesis, the physician should pay attention to conditions under which the patient lives and works. Damp premises with inadequate ventilation or work in the open (builders, truck drivers, agricultural workers, etc.) can become the cause of acute inflammation of the lungs with more frequent conversion into chronic diseases. Some dusts are harmful and cause bronchial asthma. Coal dust causes a chronic disease of the lungs called anthracosis. Regular exposure to silica dust (cements, pottery, etc.) causes silicosis, the occupational fibrosis of the lungs.
The patient should give a detailed report of his past diseases of the lungs or pleura, which helps the physician establish connections between the present disease and diseases of the past history.
Family history is important for evaluating diseases that have a genetic component. These include disorders such as cystic fibrosis, α- antitrypsin deficiency, and asthma.
Survey of patients with diseases of respiratory system General survey
General survey has crucial importance for assessment of the general state of the patient. It is performed by studying a state of his consciousness and position. In connection with a hypoxia of a brain in respiratory failure all kinds of disordered consciousness can be observed: sopor, stupor, hypoxemic coma, hallucinations.
The forced lateral recumbent (edgewise) position (lateral decubitus) is accepted by patients in pneumonia, tuberculosis, exudative and dry pleurisy, pulmonary abscess or gangrene, bronchiectases.
The forced sitting position is connected mainly to dyspnea (in pneumothorax, an attack of bronchial asthma, emphysema, stenosis of a larynx). In sharp degrees of dyspnea the patients put arms on knees, on edges of a bed, a seat of a chair or the handle of an armchair fixing thus a shoulder girdle and starting auxiliary respiratory muscles.
The characteristic face is observed in acute stage of pneumonia: it is a little reddened and edematous (facies febrilis), restless, with suffering expression, with running over at coughing (in view of its tenderness) a grimace, with motility of wings of a nose (owing to a short breathlessness), with typical blisters of herpes on lips of the mouth and wings of a nose.
In presence of respiratory failure, central cyanosis is observed in various degrees of blueness from moderate cyanosis of the face up to diffuse cyanosis with crimson shade owing to a hyperglobulinemia.
Typical changes of fingers of arms are observed in prolonged suppurative processes in lungs (abscesses and gangrene), emphysema, tumours of a mediastinum, a bronchoectatic disease. Clubbing of the
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fingers is enlargement of the terminal digital phalanxes with loss of the nail bed angle. In the typical cases distal phalanxes are represented drumstick (clubbed, Hippocratic) fingers. Nails become convex and get looking alike watch glass.
Inspection of the chest
Examination of the chest should be done according to a definite plan. The general configuration of the chest should first be estimated (position of the clavicles, supraand subclavicular fossae, shoulder blades) during static survey; the next step (dynamic survey) is to define the type, rhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder girdle, and involvement of the accessory respiratory muscles in the breathing act. The patient should be better examined in the upright (standing or sitting) position with the chest being naked. Illumination of the body should be uniform.
Static survey of the chest
Static survey estimates the shape of the chest at quiet respiration. The shape of the chest may be normal or pathological. A normal chest is characteristic of healthy persons with regular body built. Its right and left sides are symmetrical, the clavicles and the shoulder blades should be at one level and the supraclavicular fossae equally pronounced on both sides. Since all people with normal constitution are conventionally divided into three types, the chest has different shape in accordance with its constitutional type. Pathological shape of the chest may be the result of congenital bone defects and of various chronic diseases (emphysema of the lungs, rickets, tuberculosis).
Normal form of the chest
Normosthenic (conical) chest in subjects with normosthenic constitution resembles a truncated cone whose bottom is formed by welldeveloped muscles of the shoulder girdle and is directed upward. The anteroposterior (sternovertebral) diameter of the chest is smaller than the lateral (transverse) one, and the supraclavicular fossae are slightly pronounced. There is a distinct angle between the sternum and the manubrium (angulus Ludowici); the epigastric angle nears 90°. The ribs are moderately inclined as viewed from the side; the shoulder blades closely fit to the chest and are at the same level; the chest is about the same height as the abdominal part of the trunk.
Hypersthenic chest in persons with hypersthenic constitution has the shape of a cylinder. The anteroposterior diameter is about the same as the transverse one; the supraclavicular fossae are absent (level with the chest). The manubriosternal angle is indistinct; the epigastric angle exceeds 90°; the ribs in the lateral parts of the chest are nearly horizontal, the intercostal space is narrow, the shoulder blades closely fit to the chest,
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the thoracic part of the trunk is smaller than the abdominal one.
Asthenic chest in persons with asthenic constitution is elongated, narrow (both the anteroposterior and transverse diameters are smaller than normal); the chest is flat. The supraand subclavicular fossae are distinctly pronounced. There is no angle between the sternum and the manubrium: the sternal bone and the manubrium make a straight "plate". The epigastric angle is less than 90°. The ribs are more vertical at the sides, the tenth ribs are not attached to the costal arch (costa decima fluctuens); the intercostal spaces are wide, the shoulder blades are winged (separated from the chest), the muscles of the shoulder girdle are underdeveloped, the shoulders are sloping, the chest is longer than the abdominal part of the trunk.
Pathological chest
Emphysematous (barrel-like) chest resembles a hypersthenic chest in its shape, but differs from it by a barrel-like configuration, prominence of the chest wall, especially in the posterolateral regions, the intercostal spaces are enlarged. This type of chest is found in chronic emphysema of the lungs, during which elasticity of the lungs decreases while the volume of the lungs increases; the lungs seem to be as if at the inspiration phase. Natural expiration is therefore difficult not only during movements but also at rest (expiratory dyspnea is found). Active participation of accessory respiratory muscles in the respiratory act (especially m. sternocleidomastoideus and m. trapezius), depression of the intercostal space, elevation of the entire chest during inspiration and relaxation of the respiratory muscles and lowering of the chest to the initial position during expiration become evident during examination of emphysema patients.
Paralytic chest resembles the asthenic chest. It is found in emaciated patients, in general asthenia and constitutional underdevelopment; it often occurs in grave chronic diseases, more commonly in pulmonary tuberculosis and pneumosclerosis, in which fibrous tissue contracts the lungs and diminishes their weight due to the progressive chronic inflammation. During examination of patients with paralytic chest, marked atrophy of the chest muscles and asymmetry of the clavicles and dissimilar depression of the supraclavicular fossae can be observed along with typical signs of asthenic chest. The shoulder blades are not at one level either, and their movements during breathing are asynchronous.
Rachitic chest (keeled or pigeon chest). It is characterized by a markedly greater anteroposterior diameter (compared with the transverse diameter) due to the prominence of the sternum (which resembles the keel of a boat.) The anterolateral surfaces of the chest are as if pressed on both sides and therefore the ribs meet at an acute angle at the sternal bone, while the costal cartilages thicken like beads at points of their transition to bones (rachitic beads). As a rule, these beads can be palpated after rickets
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only in children and youths.
Funnel chest can occur in normosthenic, hypersthenic or asthenic subjects; it has a funnel-shaped depression in the lower part of the sternum. This deformity can be regarded as a result of abnormal development of the sternum or prolonged compressing effect. In older times this chest would be found in shoemaker adolescents. The mechanism of formation of the funnel chest was explained by the permanent pressure of the chest against the shoe; the funnel chest was therefore formerly called cobbler chest.
Foveated chest is almost the same as the funnel chest except that the depression is found mostly in the upper and the middle parts of the anterior surface of the chest. This abnormality occurs in syringomyelia, a rare disease of the spinal cord.
Spine deformities
The chest may be abnormal in subjects with various deformities of the spine which arise as a result of injuries, tuberculosis of the spine, rheumatoid arthritis (Bekhterev's disease), etc. Four types of spine deformities are distinguished: (1) lateral curvature of the spine, called scoliosis; (2) excessive-forward and backward curvature of the spine (gibbus and kyphosis, respectively); (3) forward curvature of the spine, generally in the lumbar region (lordosis); (4) combination of the lateral and forward curvature of the spine (kyphoscoliosis).
Scoliosis is the most frequently occurring deformity of the spine. It mostly develops in schoolchildren due to bad habitual posture. Kyphoscoliosis occurs less frequently. Lordosis only occurs in rare cases. Curvature of the spine, especially kyphosis, lordosis, and kyphoscoliosis cause marked deformation of the chest to change the physiological position of the lungs and the heart and thus interfere with their normal functioning.
Asymmetry of the chest
The shape of the chest can readily change due to enlargement or diminution of one half of the chest (asymmetry of the chest). These changes can be transient or permanent.
The enlargement of the volume of one half of the chest can be due to escape of considerable amounts of fluid as the result of inflammation (exudate) or non-inflammatory fluid (transudate) into the pleural cavity, or due to penetration of air inside the chest in injuries (pneumothorax). Leveling or protrusion of the intercostal spaces, asymmetry of the clavicles and the shoulder blades and also unilateral thoracic lagging can be observed during examination of the enlarged part of the chest. The chest assumes normal shape after the air or fluid is removed from the pleural cavity.
One part of the chest may diminish due to (1) pleural adhesion or complete closure of the pleural slit after resorption of effusion (after prolonged presence of the fluid in the pleural cavity); (2) contraction of a considerable portion of the lung due to growth of connective tissue
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