PERCUSSION (percussio tapping) is one of the main objective methods of examining a patient, consisting of tapping areas of the body and determining by the nature of the sound that arises physical properties organs and tissues located under the percussed area (mainly their density, airiness and elasticity).
Attempts to use P. arose in ancient times. It is believed that Hippocrates, by tapping the abdomen, determined the accumulation of liquid or gases in it. P. as a method of physical diagnosis was developed by the Viennese physician L. Auenbrugger, who described it in 1761. The method became widespread only after J. Corvisart translated the work of A. Auenbrugger into French in 1808. language. In the 20s 19th century a plessimeter and a percussion hammer were proposed. J. Skoda (1831) developed the scientific foundations of percussion sound, explained the origin and features of percussion sound, based on the laws of acoustics and physical condition percussed tissues. In Russia, P. began to be used at the end of the 18th century, and at the beginning of the 19th century. its introduction into widespread practice was facilitated by F. Uden (1817), P. A. Charukovsky (1825), K. K. Seydlitz (1836) and especially G. I. Sokolsky (1835), who contributed to the improvement of the method, so the same as later V.P. Obraztsov and F.G. Yanovsky.
When you tap on an area of the body, vibrations of the underlying media occur. Some of these vibrations have a frequency and amplitude sufficient for auditory perception of sound. The attenuation of the induced oscillations is characterized by a certain duration and uniformity. The frequency of vibration determines the pitch of the sound; the higher the frequency, the higher the sound. Accordingly, high and low percussion sounds are distinguished. The pitch of the sound is directly proportional to the density of the underlying media. So, with P. areas of the chest at the site of adjoining low-density air lung tissue Low sounds are formed, and high sounds are formed in the area where the dense tissue of the heart is located. The strength, or volume, of the sound depends on the amplitude of the vibrations: the greater the amplitude, the louder the percussion sound. The amplitude of body oscillations, on the one hand, is determined by the force of the percussion blow, and on the other hand, it is inversely proportional to the density of the oscillating body (the lower the density of the percussed tissues, the greater the amplitude of their oscillations and the louder the percussion sound).
The duration of the percussion sound is characterized by the decay time of the vibrations, which is directly dependent on the initial amplitude of the vibrations and inversely on the density of the vibrating body: than denser body, the shorter the percussion sound, the lower the density, the longer it is.
The nature of the percussion sound depends on the homogeneity of the medium. With P. of bodies of homogeneous composition, periodic oscillations of a certain frequency occur, which are perceived as a tone. When the density of a medium is inhomogeneous, vibrations have different frequencies, which is perceived as noise. Among the media of the human body, only the air contained in the cavities or hollow organs of the body has a homogeneous structure (stomach or intestinal loop filled with air or gas, accumulation of air in the pleural cavity). With P. of such organs and cavities, a harmonic musical sound arises, in which the fundamental tone dominates. This sound is similar to the sound of hitting a drum (Greek, tympanon drum), so it is called tympanite or tympanic percussion sound. A characteristic property of tympanic sound is the ability to change the pitch of the fundamental tone with a change in the tension of the walls of the cavity or the air in it. This phenomenon is observed when spontaneous pneumothorax: with an increase in pressure in the pleural cavity (with valvular pneumothorax), tympanitis disappears and the percussion sound first takes on a dull-tympanic and then non-tympanic character.
The tissues of the human body are heterogeneous in density. Bones, muscles, fluids in cavities, and organs such as the liver, heart, and spleen have greater density. P. in the area where these organs are located gives a quiet, short-lived or dull percussion sound. Low-density tissues or organs include those that contain a lot of air: lung tissue, hollow organs containing air (stomach, intestines). P. of the lungs with normal airiness gives a fairly long or clear and loud percussion sound. As the airiness of the lung tissue decreases (atelectasis, inflammatory infiltration), its density increases and the percussion sound becomes dull and quiet.
Thus, with P. of different parts of the body healthy person three main characteristics of percussion sound can be obtained: clear, dull and tympanic (Table 1).
Table 1. CHARACTERISTICS OF THE MAIN TYPES OF PERCUTORY SOUND BY STRENGTH, DURATION AND FREQUENCY
A clear percussion sound occurs when P. of normal lung tissue. A dull percussion sound (or dull) is observed in P. areas under which there are dense, airless organs and tissues - the heart, liver, spleen, massive muscle groups (on the thigh - “femoral dullness”). Tympanic sound occurs when P. areas to which air cavities are adjacent. In a healthy person, it is detected above the place where the stomach, filled with air, adheres to the chest (the so-called Traube space).
Depending on the method of tapping, a distinction is made between direct or immediate and mediocre tapping. Direct tapping is performed by striking the fingertips on the surface of the body being examined; with mediocre tapping, strikes with a finger or a hammer are applied to another finger or plessimeter placed on the body (Greek: plexis blow + metreo measure, measure) - a special plate made of metal, wood, plastic or bone.
Among the methods direct P. the methods of Auenbrugger, Obraztsov, and Yanovsky are known. L. Auenbrugger covered the percussed area with a shirt or put a glove on his hand and tapped the chest with the tips of his outstretched fingers, delivering slow, gentle blows (Fig. 1). V.P. Obraztsov used under P. index finger right hand(nail phalanx), and in order to increase the force of the blow, he secured the ulnar part to the radial surface of the middle finger and then, when the index finger slipped from the middle finger, struck a percussion blow with it. With the left hand, the skin folds of the percussed area are straightened and the propagation of sound is limited (Fig. 2, a, b). F. G. Yanovsky used one-finger P., in which percussion blows were applied with minimal force with the flesh of the two terminal phalanges of the middle finger of the right hand. Direct P. is used to determine the boundaries of the liver, spleen, and absolute dullness of the heart, especially in pediatric practice and in debilitated patients.
Methods of mediocre P. include tapping with a finger on a plessimeter, with a hammer on a plessimeter, and the so-called. finger bimanual P. The priority of introducing the finger bimanual P. belongs to G.I. Sokolsky, who struck with the tips of two or three fingers of the right hand put together on one or two fingers of the left hand. Gerhardt (S. Gerhardt) offered P. a finger; she received universal recognition. The advantage of this method is that, along with sound perception, the doctor receives a tactile sensation of the resistance force of the percussed tissues using a pleximeter finger.
When P. finger on finger middle finger The left hand (serves as a plessimeter) is placed flat on the area being examined, the remaining fingers of this hand are spread apart and barely touch the surface of the body. The end phalanx of the middle finger of the right hand (acts as a hammer), bent at the first joint almost at a right angle, strikes the middle phalanx of the plessimeter finger (Fig. 3). To obtain a clear sound, apply uniform, abrupt, short blows directed vertically to the surface of the plessimeter finger. During P., the right arm is bent at the elbow joint at a right angle and brought with the shoulder to the lateral surface of the chest; it remains motionless in the shoulder and elbow joints and performs only flexion and extension at the wrist joint.
The method of auscultation P. consists of listening to the percussion sound with a stethoscope (see Auscultation), which is installed on the side of the chest opposite to the percussed organ (when examining the lungs) or above the percussed organ (when examining the liver, stomach, heart) in the place of its contact with the abdominal or chest wall. Weak percussion blows or dashed palpatory movements (auscultatory palpation) are applied across the body from the point of contact of the stethoscope with it towards the edge of the organ being examined. While percussion strikes are made within the organ, the percussion sound is heard clearly; as soon as P. goes beyond the organ, the sound is sharply muffled or disappears (Fig. 4.).
Depending on the force of the blow applied, a distinction is made between strong (loud, deep), weak (quiet, superficial) and medium P. Strong P. is determined by deeply located organs and tissues (seals or a cavity in the lung at a distance of 5-7 cm from the chest wall). Average P. is used when determining relative stupidity heart and liver.
Silent P. is used to find the boundaries of absolute dullness of the heart and liver, lung and spleen, small pleural exudates and superficially located lung compactions. So-called the quietest (minimal), delimiting P. is produced with such weak blows that the sound that arises is in the “threshold of perception” by the ear - threshold P. It is used to more accurately determine the absolute dullness of the heart; in this case, tapping is performed in the direction from the heart to the lungs.
The supraclavicular and subclavian areas are percussed according to Plesch: the pessimeter finger is bent at a right angle at the first interphalangeal joint and pressed against the skin only with the end of the nail phalanx, blows are applied with a hammer finger on the main phalanx (Fig. 5). Depending on the purpose, two types of P. are distinguished: topographic (restrictive) and comparative. With topographic P., the boundaries and dimensions of an organ (heart, lungs, liver, spleen), the presence of a cavity or focus of compaction in the lungs, fluid or air - in abdominal cavity or pleural cavity. With its help, the boundary of the transition of one sound to another is established. Thus, the right relative border of the heart is judged by the transition of a clear pulmonary sound to a dull one, and the absolute border is judged by the transition of a dull sound to a dull one. With P., tapping is usually done from a clear percussion sound to a dull one, delivering weak or medium-strength blows.
Comparative P. is performed using percussion blows of varying strength depending on the location of the patol, the focus. A deep-located focus can be detected by strong P., and a superficial one - moderate or quiet. Percussion blows are applied to (strictly symmetrical areas. They must be equal in strength on both sides. For better perception, two blows are usually made at each point.
With percussion of the heart define its boundaries. There are boundaries of relative and absolute dullness of the heart (see). In the zone of relative dullness, a dull percussion sound is determined, and in the zone of absolute dullness - dull. The true size of the heart corresponds to the boundaries of relative dullness, and the part of the heart not covered by the lungs is the zone of absolute dullness.
The right, upper and left borders of the heart are distinguished (P. is performed in this order). First, the right border of relative cardiac dullness is determined. The border of hepatic dullness is first determined. To do this, the finger-pessimeter is installed horizontally and the P. is guided along the intercostal spaces from top to bottom along the right midclavicular line. The place where the percussion sound changes from clear to dull corresponds to the border of hepatic dullness; it is usually located on the VI rib. Next, the P. is carried out in the fourth intercostal space from right to left (the plessimeter finger is located vertically).
The right border of relative dullness of the heart is normally located along the right edge of the sternum, and absolute dullness is along the left edge of the sternum.
The upper border is percussed in the direction from top to bottom, slightly retreating from the left edge of the sternum (between the sternal and parasternal lines). The pessimeter finger is positioned obliquely, parallel to the desired boundary. The upper limit of relative dullness of the heart is on the third rib, absolute - on the fourth. When determining the left border of cardiac dullness, P. begins outward from its apical impulse. If the apical impulse is absent, then the fifth intercostal space is found on the left and percussed, starting from the anterior axillary line, medially. The pessimeter finger is positioned vertically, percussion blows are applied in the sagittal plane.
The left border of absolute dullness usually coincides with the border of relative cardiac dullness and is normally determined 1 - 1.5 cm medially from the left midclavicular line in the fifth intercostal space.
P. vascular bundle formed by the aorta and pulmonary artery, carried out in the second intercostal space sequentially to the right and left of the sternum in the direction from the outside to the inside. The width of the vascular bundle (the zone of dullness of percussion sound) normally does not extend beyond the sternum.
Percussion of the lungs It is produced in those places of the chest where normally the lung tissue is directly adjacent to the chest wall and causes a clear pulmonary sound in P.
Comparative and topographical P. of the lungs are used (see). With comparative P., the presence of patols, changes in the lungs or pleura is established by comparing the percussion sound in symmetrical areas of the right and left halves of the chest. With topographic P., the borders of the lungs are found and the mobility of the lower pulmonary edge is determined. The study begins with comparative percussion. With P. of the lungs, the patient occupies a vertical or sitting position; when examining the anterior and lateral walls, the percussionist is in front of the patient, and with P. back surface- behind the patient. With P., the patient stands on the front surface with his arms down, on the side surfaces - with his hands behind his head, on the back surface - with his head down, slightly bent forward, with his arms crossed, with his hands on his shoulders.
The finger-pessimeter in the supraclavicular areas is applied parallel to the clavicle, in front below the clavicle and in the axillary areas - in the intercostal spaces parallel to the ribs, in the suprascapular area - horizontally, in the interscapular spaces - vertically, parallel to the spine, and below the angle of the scapula - horizontally, parallel to the ribs. The same percussion blows are applied with a hammer finger, usually of medium strength.
Comparative P. is carried out in front in the supraclavicular fossae, directly along the clavicles, below the clavicles - in the first and second intercostal spaces (from the third intercostal space on the left, the dullness of percussion sound from the adjacent heart begins, therefore, in the third and lower intercostal spaces in front, comparative P. is not performed). In the lateral areas of the chest, they percussion in the axillary fossa and along the fourth and fifth intercostal spaces (lower on the right, dullness of sound begins from the adjacent liver, and on the left, the sound acquires a tympanic hue from the proximity of Traube’s space). Behind the P. they lead in the suprascapular areas, in the upper, middle and lower parts interscapular spaces and under the shoulder blades - in the eighth and ninth intercostal spaces.
Patol, changes in the lungs or in the pleural cavity are determined by changes in percussion sound. A dull sound appears when fluid accumulates in the pleural cavity (exudative pleurisy, hydrothorax, hemothorax, pyothorax), massive compaction of the lung tissue (lobar pneumonia, extensive atelectasis). Shortening and dulling of percussion sound indicates a decrease in the airiness of the lung tissue, which occurs when it is focally compacted.
If a decrease in the airiness of the lung tissue is combined with a decrease in its elastic tension, the percussion sound becomes dull-tympanic (fine-focal infiltration, initial stage lobar pneumonia, a small air cavity in the lung with lung tissue compacted around it, incomplete pulmonary atelectasis).
A tympanic sound is detected when the airiness of the lung tissue is sharply increased, when there is a cavity filled with air (abscess, cavern, bronchiectasis) and when air accumulates in the pleural cavity (pneumothorax). A type of tympanic sound is a box percussion sound, which is determined by pulmonary emphysema, accompanied by an increase in airiness and a decrease in the elastic tension of the lung tissue. If there is a large, smooth-walled cavity adjacent to the chest wall, the tympanic sound acquires a metallic tint, and if the cavity is connected by a narrow slit-like opening to the bronchus, air during P. comes out jerkily through the narrow opening in several stages and a peculiar intermittent rattling noise occurs - the sound of a cracked pot, described by R. Laennec.
In the presence of a large cavern or other pathol, a cavity communicating with the bronchus, the height of the tympanic sound changes when opening the mouth (Wintrich's symptom), with deep inhalation and exhalation (Friedreich's symptom), and if the cavity is oval, then when the body position changes (phenomenon Gerhardt).
With topographic P., the boundaries of the lungs are first determined: a finger-pessimeter is placed in the intercostal spaces parallel to the ribs and, moving it from top to bottom, quiet percussion blows are applied. Then the mobility of the lower edge of the lungs and their upper border are determined.
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 2 shows the location of the lower border of the lung in a normosthenic patient.
Table 2. POSITION OF THE LOWER BOUNDAR OF THE LUNG IN A NORMOSTHENIC
The lower boundaries fall as lung volume increases due to emphysema or acute swelling (attack bronchial asthma).
The lower border rises with the accumulation of fluid in the pleural cavity (effusion pleurisy, hydrothorax), with the development of pulmonary fibrosis, with a high diaphragm in patients with obesity, ascites, and flatulence.
When studying the mobility of the lower edges of the lungs, the lower border is determined separately at the height of a deep inspiration and after a complete exhalation. Distance between position edge of the lung during inhalation and exhalation, it characterizes the general mobility of the pulmonary edge, which is normally 6-8 cm along the axillary lines. A decrease in the mobility of the pulmonary edges is observed with emphysema, inflammation and edema of the lungs, the formation of pleural adhesions, accumulation of air or fluid in the pleural cavity, dysfunction of the diaphragm .
With P., the upper border of the lungs determines the height of the apexes and their width - the so-called. Krenig fields (see Krenig fields).
Percussion of the abdomen used to determine the size of hepatic and splenic dullness, identify fluid and gas in the abdominal cavity, as well as to identify painful areas abdominal wall(see Belly). The latter are revealed by applying light jerky blows to different areas abdominal wall - in the epigastric region, at the xiphoid process (projection of the cardiac part of the stomach), to the right of the midline to the right hypochondrium (projection of the duodenum and gall bladder), along the midline and in the left hypochondrium (ulcer of the lesser curvature of the stomach, damage to the pancreas) . Pain that appears at the height of inspiration during P. in the area of the gallbladder is characteristic of cholecystitis (Vasilenko’s symptom).
Bibliography: Dombrovskaya Yu. F., Lebedev D. D. and M o l c h a n o v V. I. Propaedeutics of childhood diseases, p. 230, M., 1970; Kurlov M. G. Percussion of the heart and its measurement, Tomsk, 1923; L and with t about in A.F. Fundamentals of percussion and its features in children, M. - L., 1940; Obraztsov V.P. Selected works, p. 119, Kyiv, 1950; Propaedeutics of internal diseases, ed. V. X. Vasilenko et al., p. 43 and others, M., 1974; Skoda J. The doctrine of tapping and listening as a means of recognizing diseases, trans. from German, M., 1852; H o 1 1 d a with k K. Lehrbuch der Auskultation und Perkussion, Stuttgart, 1974; P i about g g at P. A. Traite de plessimetrisme et d’organographisme, P., 1866.
G. I. Alekseev; V. P. Bisyarina (ped.).
General inspection
GENERAL INSPECTION
Sequence general examination:
– general condition;
– position;
- consciousness;
– gait;
– examination of body parts with assessment of physique, type of constitution, posture;
– physical development;
– neuropsychic development.
1. Assessment of general condition
An objective examination of the child begins with a description of the general condition, which is assessed according to external examination data (position in bed, consciousness, behavioral activity) and the entire complex of objective examination of the patient. When assessing the general condition, the child’s complaints are taken into account. The final conclusion on the assessment of the patient’s condition is made at the end of the objective examination, however, when describing his status, this characteristic of the assessment of the objective examination is placed in first place.
General condition the patient may be: satisfactory, moderate severity, heavy, extremely heavy.
A satisfactory condition is said to be when no significant patient complaints are detected, but with an objective study of symptoms indicating a state of decompensation of vital functions. A moderately severe condition is characterized by the presence of significant complaints and subcompensation of vital signs important organs. In a severe condition, complaints are pronounced; loss of consciousness, limited mobility and decompensation of the main physiological systems body. Extremely serious condition characterized by aggravation of these phenomena and the appearance of signs, life-threatening child.
At the same time, the child’s well-being is assessed taking into account his mood (even, calm, elevated, excited or depressed, unstable), his reaction to examination and contact with others, and interest in toys.
2. Position assessment
The child’s position can be: active, passive and forced. By active we mean such a position of the child in which he can voluntarily change his posture and make active movements. A passive position is said to exist if the child cannot change his position without outside help. Finally, if, in order to alleviate his condition, the child takes some special position (the “coping dog” position during meningitis, a sitting position with support on the edge of the bed or on his knees during an attack of bronchial asthma, etc.), then it is assessed as forced. Limitation of the regimen for therapeutic indications is not evidence of the patient’s passive position.
3. Assessment of consciousness
Consciousness can be: clear, doubtful (stunned, stupor), soporous, comatose (lack of consciousness). Consciousness is characterized as clear if the patient is oriented in his own personality, place, time and environment, answers questions adequately and without difficulty.
With doubtful consciousness, the reaction to the environment is slow, the child reacts to irritation by crying, answers questions sluggishly, inappropriately. At soporotic state consciousness is clouded, there is no reaction to the environment, but the reaction to painful stimuli remains.
With a significant degree of depression of the cerebral cortex, loss of consciousness occurs - coma ( coma). It is rational to determine the degree of coma. In the first degree of coma – there is no consciousness and voluntary movements; corneal and corneal reflexes are preserved. The second degree of coma is characterized by a lack of consciousness, areflexia (only sluggish reflexes of the pupils are preserved), and respiratory rhythm disorders are often observed. In the third degree of coma, there is an absence of all reflexes, profound disorders breathing rhythm and cardiac activity, cyanosis, hypothermia.
An overly excited consciousness with unrealistic sensations, hallucinations and psychomotor agitation is called delirium.
4. Gait
To identify changes in gait, the patient is asked to walk around the room. Normally, the gait is smooth, confident, and the movements when walking are free, smooth and relaxed. Gait disturbances may be caused by pathologies of the joints, bones, muscles, nerves or main arteries lower extremities, as well as diseases of the brain and spinal cord.
5. Examination by body parts
Description individual parts body is carried out in a certain sequence: head, neck, torso (front, back surface), upper limbs, lower limbs. When conducting an examination of body parts, it is necessary to describe the shape, symmetry of individual parts of the body, as well as the presence of minor developmental anomalies, or signs of dysembryogenesis (Appendix 2). The detection of 5 or more minor anomalies is of diagnostic significance.
Body type, constitution type and posture are assessed.
Physique is understood as the ratio of height and transverse dimensions of the body, symmetry and proportionality of its individual parts. There is a difference between correct and incorrect physique. With the correct physique, the chest circumference is approximately half of the height, both halves of the body are symmetrical, the sizes of the body and its individual parts are proportional, there are no injuries, physical disabilities or developmental anomalies.
Body type must be specified taking into account age characteristics. It is customary to distinguish between five body types, which are listed in Appendix 3.
The constitution is determined in school-age children. According to M.V. Chernorutsky usually distinguishes three constitutional types: normosthenic, hypersthenic, asthenic.
Normosthenic type - average height, its correct relationship with the transverse dimensions of the body, proportional dimensions of the head, neck, torso and limbs. The thoracic and abdominal sections of the body are approximately the same. The anteroposterior size of the chest is slightly smaller than the transverse one. The epigastric angle is straight. The supra- and subclavian fossae are moderately expressed, the clavicles are also moderately contoured, the course of the ribs is moderately oblique, the ratio of the width of the rib and the intercostal space is 1:1, the shoulder blades are moderately adjacent to the chest.
Hypersthenic type – short stature with a relative predominance of transverse body dimensions. The head is round in shape, the neck is short and thick, the limbs are disproportionately short and wide. The body is relatively long, the abdominal region predominates over the thoracic region. The chest is short, wide; epigastric angle blunt. The anterior-posterior size of the chest approaches the transverse one. The supra- and subclavian fossae are poorly defined, the clavicles are poorly contoured, the course of the ribs is closer to horizontal, the ratio of the width of the rib and the intercostal space is 2:1, the shoulder blades fit tightly to the chest.
Asthenic type - tall growth with a relative predominance of body dimensions in length over transverse dimensions. The head is elongated in a vertical direction, the neck is long and thin, the limbs are long and thin. The body is relatively short, thoracic region it is more abdominal. The chest is elongated, narrow and flattened. The epigastric angle is acute. The anterior-posterior size of the chest is reduced in relation to the transverse one. The supra- and subclavian fossae are pronounced, the clavicles are well contoured, the course of the ribs is oblique, the ratio of the width of the rib and the intercostal space is 1:2, the shoulder blades are wing-shaped from the chest.
To assess posture, the child is asked to stand up and place his arms along his body. To identify violations of posture, it is necessary to compare the level of standing of the shoulders (same or different), collarbones, the severity of the supra- and subclavian fossae, the level of standing of the nipples, as well as the relative length of the limbs (upper and lower). Next, an examination is carried out from behind: the level of standing of the shoulders, the angles of the shoulder blades, the degree of fit of the shoulder blades to the chest, and the symmetry of the waist triangles are also assessed.
Using a measuring tape, measure the distance from the spine to the angle of the shoulder blades on the right and left. Next, it is necessary to describe the severity of the physiological curves of the spine - cervical and lumbar lordosis, thoracic kyphosis. Then they ask the child to lean forward (arms are freely lowered) and the doctor palpably (using the spinous processes) evaluates the course of the spine. If curvatures are determined, then it is necessary to indicate in which part of the spine: cervical, thoracic, lumbar. Types of postures are indicated in Appendix 4.
6. Evaluation physical development(according to algorithm)
7. Nervous assessment - mental development(for children under 3 years old)
SKIN RESEARCH METHOD
The study of leather and its derivatives is carried out in a certain sequence:
color;
purity;
humidity;
elasticity;
temperature.
Skin color healthy child smooth pale pink, pink, dark. The pathological color is pale, hyperemic, icteric (icteric), cyanotic (acrocyanosis, total cyanosis, regional), earthy gray, bronze (dark brown).
Clean skin. The nature of pathological changes on the skin is described. These include rashes (exanthema), focal depigmentation and hyperpigmentation, increased vascular pattern, vascular tumors, scars, maceration.
Scheme for describing pathological elements:
– localization;
- size;
– character – inflammatory, non-inflammatory (when pressing on the element);
– quantity (single, multiple);
– adhesion to the underlying tissues.
In children special attention should be given to inspecting skin folds during ears, on the neck, in the armpits, groin areas, on the hips, under and between the buttocks, in the spaces between the fingers and the navel area in newborns.
Study of skin derivatives (hair, nails).
Characteristics of the scalp: hair thickness, density, fragility, dryness, shine, condition of fat secretion, dandruff, patchy or diffuse baldness, level of hair growth.
Body hair: increased hair growth (hypertrichosis), type of hair growth (normal - appropriate for gender and age, hirsutism, verification).
Characteristics of nails: shape, color, striations, fragility, condition of the periungual fold.
Examination of visible mucous membranes - oral cavity, conjunctiva, sclera. The degree of their blood filling and color change (pallor, cyanosis, hyperemia, jaundice) are noted. Detailed examination of the oral cavity and pharynx, as the procedure is unpleasant for the child early age, should be placed at the very end of objective research.
Humidity. To determine humidity, the skin is stroked with the back of the hands on symmetrical areas of the body in the following sequence: face, neck, chest, abdomen, back, buttocks, outer and inner surfaces upper limbs palms axillae lower extremities soles.
Special diagnostic value in children infancy has a determination of skin moisture on the back of the head, in children of puberty - on the palms and soles. Normally, a child's skin has moderate moisture.
Elasticity. To determine the elasticity of the skin, the index and thumb are used to grasp the skin without the subcutaneous fat layer in a small fold, then the fold is released. The study of skin elasticity is carried out in places of small accumulation of the subcutaneous fat layer in the following order: on the dorsum of the hand, the armpit, the elbow folds, and the dorsum of the foot.
The elasticity of the skin is considered normal if the skin fold straightens immediately; with reduced elasticity, the skin fold straightens gradually. Especially great value has a definition of skin elasticity in young children.
Temperature. Skin temperature is determined by palpating symmetrical areas of the body with the palmar surfaces of the hands in the same sequence as determining skin moisture, including large joints and distal sections limbs. Skin temperature can be normal, increased, or decreased.
To study the fragility of skin vessels, it is necessary to apply a rubber bandage, tourniquet or cuff to the lower third of the child’s shoulder for 3-5 minutes (tourniquet symptom, Konchalovsky-Rumpel-Leede), while increasing the pressure in the cuff to the level of systolic pressure, pulse to radial artery must be saved. With increased fragility of blood vessels, after removing the bandage or tourniquet, small hemorrhages appear at the site of its application, as well as in the elbow and forearm (normally no more than 4-5 petechiae). You can also grab a skin fold (pinch test), preferably on the front or side surface of the chest, with your thumb and forefinger and squeeze the fold or pinch. If a bruise appears at the site of the pinch, the fragility of the blood vessels is considered increased.
The study of dermographism is carried out from top to bottom back side the index finger of the right hand or the handle of a hammer on the skin of the chest and abdomen. After some time, a white stripe (white dermographism) or a red stripe (red dermographism) appears at the site of mechanical irritation, and the speed of its appearance and disappearance (persistent, unstable) is also noted.
TECHNIQUE FOR STUDYING THE SUBSCUTANEOUS FAT LAYER
The technique includes inspection and palpation.
During the examination, the following is assessed:
* degree of expression of the subcutaneous fat layer (developed satisfactorily, moderately, insufficiently, excessively, absent);
* uniformity of distribution (distributed evenly, unevenly).
Upon palpation the following is assessed:
* thickness of the subcutaneous fat layer - with the thumb and forefinger, grab the skin and subcutaneous tissue into the fold in the following areas: in the area of the large pectoral muscle, on the stomach - at the level of the navel outward from it, on the inner surfaces of the shoulder and thigh. In older children, instead of the inner surface of the thigh, the fold under the angles of the shoulder blades is examined. In young children, the thickness of the subcutaneous fat fold is: on the chest - 1.5 - 2.0 cm; on the stomach - 2.0 - 2.5 cm; on the shoulder - at least 1.5 cm; on the hip - 3.0 - 4.0 cm.
In older children, fold thickness is assessed using centile distributions.
* consistency – satisfactory, softening (pasty, loose), compaction;
* soreness;
* presence of subcutaneous formations (tumors, wen);
* the presence of edema - the study of edema in the subcutaneous tissue system is carried out in places where it is weakly expressed - in the sacrolumbar region, on the anterior surface of the legs (above the tibia) and feet. Gentle finger pressure is applied in these areas for 5 - 10 seconds and the presence, depth and speed of expansion of the resulting pit are assessed. In a healthy child, an impression does not form. If, when pressed, an impression is obtained that disappears gradually, then this is swelling of the subcutaneous tissue; if the depression disappears immediately, they speak of mucous edema (pastyness).
Soft tissue turgor is determined by squeezing all soft tissues on the inner surface of the shoulder and thigh with the thumb and index finger, and the degree of tissue resistance to pressure is assessed.
Soft tissue turgor can be:
* elastic – good degree of soft tissue resistance;
* flabby – poor (flabby, reduced) degree of soft tissue resistance.
METHOD FOR STUDYING THE RESPIRATORY ORGANS
Objective examination of the respiratory organs includes following methods:
* inspection;
* palpation;
* percussion;
* auscultation.
Inspection
1. Upper respiratory tract:
Nose - nasal breathing not difficult, difficult (breathing open mouth), participation of the wings of the nose in breathing, discharge from the nasal passages and their nature (serous, mucous, mucopurulent, purulent, sanguineous); the participation of each nasal passage in breathing is alternately checked;
paranasal sinuses(maxillary, frontal) – changes in the skin in the sinus area (hyperemia, edema), the presence of pain on palpation and percussion;
pharynx (anterior and posterior arches, soft palate, tonsils, posterior wall of the pharynx) - the presence of hyperemia, swelling, plaque, the state of lacunae and hypertrophy of the tonsils, the presence of granularity and discharge on back wall throats.
2. Chest. On examination the following is described:
* shape, symmetry of the chest; attention is paid to the ratio of anteroposterior and transverse dimensions, features of the position of the shoulder girdle, the state of the supra- and subclavian regions, the jugular fossa, the course of the ribs, the width of the intercostal spaces, the epigastric angle;
* participation in the act of breathing of both halves of the chest - symmetrical, lag in breathing of one of the halves of the chest;
* participation in the act of breathing of auxiliary muscles (trapezius, pectoralis major, sternocleidomastoid, intercostal muscles, diaphragm, abdominal muscles);
* breathing characteristics:
frequency of respiratory movements per minute (normally in a newborn 60 - 40; at 6 months 40 - 35; at 1 year 35 - 30; at 2 years 30 - 25; at 5 years 25 -20; at 10 years 20; at 15 16-18 years old; with pathology - tachypnea - increased respiratory rate, bradypnea - decreased).
rhythm – correct, incorrect (type of violation),
depth – superficial, medium depth, deep,
type – thoracic, abdominal, mixed,
character - the ratio of inhalation and exhalation (normally 3:1); in case of dyspnea pathology: inspiratory dyspnea– inhalation is prolonged, expiratory – exhalation is prolonged, mixed – both phases of breathing are difficult.
* chest excursion - the circumference of the chest is measured during quiet breathing, at the height of maximum inhalation and maximum exhalation, the difference between them is determined in cm.
Palpation of the chest reveals:
* soreness;
* elasticity (resistance);
* vocal tremor (determined in the same areas as comparative percussion, see below).
In young children, vocal tremors are examined during crying. Normally, vocal tremors are weak and more pronounced on the right side. upper sections chest. Increased vocal tremors are observed with compaction of the lung tissue and the presence of cavities in the lungs. Weakening - when the bronchus is blocked (pulmonary atelectasis), when the bronchi are pushed away from the chest wall (exudate, pneumothorax).
Percussion. There are two types of percussion: indirect and direct. Direct percussion is preferable for young children.
Comparative percussion allows you to determine the background sound of the lung and find areas of pathology. Anatomically identically located areas of the lungs on the right and left sides are compared, using a blow of average force.
Percussion points:
Along the anterior surface of the chest:
* supra- and subclavian fossae,
* collarbones,
* 2nd intercostal space along the parasternal line,
* 4th intercostal space along the midclavicular line.
Along the lateral surfaces of the chest (along the midaxillary line):
2nd intercostal space - depth of the axillary fossa,
4th intercostal space,
6th intercostal space.
Along the back of the chest:
* above the shoulder blades,
* between the shoulder blades - two levels (the plessimeter finger is located parallel to the spine),
* under the shoulder blades - one or two levels (depending on age).
When conducting comparative percussion, the nature of the percussion sound (clear pulmonary, tympanic, box, dull, dull, etc.) and its symmetry on the right and left are assessed.
In young children (up to 2 years), the number of comparative percussion points decreases:
* along the anterior surface of the chest: supra- and subclavian areas, clavicles, 2nd intercostal space;
* along the lateral surfaces: 2nd and 4th intercostal spaces;
* on the back surface of the chest, the points of comparative percussion remain the same as in older children.
Determining the lower bounds begins with right lung. In this case, the pessimeter finger is placed parallel to the desired boundary. In children over 3 years of age, percussion is carried out along seven lines, before 3 years of age - along three lines (midclavicular, middle axillary, scapular).
Table 2
The lower boundaries of the lungs in children over 2 years of age
In children under 2 years of age, the lower borders of the lungs are located one rib higher (due to the high position of the diaphragm)
Definition upper limits lungs is carried out in children starting from 7 years old. The upper border of the lungs in front is at a distance of 2-4 cm from the middle of the clavicle, in the back - at the level of the spinous process VII cervical vertebra.
Determination of the width of the Krenig fields (width of the dome of the lung) is carried out from the middle of the trapezius muscle towards the neck and shoulder.
In older children, the mobility of the lower pulmonary edge is determined along the midaxillary line. The mobility of the pulmonary borders is expressed in centimeters and is the difference between the borders of the lungs at maximum inhalation and exhalation.
Using percussion, you can determine the condition lymph nodes in the area lung root.
Koranyi's sign: direct percussion is performed along the spinous processes from the VII-VIII thoracic vertebrae from bottom to top. Normally, dullness of percussion sound is determined due to tracheal bifurcation in young children at II thoracic vertebra, in older children - on the IV vertebra. If there is dullness below these vertebrae (enlarged intrathoracic lymph nodes), the symptom is considered positive.
Symptom of the Philosopher's cup: loud percussion is performed in the first and second intercostal spaces on both sides towards the sternum (the pessimeter finger is located parallel to the sternum). Normally, dullness is noted on the sternum (negative symptom), if dullness is noted to the side of the sternum, the symptom is positive.
Arkavin's symptom: percussion is carried out along the anterior axillary lines from bottom to top towards the armpits. Normally, no shortening is observed - the symptom is negative. In the case of enlargement of the lymph nodes of the root of the lung, a shortening of the percussion sound is noted - a positive symptom (it should be remembered that if the plessimeter finger is applied to the edge of the pectoralis major muscle, then a dullness of the percussion sound will follow, which can be mistakenly regarded as a positive Arkavin symptom).
Auscultation. Before listening, it is necessary to empty the child's nasal passages of contents. Listening to the lungs is carried out with a stethoscope in symmetrical areas on the right and left:
1. along the front surface of the chest:
* supra- and subclavian fossae,
* 2nd intercostal space,
* 4th intercostal space.
2. Along the lateral surfaces of the chest:
* 2nd intercostal space,
* 4th intercostal space,
* 6th intercostal space.
3. Along the back of the chest:
* above the shoulder blades,
* between the shoulder blades - 2 levels,
* under the shoulder blades - 1-2 levels (depending on age).
During auscultation the following is assessed:
* the nature of the main respiratory noise - vesicular, puerile, hard, bronchial, weakened, enhanced. When listening to a child in the first half of life, the respiratory sound seems weakened. Starting from 6 to 18 months of life, children can hear breathing of the enhanced vesicular type with prolonged exhalation (the so-called puerile breathing).
* adverse respiratory sounds - wheezing, crepitus, pleural friction noise. Their location, character, sonority and breathing phase in which they are heard are indicated.
Wheezing can be: dry – high (wheezing, squeaking), low (buzzing, buzzing); wet (large, medium and fine bubbles, sonorous, silent). It is necessary to distinguish wheezing coming from the pulmonary and bronchial tissue from wheezing coming from the upper respiratory tract - the so-called oral or conductive wheezing.
* bronchophony – conduction of voice from the bronchi to the chest, determined by auscultation; It is preferable to use whispered speech. Normally, speech is not heard clearly. An increase in bronchophony is observed when the lung is compacted, a weakening is observed in the presence of fluid, air, or increased airiness of the lungs in the pleural cavity.
With enlargement of the bronchial lymph nodes, d'Espin's symptom is revealed: upon auscultation over the spinous processes, starting from the 7th - 8th thoracic vertebrae from bottom to top, during the child's whisper, a sharp increase in sound conduction is observed below the 1st - 2nd thoracic vertebrae (positive symptom).
Dombrovskaya's symptom: heart sounds are heard in the area of the left nipple, and then the phonendoscope is transferred to the right axillary region. Normally, the tones are practically inaudible here (negative symptom). When the lung tissue thickens (pneumonia), they are well carried here (positive symptom).
TECHNIQUE FOR STUDYING THE CARDIOVASCULAR SYSTEM
Cardiovascular examination includes:
* inspection;
* palpation;
* percussion;
* auscultation;
* measurement blood pressure;
* carrying out functional tests.
The examination begins with the patient's face and neck. Pay attention to:
* coloring skin;
* presence of pathological pulsation carotid arteries(symptom of “carotid dancing”) medially from the sternocleidomastoid muscles (normally only a weak pulsation of the carotid arteries is noted);
* swelling and (or) pulsation of the jugular veins outward from the sternocleidomastoid muscles (noted only in pathology - stagnation in the superior vena cava system).
II. Inspection and palpation of the heart area
Inspection and palpation of the heart area are carried out simultaneously.
Upon examination and palpation, the presence or absence of deformation of the chest in the area of the heart is described.
Apex impulse assessment
Initially, the apex beat is determined visually. In the absence of visualization of the push, it is determined by palpation (the palm of the subject is placed in the area of the left half of the chest at the base of the sternum parallel to the ribs). Then palpation is carried out with the tips of 2–3 bent fingers of the right hand in the intercostal spaces, where the apical impulse has been previously determined.
Characteristics of the apical impulse:
* localization (intercostal space and relation to the midclavicular line; age-appropriate; displaced);
* character: positive (during systole there is a bulging of the intercostal spaces); negative (during systole – retraction of the intercostal spaces);
* width (area): localized (the area normally does not exceed 1-1.5 cm2); diffuse (in young children, a push palpated in two or more intercostal spaces should be considered diffuse);
* height (amplitude): low (low or low amplitude), medium height (medium amplitude), high (high amplitude);
* strength: weakened, medium strength, strengthened (lifting);
* displacement in a standing position, lying down, lying on the left and right side;
* rhythm: correct, incorrect (arrhythmia);
* presence of tremor (diastolic tremor with mitral stenosis).
3. Cardiac impulse assessment
The cardiac impulse is determined visually and by palpation. The hand of the subject is placed parallel to the sternum on the sternum itself and the left half of the chest. Normally, the heartbeat is not detected.
Characteristics of the cardiac impulse:
* not visually determined, not palpable;
* determined visually, palpated (only with pathology);
* presence of a symptom of systolic or diastolic tremor: systolic tremor coincides with the impulse, diastolic is determined in the interval between contractions.
4. Assessment of the vascular bundle (2nd intercostal space on the right and left at the edge of the sternum)
The vascular bundle is assessed visually and by palpation.
Characteristics of the vascular bundle:
* presence of visual and palpable pulsation, bulging;
* presence of symptoms of systolic and distolic tremors.
5. Epigastric pulsation (pulsation of the epigastric region of cardiac origin is characterized by its direction from top to bottom, from under the xiphoid process, and a noticeable increase with deep inspiration):
* not determined visually or by palpation;
* if determined (only for pathology): positive or negative;
III. Orthopercussion of the heart
Direct percussion. This type percussion is more convenient to use in young children, especially newborns and infants.
Indirect percussion is used in children of all age groups.
1) Determination of the boundaries of relative cardiac dullness (RCD). Before determining the boundaries of relative dullness of the heart, it is necessary to percussion find the lower edge of the right lung to determine the height of the diaphragm, then “rise” one rib up. Next, install the pessimeter finger (end phalanx) into the intercostal space perpendicular to the course of the rib. Determination of the boundaries of the heart is carried out in the following sequence:
* right border of relative dullness of the heart;
* left border of relative dullness of the heart;
* upper limit of relative cardiac dullness.
Measuring the diameter of cardiac dullness in childhood necessary to assess the dynamics of the pathological process in the form of changes in the boundaries of relative dullness of the heart.
Pay attention! The diameter of the heart is measured by adding the distances from the right border to the midline of the body and from the midline of the body to the left border.
1. Percussion of the lungs in front above the collarbones (the plessimeter is located parallel to the collarbone)
2. Percussion on the collarbone
3. Percussion of the subclavian region up to the 4th rib (pessimeter - parallel to the clavicle)
4. Percussion of the axillary areas along the anterior axillary line
5. Percussion of the suprascapular region (pessimeter - horizontal)
6. Percussion of the interscapular space (the pleximeter is positioned vertically), the child hugs himself with his hands
7. Percussion subscapular region along the scapular line (the plessimeter is located horizontally)
AUSCULTATION of the lungs in children is of great importance. The position is the same as for percussion. Symmetrical areas of the lungs are heard on both sides. During auscultation, the nature of breathing, the nature and localization of pathological breath sounds– wheezing.
Breathing pattern: vesicular - a deep inhalation with the letter “F” and the beginning of an exhalation with the letter “x” are clearly audible. Audible in healthy children over 6 years of age. Up to 6 months in infants, weakened vesicular breathing can be heard. Puerile
(children’s) - a deep breath with the letter “f” and almost the entire exhalation with the letter “X” is clearly audible. Audible in children from 6 months to 3-5 years. In diseases, the nature of auscultatory data changes: hard breathing– a hard inhalation with increased amplitude and a hard exhalation with the letter “x”. It is heard when the walls of the bronchi become thicker. Bronchial breathing - a small inhalation with the letter “x” and a deep exhalation with the letter “x”. It is heard in case of compaction of lung tissue. Physiological bronchial breathing heard: above the larynx; above the trachea; in the interscapular space at the level of T3-T4.
Amphoric breathing - bronchial breathing takes on a blowing character. Indicates the presence of an encapsulated cavity associated with the bronchus. Weakened physiological breathing heard: in premature babies, with excessive development of the subcutaneous fat layer. Pathological weakening of breathing over an area of the pulmonary field is observed with: pneumothorax, exudative pleurisy, rib fractures, with a decrease in the lumen of the bronchi due to the accumulation of sputum.
Wheezing is an additional noise and is formed when secretions, mucus, edematous fluid, etc. move or oscillate in the air cavities. Wheezes can be dry and wet (fine-, medium-, and large-bubble). Dry wheezing is heard as air passes through narrowed airways. Fine bubble moist rales are heard with: bronchiolitis; pneumonia; stagnation of blood in the pulmonary circulation.
Large bubbling rales are heard when mucus comes off the walls of large bronchi during inspiration.
Diagnosis of the respiratory system necessarily includes percussion. This is a procedure that evaluates the sound produced during chest tapping.. With its help, you can identify various abnormalities in the lung area (comparative), as well as find out where the boundaries of the organ end (topographic percussion).
To obtain a more accurate result, the patient should stand upright with his arms down when examining the front of the chest. While palpating the back, the patient should cross his arms in the chest area and lean forward slightly.
It is necessary to distinguish between percussion and auscultation of the lungs. During auscultation, the organ is simply audible during the patient's natural breathing. Usually the procedure is carried out to detect any noise in the lungs (helps to identify pneumonia, bronchitis, tuberculosis and other diseases). But during percussion, the doctor taps to hear certain sounds.
Percussion of the lungs is a process that is based on the ability of elastic bodies to vibrate when struck. And if there is any obstacle in the path of the wave, the sound will begin to intensify. Based on this, conclusions are drawn regarding the presence of any lung diseases in the patient.
There are several main methods for performing the procedure:
Another option for percussion is a slight tap on the back with a fist. This procedure is aimed at identifying pain in the lung area.
Depending on the purpose of the procedure, there are two main types: topographical and comparative. In the first case, the boundaries of the lungs are assessed, and in the second, various pathologies of the organ are identified.
Topographic percussion of the lungs is aimed at determining the lower boundaries of the organ, its width, and height. Both parameters must be measured on both sides - front and back.
The doctor gently strikes within the chest, from top to bottom. When there is a transition from a clear sound to a dull sound, the border of the organ will be located in this place. After this, the found points of percussion of the lungs are recorded with a finger, after which it is necessary to find their coordinates.
You can take the necessary measurements with your fingers. However, to do this, you should know in advance their exact size - the width and length of the phalanges.
Determination of the lower border of the lungs is performed using vertical identification lines. The process begins with the anterior axillary lines. The doctor faces the patient, instructs him to raise his hands and place them behind his head. After this, he begins to tap from top to bottom in a vertical straight line, starting from the armpits and ending with the hypochondrium. The doctor taps in the area of the ribs, listening carefully to the sounds produced to determine exactly where the transition zone between clear and muffled sounds is located.
It must be taken into account that it may be difficult to determine the boundaries of the left lung. Indeed, in the area of the axillary line there is also another noise - heartbeat. Because of the extraneous sound, it is difficult to determine where the clear sound is replaced by a dull one.
Then the procedure is repeated, but on the back. The doctor stands behind the patient, and at the same time the patient should put his hands down, relax and breathe calmly. After this, the doctor taps from the bottom of the scapula, reaching spinal column and goes down.
The localization of the organ is indicated by the ribs. The count starts from the collarbone, nipple, lower border of the scapula or the lowest 12th rib (the results of the study must indicate from which rib the count started).
When determining the location of the lungs with reverse side the starting point is the vertebrae. This is due to the fact that the ribs on the back are difficult to palpate, as muscles prevent this.
Normally, the lower border of the right lung should have the following coordinates: 6th rib along the midclavicular line, 7th rib along the anterior axillary line, 8th along the middle and 9th rib along the posterior axillary line. But the lower border of the left organ falls on the 7th rib of the anterior axillary line, the 9th rib of the middle and posterior axillary line. From the back, the lower border of both lungs runs along the 11th thoracic vertebra.
Usually, in normosthenics, the lung boundaries are normal – they correspond to the above parameters. But for hypersthenics and asthenics these indicators differ. In the first case, the lower boundaries are located one edge higher, and in the second - one edge lower.
If a person has a normal physique, but the lungs are in the wrong position, we are talking about some kind of disease.
When the borders of both lungs sag, emphysema is often diagnosed. In addition, the pathology can be unilateral, developing only on the left or right side. This condition is often caused by the formation postoperative scars in the area of one organ.
Simultaneous elevation of both lungs can be caused by increased intra-abdominal pressure. This phenomenon is often associated with excess weight, chronic flatulence and other pathological conditions in the body.
When a large amount of fluid accumulates in the pleural cavity (more than 450 ml), the lungs shift upward. Therefore, in this area, instead of a clear sound, a muffled sound is heard. If there is too much fluid in the pleural cavity, a dull sound is heard over the entire surface of the lungs.
It must be taken into account that if the dullness extends to both lungs at once, this indicates the accumulation of transudate in the area of them. But if a clear sound is heard in one of the lungs, and a dull sound in the second, we are talking about the accumulation of purulent effusion.
The standing height of the pulmonary apexes is also determined from both sides - back and front. The doctor stands in front of the patient, who must stand straight and be completely motionless. Then the doctor places his finger in the supraclavicular fossa, but always parallel to the collarbone. Begins to gently strike the finger from top to bottom at a distance of 1 cm between each strike. But at the same time, the horizontal position of the finger must be maintained.
When a transition from a clear sound to a dull sound is detected, the doctor holds the finger in this place, and then measures the distance from the middle phalanx to the middle of the clavicle. If there are no deviations, this distance should be approximately 3-4 cm.
To determine the height of the apex from the back, palpation of the lungs and percussion begins from the center of the lower part of the scapula, moving upward. In this case, after each percussion blow, the finger rises up by about 1 cm, but its position must be horizontal. When the point of transition from clear to dull sound is found, the doctor fixes it with a finger and asks the patient to lean forward to better see the seventh cervical vertebra. Normally, the upper border of the lungs should pass at this level.
Comparative lung percussion is aimed at diagnosing certain diseases. Tapping is carried out in the area of both lungs from all sides - front, back and side. The doctor listens to the sound during percussion and compares all the results. In order for the study to be as accurate as possible, the doctor must perform percussion with the same finger pressure in all areas, as well as with the same impact force.
Typically, when performing pulmonary percussion, blows of medium strength are necessary, since if they are too weak, they may not reach the surface of the organ.
The procedure is performed according to the following scheme:
If instead of a clear sound a dull sound is produced, it is necessary to indicate the location of this area in the patient’s medical record. Dullness of sound may indicate that the lung tissue is compacted, so airiness in the percussion zone is reduced. This condition indicates pneumonia, tumors respiratory organ, tuberculosis and other diseases.
A dull sound is usually quieter, has a higher pitch and shorter duration compared to a clear sound. In the case of fluid accumulation in the pleural cavity, the sound produced is similar to that obtained during percussion of the thigh muscles.
Comparative percussion of the lungs in children is carried out according to the same algorithm as in adults. But during it you must follow a number of rules:
Topographic percussion of the lungs in children is carried out in compliance with the same rules. Unlike percussion in adults, the norm for children varies and depends on age.
Table by age
Percussion is very important procedure, which is held in diagnostic purposes, as well as to prevent the development of certain diseases. In children under 10 years of age, the procedure is recommended to be performed annually to monitor lung development. The check can then be performed every 5-10 years. for preventive purposes, and, as necessary, in diagnostic ones.
Determining the boundaries of the lungs is of great importance for the diagnosis of many pathological conditions. The ability to percussion detect displacement of the chest organs in one direction or another allows already at the stage of examining the patient without the use of additional methods studies (in particular, x-ray) to suspect the presence of a certain disease.
Of course you can use instrumental methods diagnostics, make x-ray and use it to evaluate how the lungs are located relative to the bone frame of the chest. However, this is best done without exposing the patient to radiation.
Determination of the boundaries of the lungs at the examination stage is carried out using the method of topographic percussion. What is it? Percussion is a study that is based on identifying the sounds that arise when tapping on the surface of the human body. The sound changes depending on the area in which the research takes place. Over parenchymal organs (liver) or muscles it becomes dull, over hollow organs (intestines) it becomes tympanic, and over air-filled lungs it acquires a special sound (pulmonary percussion sound).
In progress this study as follows. One hand is placed with the palm on the area of study, two or one fingers of the second hand hit the middle finger of the first (plesimeter), like a hammer on an anvil. As a result, you can hear one of the variants of percussion sound, which were already mentioned above. Percussion can be comparative (sound is assessed in symmetrical areas of the chest) and topographic. The latter is precisely intended to determine the boundaries of the lungs.
The pessimeter finger is installed at the point from which the study begins (for example, when determining the upper border of the lung along the anterior surface, it begins above the middle part of the clavicle), and then moves to the point where approximately this measurement should end. The limit is determined in the area where the pulmonary percussion sound becomes dull.
For ease of research, the pessimeter finger should lie parallel to the desired boundary. The displacement step is approximately 1 cm. Topographic percussion, unlike comparative, is performed by gentle (quiet) tapping.
The position of the apexes of the lungs is assessed both anteriorly and posteriorly. On the front surface of the chest, the clavicle serves as a reference point, on the back - the seventh cervical vertebra (it has a long spinous process, by which it can be easily distinguished from other vertebrae). The upper boundaries of the lungs are normally located as follows:
Research should be performed as follows:
An upward shift of the boundaries occurs due to excessive airiness of the lung tissue. This condition is characteristic of emphysema, a disease in which the walls of the alveoli are overstretched, and in some cases, their destruction with the formation of cavities (bullas). Changes in the lungs with emphysema are irreversible, the alveoli are swollen, the ability to collapse is lost, elasticity is sharply reduced. The boundaries of a person’s lungs (in this case, the limits of the apex) can shift downward. This is due to a decrease in the airiness of the lung tissue, a condition that is a sign of inflammation or its consequences (proliferation connective tissue and shrinkage of the lung). Borders of the lungs (upper), located below normal level, – diagnostic sign pathologies such as tuberculosis, pneumonia, pneumosclerosis.
To measure it, you need to know the main topographic lines of the chest. The method is based on moving the researcher's hands along the indicated lines from top to bottom until the percussion pulmonary sound changes to dull. You should also know that the anterior border of the left lung is not symmetrical to the right due to the presence of a pocket for the heart.
In front, the lower borders of the lungs are determined by a line running along the lateral surface of the sternum, as well as along a line going down from the middle of the clavicle. From the side, important landmarks are the three axillary lines - anterior, middle and posterior, which start from leading edge, center and rear edge armpit respectively. The posterior edge of the lungs is defined relative to a line that descends from the angle of the scapula and a line located on the side of the spine.
It should be noted that during breathing the volume of this organ changes. Therefore, the lower borders of the lungs normally shift 20-40 mm up and down. A persistent change in the position of the border indicates pathological process in the chest or abdomen.
The lungs become excessively enlarged with emphysema, which leads to a bilateral downward displacement of the boundaries. Other causes may be hypotension of the diaphragm and severe prolapse of the abdominal organs. The lower border moves down from one side in case of compensatory expansion healthy lung when the second is in a collapsed state as a result, for example, of total pneumothorax, hydrothorax, etc.
The borders of the lungs usually move upward due to wrinkling of the latter (pneumosclerosis), collapse of the lobe as a result of bronchial obstruction, and accumulation of exudate in the pleural cavity (as a result of which the lung collapses and is pressed towards the root). Pathological conditions in the abdominal cavity can also shift the pulmonary boundaries upward: for example, accumulation of fluid (ascites) or air (with perforation of a hollow organ).
Lower limits in an adult
Field of study
Right lung
Left lung
Line at the lateral surface of the sternum
5th intercostal space
-
A line descending from the middle of the collarbone
6 rib
-
A line originating from the anterior edge of the axilla
7th rib
7th rib
A line extending from the center of the armpit
8 rib
8 rib
Line from the posterior edge of the armpit
9th rib
9th rib
Line descending from the angle of the scapula
10 rib
10 rib
Line on the side of the spine
11th thoracic vertebra
11th thoracic vertebra
The location of the upper pulmonary borders is described above.
In asthenics, the lungs are elongated in the longitudinal direction, so they often fall slightly below the generally accepted norm, ending not at the ribs, but in the intercostal spaces. Hypersthenics, on the contrary, are characterized by a higher position of the lower border. Their lungs are wide and flattened in shape.
Strictly speaking, the boundaries of the lungs in children practically correspond to those of an adult. The tops of this organ are in guys who have not yet reached preschool age, which are not defined. Later they appear in front 20-40 mm above the middle of the collarbone, in the back - at the level of the seventh cervical vertebra.
The location of the lower boundaries is discussed in the table below.
Boundaries of the lungs (table)
Field of study
Age up to 10 years
Age over 10 years
Line running from the middle of the collarbone
Right: 6th rib
Right: 6th rib
A line starting from the center of the armpit
Right: 7-8 rib Left: 9 rib
Right: 8th rib Left: 8th rib
Line descending from the angle of the scapula
Right: 9-10 rib Left: 10 rib
Right: 10th rib Left: 10th rib
Reasons for displacement of the pulmonary boundaries in children up or down relative to normal values the same as in adults.
It was already mentioned above that when breathing, the lower boundaries shift relative to normal indicators due to the expansion of the lungs on inhalation and decrease on exhalation. Normally, such a shift is possible within 20-40 mm up from the lower border and the same amount down. Determination of mobility is carried out by three main lines, starting from the middle of the collarbone, the center of the armpit and the angle of the scapula. Research is carried out as follows. First, determine the position of the lower border and make a mark on the skin (you can use a pen). The patient is then asked to take a deep breath and hold his breath, after which the lower limit is again found and a mark is made. And finally, determine the position of the lung at maximum exhalation. Now, based on the estimates, we can judge how the lung shifts along its lower border. In some diseases, lung mobility is noticeably reduced. For example, this occurs with adhesions or a large amount of exudate in pleural cavities, loss of lung elasticity due to emphysema, etc.
This research method is not easy and requires certain skills, and better yet, experience. Complications that arise during its use are usually associated with incorrect execution technique. As for the anatomical features that can create problems for the researcher, these are mainly severe obesity. In general, it is easiest to perform percussion on asthenics. The sound is clear and loud.
What needs to be done to easily determine the boundaries of the lung?
And, of course, experience is very important. Practice gives you confidence in your abilities.
Percussion is a very important diagnostic method. It allows one to suspect many pathological conditions chest organs. Deviations of the borders of the lungs from normal values, impaired mobility of the lower edge are symptoms of some serious illnesses, timely diagnosis of which is important for proper treatment.
