Peripheral lymph nodes in healthy people are very small, soft and therefore not palpable. But there are very few absolutely healthy people. Most often we use the term practically healthy, i.e. We are not talking about a perfectly healthy person. In most adults, two small groups of peripheral lymph nodes are palpable: submandibular and inguinal. The increase in the former is due to the widespread prevalence of periodontal disease, caries and other diseases of the oral cavity. The inguinal lymph nodes enlarge and remain enlarged for many years due to the widespread prevalence of athlete's foot and the accompanying bacterial infection of the feet, as well as as a result of frequent microtraumatization of the legs.
In these cases, the lymph nodes are enlarged to a size of 0.5 - 1 cm, soft-elastic, mobile, painless, not fused to each other or to the underlying tissues, the skin over them does not change. Please note that the main palpation characteristics of the lymph nodes are listed. Any lymph nodes found should be described in the same style.
It is necessary to look for the following peripheral lymph nodes: submandibular, parotid, occipital, groups of lymph nodes located in front and behind m. sternocleidomastoideus, supra- and subclavian, axillary and ulnar, inguinal and popliteal. With significant magnification, mesenteric and retroperitoneal lymph nodes can be palpated (for example, with lymphosarcoma). It is important to determine whether there is systemic or local enlargement of the lymph nodes. Is it combined with an enlarged spleen or liver?
In some cases, the palpation properties of the lymph nodes allow a preliminary diagnosis to be made (the final diagnosis must be confirmed by a biopsy and a morphologist's report). Thus, tumor metastases to the lymph nodes are palpated in the form of hard, painful nodes that adhere to the underlying tissues and can grow into the skin. With lymphogranulomatosis, lymph nodes are often connected to each other, forming packets. At one stage, tuberosity may be detected in them. With tuberculous lymphadenitis, significantly enlarged nodes are painful. At the stage of caseosis, the lymph nodes acquire a doughy character, i.e. Its softening is palpable. Over time, the lymph node is soldered to the skin, it turns red, and in the center it becomes necrotic with the formation of a fistula. Currently, such dynamics of tuberculous lymphadenitis are quite rare. The process is usually diagnosed early, long before the formation of a fistula.
Palpation of the thyroid gland
Palpation thyroid gland carried out along the anterior and lateral surfaces of the neck below the thyroid cartilage. They examine with 2–4 fingers of both hands, with which they push the sternocleidomastoid muscles back and reach the posterolateral surface of the lateral lobes of the gland. The patient is asked to make a swallowing movement, which facilitates palpation. The isthmus of the thyroid gland is examined by sliding fingers along its surface from top to bottom. The size of the gland, the nature of its enlargement (diffuse, nodular, diffuse-nodular), surface features, displacement during palpation, and pulsation are noted.
Degrees of enlargement of the thyroid gland: O – the thyroid gland is not palpable; I degree – the isthmus of the thyroid gland is enlarged, which is clearly palpable and visible when examined during swallowing; II degree – the lobes of the gland and the isthmus are well defined both by palpation and by swallowing; III degree - the thyroid gland fills the anterior surface of the neck, smoothes its contours and is visible upon examination, the so-called thick neck; IV degree – the shape of the neck is sharply changed, the enlarged thyroid gland appears in the form of a tumor; V degree – the thyroid gland is very large.
Palpation of lymph nodes
Indications. Palpation of the lymph nodes is indicated for many inflammatory diseases and especially for diseases of the blood system. Superficially located lymph nodes, as well as abdominal and thoracic ones if they are significantly enlarged, are available for clinical examination.
To examine the lymph nodes, inspection and palpation are used. The room where the patient is located must be warm, the researcher’s hands must be clean, dry and warm.
It is necessary to palpate systematically, on both sides.
Execution technique. To palpate the occipital lymph nodes, the examiner's hands are placed flat on occipital bone. Using circular movements, methodically moving your fingers and pressing them against the child’s skin, they feel the entire surface of the occipital bone.
For examination of lymph nodes mastoid process Carefully palpate the mastoid area on both sides.
When examining the mental lymph nodes, the child's head is slightly tilted down, and the examiner's fingers feel the area under the chin.
To examine the submandibular lymph nodes, the child's head is slightly lowered. Four fingers of the researcher’s half-bent hand are brought under the branches lower jaw and slowly move out from there.
Anterior cervical or tonsillar lymph nodes are palpated anterior to m. sternoclaidomastoideus.
When palpating the posterior cervical lymph nodes, the fingers are moved parallel to the course of the muscle fibers behind the rasternoclaklomastoideus.
Supraclavicular lymph nodes are palpated in the supraclavicular fossa between m.sternoclaidomastoideus and m.trapezium.
Subclavian lymph nodes are palpated under the collarbone along the upper ribs. To palpate the axillary lymph nodes of the patient, you need to move your hand to the side so that the researcher can insert his fingers into the axillary region, after which the patient lowers his hand and the researcher can palpate these nodes on the surface of the chest.
To palpate the ulnar lymph nodes, it is necessary to grab the lower third of the shoulder of the opposite arm of the child being examined with the left hand, bend the latter’s arm at the elbow joint at a right angle and use the middle and index fingers right hand Using longitudinal sliding movements, they probe the sulcus bicipitalis medialis in the area of the elbow and slightly above.
Thoracic lymph nodes are palpated on the anterior surface of the chest under the lower edge of the m.pectoralts.
The inguinal lymph nodes are palpated along the inguinal ligament.
The mediastinal group of lymph nodes is available for examination by percussion and x-ray. The abdominal group is mainly located in the area of attachment of the root of the mesentery to the left of the umbilicus. Normally, in healthy children, no more than 3 groups of lymph nodes are palpated - submandibular, axillary and inguinal. If in each group of lymph nodes no more than 3 nodes are palpated, then they speak of single lymph nodes; if more than 3, then they speak of multiple lymph nodes. When examining lymph nodes, it is necessary to determine their size and quantity, mobility, relationship to the skin, subcutaneous fat and among themselves, and sensitivity. The size of the lymph node is compared with the size of grains of millet, peas, cherry pits, beans, hazelnut etc. Conventionally, it is customary to distinguish the following sizes of lymph nodes - the size of millet grain - I degree, the size of lentils -
II degree, the size of a pea - III degree, the size of a bean - IV degree, the size of a walnut - V degree, the size of a pigeon egg - VI degree. The normal size is from a lentil to a small pea. The consistency of the lymph nodes in healthy children is elastic, palpation is painless.
Palpation of the lymph nodes also depends on the condition of the subcutaneous fat. In children in the first year of life, due to well-developed subcutaneous fat and insufficient development of the capsule of the lymph nodes, the latter are difficult to palpate.
Enlargement of the lymph nodes can be symmetrical, widespread or isolated and reach such an extent that they become visible upon simple examination. The mobility of lymph nodes also has a certain significance in diagnosis. Their soreness indicates an acute inflammatory process. The consistency of the lymph nodes depends on how long ago they were damaged and the nature of the inflammatory process: if the lymph nodes have recently enlarged, they are usually of a soft consistency, with chronic processes they are dense.
Stool examination
Purpose of the study. Feces are the final product formed as a result of complex biochemical processes and absorption of the final products of breakdown in the intestine. Stool analysis is an important diagnostic area that allows making a diagnosis, monitoring the development of the disease and treatment, and initially identifying pathological processes. Examination of the intestinal tract when examining patients suffering from diseases digestive system, makes it possible to judge some pathological processes in the digestive organs and, to a certain extent, makes it possible to assess the state of enzymatic function.
Contraindications for the study- No.
Rules for collecting material. Preliminary preparation of the subject for general analysis feces (macroscopic, chemical and microscopic examination) consists of eating food with a dosed content of proteins, fats and carbohydrates for 3-4 days (3-4 bowel movements). The Schmidt diet and the Pevzner diet meet these requirements.
Schmidt's diet (gentle), includes 1-1.5 liters of milk, 2-3 soft-boiled eggs, 125 g of lightly fried minced meat, 200-250 g of mashed potatoes, mucous broth (40 g of oatmeal), 100 g white bread or crackers, 50 g butter, total calorie content 2250 kcal. After its consumption, during normal digestion, food residues are not found in the feces.
The Pevzner diet is based on the principle of maximum food load for healthy person. She is ordinary diet healthy people, which is convenient in outpatient settings. It consists of 400 g of white and black bread, 250 g of meat, fried in pieces, 100 g of butter, 40 g of sugar, buckwheat and rice porridge, fried potatoes, salad, sauerkraut, dried fruit compote and fresh apples. Calorie content reaches 3250 kcal. After its administration in healthy people, microscopic examination reveals only isolated changes in rare fields of vision. muscle fibers. This diet allows you to identify even a small degree of disruption of the digestive and evacuation capacity of the gastrointestinal system.
When preparing a patient for a study for hidden bleeding, fish, meat, all types of green vegetables, tomatoes, eggs, and medications containing iron (that is, catalysts that cause a false-positive reaction to blood) are excluded from the diet.
Feces are collected after spontaneous bowel movements in a specially designed container. You cannot send material for research after an enema, taking medications that affect peristalsis (beladona, pilocarpine, etc.), after taking castor or vaseline oil, after administering suppositories, or drugs that affect the color of stool (iron, bismuth, barium sulfate). The stool should not contain urine. Delivered to the clinical diagnostic laboratory immediately or no later than 10-12 hours after defecation, subject to storage in the refrigerator.
In the laboratory, stool is subjected to chemical analysis, macroscopic and microscopic examination.
Chemical research feces consists of determining the pH, identifying a hidden inflammatory process (mucus, inflammatory exudate), detecting hidden bleeding, diagnosing obstruction of the biliary system, and testing for dysbacteriosis. To carry out these studies, it is possible to use reagent test strips that allow you to determine the pH of feces, the presence of protein, blood, stercobilin, bilirubin, and leukocytes.
Before you begin to palpate the lymph nodes, you need to remember their anatomical location.
Location of lymph nodes
It is known that there are more than 300 lymph nodes in the neck area alone. The superficial lymph nodes of the head and neck form two main groups - horizontal and vertical. The first group drains lymph from the scalp and neck. It is formed by the chin, submandibular, ear, and occipital lymph nodes. The vertical group of nodes predominantly drains lymph from the internal structures of the head and neck. Its deep chain runs along the inner jugular vein(in the thickness of the sternocleidomastoid muscle), and the superficial one - along the external jugular vein, where lymph flows from the salivary glands and the auditory canal. Lymph from the very tip of the tongue drains into the mental nodes, from its anterior two-thirds - into the mental and submandibular nodes, and from the posterior third - into the deep lymph nodes of the neck. The lymphatic vessels of the arm and hand drain into the axillary and subclavian nodes. The ulnar lymph nodes are an intermediate group.
Lymph from the mammary glands drains medially into the internal thoracic chain, and laterally into axillary lymph nodes. Lymph from the parietal pleura also comes here (which is why this group of lymph nodes must be palpated during examination of the respiratory organs!). Lymphatic vessels lower limbs drain into the popliteal and vertical chain of inguinal lymph nodes. Lymph from the skin of the perineum, external genitalia and lower back drains into the horizontal chain of inguinal nodes, located primarily below the inguinal ligament. From the testicles, lymph drains mainly into the para-aortic lymph nodes, and from the genitals - into the pelvic, lower abdominal and para-aortic chains.
Lymph node examination
Lymph node examination involves examining and palpating the lymph nodes.
Progress of palpation of lymph nodes
If they are inflamed (lymphadenitis), then they become painful when palpating the lymph nodes, and the skin over them turns red. Sometimes small reddish stripes of inflamed areas are visible on the skin. lymphatic vessels(lymphangitis). Palpation of the lymph nodes is carried out with the pads of the fingers, in a circular motion. If the lymph nodes are enlarged, it is necessary to estimate their size (about the size of a pea, walnut and the like), consistency, soreness, mobility, their adhesion to tissues. Lymph nodes of the head and neck can be examined from a position in front or behind the patient. Palpation of the lymph nodes is recommended on both sides simultaneously. First, the parotid lymph nodes are palpated, then the tonsillar (at the angle of the lower jaw), submandibular (along the edge of the jaw) and mental groups of nodes. At the next stage, the doctor palpates the lymph nodes of the back of the head and posterior cervical triangle. The anterior group of lymph nodes in the neck is palpated along the edge of the sternocleidomastoid muscle. Palpation of the lymph nodes ends by palpating the supraclavicular nodes on both sides. Note that it is easier to palpate them when the patient takes a deep breath.
To palpate the lymph nodes of the elbow, the patient's arm is moved to the side. While holding the hand in this position, palpate the ulnar nodes between the biceps and triceps tendons, proximal to the medial condyle of the humerus. The axillary lymph nodes form several groups, of which three should be examined: the anterior ones - along the edge of the pectoralis major muscle, the posterior ones - along the anterior edge of the latissimus muscle and the upper axillary ones - at the very head of the humerus. In the latter case, the palpating fingertips should be directed towards the head of the patient's humerus. It is recommended to examine the lymph nodes of the lower extremities by palpation in the supine position. The superficial inguinal nodes form two chains. First, the horizontal chain of lymph nodes below the inguinal ligament is palpated, and then the vertical chain along the saphenous vein legs. Then, bending the patient’s leg at the knee joint, the popliteal lymph nodes are palpated. At the same time, they clasp the knee with both hands so that the tips of the palpating fingers are in the depths of the popliteal fossa. It should be noted that the liver also belongs to the lymphatic system and can enlarge with its pathology.
Enlarged lymph nodes may be clearly visible. It is always important to carefully examine the areas drained by enlarged lymph nodes, since their enlargement may be due to a local pathological process, such as an infected wound. In each case, the nature of lymphadenopathy (local or generalized) is clarified. In the latter case, it is necessary to exclude leukemia and lymphosarcoma. With tumor infiltration, the lymph nodes are usually painless on palpation. At the same time, they can reach significant sizes, become very dense, uneven and welded together with each other and surrounding tissues. If dense axillary nodes, first of all, it is necessary to exclude or pleura. In lung cancer, the supraclavicular nodes are most often affected. With tuberculous lymphadenitis, caseous discharge from the lymph nodes (scrofula or scrofula) may be observed.
Sometimes during an examination, the doctor discovers 1-2 small, mobile and painless lymph nodes in the patient. In this case, it is recommended to re-examine them after a short period of time. If they do not increase in size and the patient does not develop new symptoms, then most likely their enlargement is not a serious problem.
Causes of enlarged lymph nodes
Causes of local lymphadenopathy
- local infections
- tumor metastases
- lymphogranulomatosis
Causes of generalized lymphadenopathy
- lymphomas and leukemias
- viral infections (HIV, mononucleosis)
- bacterial infections (tuberculosis, brucellosis, syphilis)
- toxoplasmosis
- sarcoidosis
- serum sickness
Structure of the lymphatic system
Organs of the lymphatic system include lymph vessels, lymph nodes, spleen, tonsils, thymus (thymus gland). Lymphoid tissue is also found in Peyer's patches of the terminal ileum, lung tissue and liver. A network of lymphatic vessels seems to accompany the bloodstream. Through them, lymph, which is a white opalescent liquid, enters the lymph nodes. Lymph from certain regions is drained into each group of nodes. Small lymphatic vessels gather into large ones and, finally, into two main lymphatic trunks. Lymph from the upper right half of the body collects into the right lymphatic trunk, and then into the right subclavian vein. From the rest of the body, lymph drains through the thoracic duct into the left subclavian vein. Fats from the small intestine, bypassing the portal bloodstream, also enter the thoracic lymphatic duct, pulmonary vessels, and then into the mesenteric lymphatic vessels. systemic blood flow. The lymph nodes contain lymphocytic follicles and sinuses lined with reticuloendothelial cells (histiocytes and macrophages). The follicles of the cortical layer have a special germinal center rich in B-lymphocytes and macrophages. Each such center is surrounded by a muff of T-lymphocytes. Various antigens travel through the lymphatic vessels to the lymph nodes, where in response lymphocytes proliferate with the formation of antibody-producing B lymphocytes (plasma cells) and antigen-specific T lymphocytes.
The article was prepared and edited by: surgeonPalpation of lymph nodes
Great value for the diagnosis of certain diseases of internal organs (diseases of the blood system, malignant neoplasms, tuberculosis, infectious and inflammatory diseases) has a study of peripheral lymph nodes located in subcutaneous tissue.
Lymph nodes perform barrier-filtration and immune functions. Lymph flowing through the sinuses of the lymph nodes is filtered through loops of reticular tissue. Small foreign particles that enter the lymphatic system from tissues (microbial bodies, tumor cells, etc.) are retained here, and lymphocytes formed in lymphoid tissue lymph nodes. Lymph nodes during examination are detected only when sharp increase or significant weight loss of the patient. Their primary examination is carried out using palpation.
Palpation of the lymph nodes is carried out in parallel with the examination and makes it possible to determine the degree of enlargement, consistency, soreness, mobility and adhesion to the skin.
Normally, peripheral lymph nodes are round or oval formations ranging in size from 5 to 20 mm. They do not protrude above the skin level and therefore are not detected during examination. However, some of the lymph nodes can be palpated even in a healthy person (submandibular, axillary, inguinal). They are relatively small in size, soft in consistency, painless, moderately mobile and not fused to each other or to the skin. There is an opinion that the lymph nodes palpable in a healthy person are a consequence of local inflammatory processes suffered in the past.
Palpation technique consists of examining all areas where lymph nodes accessible to palpation may be located, from top to bottom, starting from the head. The areas of localization of the occipital, parotid, submandibular, sublingual, mental, posterior cervical, anterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal lymph nodes are palpated. Palpation of the lymph nodes is carried out with both hands in symmetrical areas.
The lymph nodes are palpated with the fingertips, making sliding circular movements in the area of the intended localization of this group of lymph nodes and, if possible, pressing them against denser formations (bones, muscles). When palpating the axillary lymph nodes, first take the patient's hand to the side and place the bent fingers of the examiner in the axillary region. Then they bring the patient’s hand to the chest and with one sliding movement of the hand from top to bottom they try to palpate the lymph nodes.
When palpating the lymph nodes, pay attention to:
Dimensions
consistency,
soreness,
Mobility, fusion with each other and with surrounding tissues,
Condition of the skin over the lymph nodes.
IN practical activities The doctor may encounter two types of lymph node changes:
1) common, systemic lesion lymph nodes, which can be caused by both inflammatory changes (for example, in some infections - syphilis, tuberculosis, tularemia), and changes associated with tumor growth in certain blood diseases (leukemia, lymphosarcoma, lymphogranulomatosis);
2) local increase regional lymph nodes as inflammatory (local purulent processes), and neoplastic nature (cancer metastases).
For correct interpretation local increase lymph nodes must be well represented typical paths lymphatic drainage from various areas bodies.
Lymph nodes of the angle of the mandible, sublingual and submandibular lymph nodes increase with local pathological processes (stomatitis, gingivitis, glossitis, cancer) in the tonsils and oral cavity. ABOUT ear and ear ears– with lesions of the outer and middle ear. Z occipital- in pathological processes in the scalp and neck. Cervical- with damage to the larynx and thyroid gland (cancer, thyroiditis). Supraclavicular lymph nodes on the left- for metastases of stomach cancer (Virchow's gland), etc. The most typical paths of lymphatic drainage in the upper shoulder girdle. Ulnar lymph nodes, collecting lymph from the third, fourth and fifth fingers of the hand, are affected by suppurative processes upper limbs. Axillary - collects lymph from the 1st, 2nd and 3rd fingers, as well as from the breast area - for cancer, mastitis. Inflammatory or tumor lesions of the mammary glands are often accompanied by enlargement of the axillary, subclavian, supraclavicular and parasternal lymph nodes.
Metastasis of lung cancer to the axillary lymph nodes is of particular diagnostic importance. With inflammatory lesions of this localization, subclavian and even supraclavicular lymph nodes can also be involved in the pathological process.
Inguinal lymph nodes collect lymph from the genital and pelvic organs, as well as from the tissues of the lower extremities, popliteal- mainly from the area of the back surface of the legs.
Remember: Lymph nodes when acute inflammatory lymphadenitis always painful, slightly compacted, mobile, not fused with the surrounding tissues.
Sometimes, especially with purulent-necrotic processes in the skin and festering wounds, a reddish cord can be seen between the area of inflammation and enlarged lymph nodes, caused by inflammation of the corresponding lymphatic vessels (lymphangitis); the skin over the lymph node may be hyperemic.
With systemic damage, the lymph nodes are usually painless, dense, with an uneven surface. They can reach large sizes (with lymphogranulomatosis up to 15-20 cm). With tuberculosis and lymphosarcoma, the lymph nodes are soldered together, form conglomerates, become inactive, and suppurate.
The following factors help in the differential diagnosis of diseases accompanied by enlarged lymph nodes (I. Magyar, 1987).
Large lymph nodes: lymphocytic leukemia, lymphogranulomatosis, lymphosarcoma, lymphoma. Rapid enlargement of lymph nodes: mononucleosis, rubella, cat scratch disease, others acute infections, nonspecific lymphadenitis.
Very dense lymph nodes: tumor metastasis, sometimes tuberculous lymphadenitis.
Lymph nodes adherent to the skin: actinomycosis, tuberculosis, purulent lymphadenitis.
Suppuration of the lymph node: tuberculosis, actinomycosis, rarely – tumors.
Enlarged lymph nodes, accompanied by high temperature: acute lymphadenitis, mononucleosis, rubella, lymphogranulomatosis, reticulosis.
Enlarged lymph glands in combination with an enlarged spleen: lymphogranulomatosis, leukemia, lymphosarcoma, disseminated lupus erythematosus, sarcoidosis.
Mediastinal tumor: lymphogranulomatosis, mononucleosis, leukemia, sarcoidosis.
Bone Changes: malignant tumors, eosinophilic granuloma, lymphogranulomatosis, Ewing's sarcoma, reticulosis, sarcoidosis.
Palpation of the thyroid gland
The doctor is positioned in front of the patient. Before palpation, the area of the thyroid gland is examined in order to detect its enlargement visible to the eye. First, the isthmus of the thyroid gland is palpated with sliding movements of the thumb of the right hand from top to bottom, and then the lateral lobes, penetrating the inner edges of the sternocleidomastoid muscles. You can ask the patient to make a swallowing movement, which facilitates palpation.
Palpation of the lobes of the thyroid gland can be carried out with the bent fingers of both hands (2 and 3 fingers), penetrating the inner edges of the sternocleidomastoid muscles and reaching the posterolateral surface of the lateral lobes of the gland. In this case, the doctor is located behind the patient.
Palpation method define the following parameters:
Position,
Dimensions (degree of enlargement of the thyroid gland),
Consistency (presence or absence of nodes), - pain,
Displaceability.
In a healthy person, the thyroid gland is not enlarged upon palpation, elastic, painless, and mobile.
At diffuse increase of the thyroid gland, a smooth surface of soft consistency is determined by palpation. At nodal form A goiter is determined by a nodular dense formation in the area of the thyroid gland. In acute and subacute thyroiditis, the thyroid gland is elastic, enlarged and painful. With a malignant lesion, the thyroid gland becomes dense and may lose mobility.
Degree of enlargement of the thyroid gland:
I degree – the isthmus of the thyroid gland is enlarged, which is clearly palpable and visible when swallowing.
II degree – the lobes of the gland and the isthmus are well defined both during palpation and when swallowing.
III degree - the thyroid gland fills the anterior surface of the neck, smoothes its contours and is visible upon examination (short neck).
IV degree – the shape of the neck is sharply changed, the enlarged thyroid gland appears in the form of a tumor.
V degree - the thyroid gland is very large.
But at the same time, palpation is not a reliable method for determining the size of the thyroid gland and gives an erroneous result in approximately 30-40%.
Clinical classification goiter sizes (WHO, 1995):
0 – no goiter.
1 – the size of the lobes is larger than the distal phalanx of the thumb, the goiter is palpable, but not visible to the eye.
2 - the goiter is palpable and visible to the eye.
The results of palpation examination of the gland are influenced by:
The size of the goiter (the smaller the goiter, the less informative the palpation);
The age of the subject (for example, than younger child, the more difficult it is to palpate the thyroid gland and the less reliable the examination results);
Short neck, powerful muscles and a thick subcutaneous fat layer;
Unusual location of the thyroid gland (sometimes the enlarged thyroid gland can descend behind the sternum partially or entirely, in this case the goiter is called retrosternal; in in rare cases the thyroid gland may be located at the root of the tongue);
Difficulty in comparing the size of the palpable thyroid gland with the phalanx of the finger.
Osteoarticular system
Bones. Determine the shape of the bones, the presence of deformations, pain when palpating and tapping.
From pathological deformations In bones, spinal deformities are more common than others. There are:
1) kyphosis- curvature of the spine with a convexity backwards, often with the formation of a hump (gibbus);
2) lordosis- curvature of the spine with a convexity forward;
3) scoliosis- lateral curvature of the spine.
A combination of kyphosis and scoliosis (kyphoscoliosis) is often found.
In patients with ankylosing spondylitis(Bechterew's disease) there is a combination of cervical hyperlordosis and kyphosis thoracic spine, which leads to very characteristic changes the patient’s posture in the form of a petitioner’s pose.
A child with respiratory system pathology is examined in a warm room. Patient position sometimes helps the doctor suggest a diagnosis:
- forced sitting position - orthopnea- occurs during an attack bronchial asthma: the child sits and rests his hands on the edge of the bed or his knees, thus strengthening the belt of the upper limbs; it facilitates the act of breathing due to participation accessory muscles;
- forced position on the painful side at pleurisy limits respiratory movements and friction of the visceral and parietal pleura, which reduces pain and the frequency of painful cough;
For easy forms of pneumonia are typical active position of the patient, for severe forms - passive.
Chest shape at healthy child older people can be of three types.
Asthenic type chest - a sign of children with an asthenic constitution. It resembles the position of maximum exhalation and is characterized by the following manifestations:
Narrow, long chest;
On palpation, the angle at the junction of the sternum and its manubrium is not felt;
The epigastric angle is approximately 90°;
The ribs in the lateral sections and wider intercostal spaces are placed more vertically;
Depressions in the areas of the supra- and subclavian fossae;
The shoulder blades lag behind the chest.
Hypersthenic type chest - a sign of children with a hypersthenic constitution. It resembles the position of maximum inspiration and is characterized by the following manifestations:
The chest has the shape of a cylinder;
The angle where the sternum and its manubrium join is significantly pronounced;
Epigastric angle greater than 90°;
The ribs are placed more horizontally in the lateral sections, the intercostal spaces are narrowed;
The supraclavicular fossa is smoothed and the subclavian fossa is not visually identified;
Normosthenic type chest - a sign of children with a normosthenic constitution - is characterized by a cone-shaped chest, for which the following signs are typical:
The chest resembles a truncated cone (the muscles of the shoulder girdle are well developed);
The transverse dimension is larger than the anteroposterior dimension;
Regular shape the angle connecting the sternum and its manubrium;
The epigastric angle is approximately 90°;
Moderately oblique placement of the ribs in the lateral sections and normal width of the intercostal spaces;
Only the supraclavicular fossae are somewhat visible;
The shoulder blades fit tightly to the chest.
Emphysematous, pathological the shape of the chest, which is based on increase in lung tissue volume as a result of prolonged pulmonary emphysema (emphysema is the stretching of an organ or tissue by air or gas formed in the tissues), characterized by the following symptoms:
Barrel-shaped appearance;
More significant increase in intercostal spaces; we can say that this shape of the chest, based on these significantly pronounced last signs, resembles the hypersthenic type.
Respiration rate per minute, rhythm and type of breathing depend on age and are indicators functional features of breathing spruce system in children.
Respiratory frequency (RR) in 1 min can be determined by the following methods:
Breathing type. The harmonious and consistent work of certain respiratory muscles is ensured by the regulation nervous system. However, depending on the age and gender of the child, there are 3 types of breathing:
-diaphragmatic- after birth the diaphragm takes the most active part in the act of breathing; rib muscles - very slight;
-thoracoabdominal (= mixed) appears in a child in infancy. However, at first the excursion of the chest is significantly expressed in the lower sections, weakly in the upper. When the child moves to a vertical position, both the diaphragm and the costal muscles will take part in the act of breathing;
-breast type- this type of breathing in children 3-7 years is marked by well-developed muscles of the shoulder girdle, the function of which during breathing significantly prevails over the diaphragmatic muscles;
-from 8 to 14 years old the type of breathing depends on gender: boys develop abdominal, for girls - chest type
Violation of the type of breathing indicates damage to the corresponding muscles.
In severe conditions of a child of various etiologies (as a result of changes in the coordination of the respiratory center), the following are noted: types of significant pathological respiratory disorders.
Breath Cheyne-Stokes (Irish doctors of the 19th century) - first, with each inhalation, there is a gradual increase in its depth and frequency to a maximum, then the amplitude and frequency of inhalation decrease (a total of 10-12 respiratory movements) and apnea occurs lasting 20-30 s, sometimes more. After this, the specified cycle is repeated. With a prolonged pause of apnea, the child may lose consciousness. This is the most unfavorable type of breathing.
The most common pathogenetic The cause of Cheyne-Stokes breathing is a violation of the blood circulation of the brain at the site of the respiratory center. This occurs with meningitis, cerebral hemorrhages, severe heart failure, inflammatory processes with significant intoxication.
No less prognostically unfavorable is impaired coordination of the diaphragmatic and pectoral muscles is Breath of Grocco-Frugoni (Grocco - Italian therapist of the 19th-20th centuries), resulting from changes in the functioning of the respiratory center. With this type of breathing top part is in condition inhale, A lower- able exhalation . Causes: meningitis, comatose states, violation cerebral circulation. This disruption of the breathing rhythm often precedes the onset of Cheyne-Stokes breathing and occurs after its completion.
Breath Kussmaul (German therapist of the 19th century) = noisy = big is tachypnea with a significant deepening of breathing, audible at a distance, reminiscent of the breathing of a “hunted animal.”
Frequent the reason is irritation of the respiratory center during acidosis, those. accumulation of acidic metabolic products, for example, with diabetes mellitus, as well as against the background of inflammatory bowel processes with significant toxicosis; maybe when III degree malnutrition.
Breath Biota (French doctor of the 19th century) (Fig. 115) - after a few (2-5) breathing movements of the same amplitude, an apnea pause occurs lasting 5-30 s. With a long pause, the child may lose consciousness.
Chaotic Breath - not only arrhythmic, but also varied in depth.
Dyspnea - one of the common signs of diseases of the respiratory system - is zat difficulty breathing with a violation of its frequency, depth and rhythm. There are 3 types of shortness of breath: inspiratory, expiratory and mixed (inspiratory-expiratory).
Inspiratory dyspnea- the result of disruption of air movement during inhalation through the upper airways.
Clinical signs:
Extended difficulty breathing;
Difficulty breathing, often with whistling inhale;
In serious condition noisy inhale;
Breath deep;
Developing bradypnea:
Participation of auxiliary muscles in the act of breathing;
Since the air intake is less than normal, there is a very characteristic feature this type of shortness of breath - retraction(English pull) intercostal mice, areas of the jugular, supra- and subclavian fossae and epigastrium;
With rickets (softening of bone tissue), retraction in the area of the Harrison groove.
Inspiratory dyspnea is one of the main signs of stenosing laryngotracheitis ( false croup) and diphtheria (true croup), foreign body in the larynx and trachea .
Expiratory dyspnea- the result of a violation of the passage of air during exhale through the lower respiratory tract (bronchioles and small bronchi).
Clinical signs:
Extended exhalation;
Difficulty exhaling;
-tachypnea, turning into bradypnea when the condition worsens;
Participation of auxiliary muscles in the act of breathing, mainly the abdominal muscles;
Since exhalation is difficult and air accumulates in the lung tissue, it is noted protrusion intercostal muscles;
If the process is prolonged, it can turn into an attack of suffocation.
Expiratory shortness of breath is one of the main signs obstructive bronchitis, bronchial asthma, at which it occurs narrowing terminal sections of the bronchi.
Mixed dyspnea- this is a difficulty inhalation and exhalation, often against a background of tachypnea.
Percussion of the lungs
It is most convenient to perform lung percussion with the patient in a calm, vertical (standing or sitting) position. His hands should be lowered or placed on his knees.
1. Topographic percussion of the lungs. With topographic percussion of the lungs, the following are determined: the height of the apexes in front and behind, the width of the apex (Krenig's field), the position of the lower edges of the lungs and their mobility (excursion of the lower edge).
In order for the boundaries of the lungs found using topographic percussion to be marked on the surface of the chest, special identification lines have been adopted in medicine. Topographic lines and the areas they form are determined by natural identification points human body. These horizontal identification the points are:
1) collarbone;
2) ribs and costal arches;
3) the sternum, its manubrium, body and xiphoid process;
4) Louis’s angle (angulus Ludovici) - the connection of the handle of the sternum with its body - an identification point for the 2nd rib;
5) spinous processes of the vertebrae (the spinous process of the VIIth is identified separately cervical vertebra- most prominent when the head is tilted forward);
6) shoulder blades, bottom corner which, with arms down, is at the level of the 7th rib;
Identification vertical lines are:
1) anterior median line (linea mediana anterior), running vertically along the middle of the sternum;
2) sternal lines (ll. sternalis dextra et sin.), passing along the edges of the sternum;
3) mid-clavicular lines (ll. medioclavicularis dex. et sin.) - vertical passing through the middle of the clavicle;
4) parasternal lines (ll. parasternalis dex. et sin.) - in the middle of the distance between the sternal and midclavicular lines;
5) anterior axillary lines (ll. axillaris anterior dex. et sin.), passing along the anterior edge of the axilla;
6) middle axillary lines (ll. axillaris media dex. et sin), passing through the middle of the armpit;
7) posterior axillary lines (ll. axillaris posterior dex. et sin.), passing along the posterior edge of the axilla;
8) scapular lines (ll. scapularis dex. et sin.), passing through the angle of the scapula with arms down;
9) paravertebral lines (ll. paravertebralis dex. et sin.) - in the middle between the vertebral and scapular lines;
10) vertebral line (l. vertebralis), passing along the transverse processes of the vertebrae;
11) posterior median line (l. mediana posterior), passing along the spinous processes of the vertebrae.
The height of the tops at the front. The plessimeter finger is placed above the clavicle (parallel to it) and from its middle is percussed upward and medially until the sound dulls along the outer edge of the sternocleidomastoid muscle. Normally, the upper border of the lungs is anterior located 3-5 cm above the collarbone.
The height of the tops at the back. The pessimeter finger is placed directly above the spine of the scapula, parallel to its spine. Middle middle phalanx located above the middle of the inner half of the spine. The pessimeter finger is moved along the line connecting the middle of the inner half of the spine of the scapula and the spinous process of the VIIth cervical vertebra. Normal height of the apexes of the lungs posteriorly it is located at the level of the spinous process of the VIIth cervical vertebra.
Low position of the apex of the lung may be associated with pulmonary (fibrosis, wrinkling upper lobe, obstructive atelectasis of the upper lobe) and extrapulmonary (low pressure in abdominal cavity, a sharp weakening of the tone of the abdominal muscles, splanchnoptosis) pathology.
High position of the apex of the lung observed in pulmonary (acute and chronic pulmonary emphysema) and extrapulmonary ( high blood pressure in the abdominal cavity due to pregnancy, flatulence, ascites, huge tumors) pathology.
Width of the lung apex (Kroenig field). The pessimeter finger is placed perpendicular to the anterior edge of the trapezius muscle above the middle of the clavicle. Percussion is first performed in the medial direction until a dull sound appears (the inner border of the Krenig field). After this, return the finger-pessimeter to starting position and percuss in an outward direction until a dull sound appears (the outer boundary of the Krenig field). The normal width of the Kroenig field is 3-5 cm. Attention!!! Only in children senior school age upon percussion of the apex it is determined the upper border of the lungs in front and behind, as well as the width of the Kroenig fields(German doctor of the 19th-20th centuries).
Reducing the width of the Kroenig field observed during sclerotic processes in the apex of the lung, and increase– for acute and chronic pulmonary emphysema.
Lower limit right lung. Determination of the lower border of the right lung begins from the parasternal line. The position of the pessimeter finger should be such that the periosternal line intersects the middle of its middle phalanx perpendicularly. Percussion is carried out from top to bottom sequentially along the parasternal, midclavicular, anterior, middle, posterior axillary, scapular, paravertebral lines from a clear to dull sound.
The lower border of the left lung. Percussion determination of the lower border of the left lung is carried out similarly to the determination of the borders of the right lung, but with two features. Firstly, its percussion along the parasternal line corresponds to the 4th intercostal space (cardiac dullness). Secondly, along the anterior and middle axillary lines, percussion stops when the clear pulmonary sound changes to a tympanic sound. This feature is due to the influence of the gas bubble of the stomach occupying Traube's space.
Auscultation of the lungs
The sound phenomena heard during auscultation of the lungs, arising in connection with the act of breathing, are called respiratory sounds (murmura espiratoria). Distinguish basic (vesicular and laryngotracheal breathing) and side (crepitus, wheezing, pleural friction noise) breathing sounds.
Rules for auscultation of the lungs
· The patient's position may vary, but it is best to listen to a sitting patient. The subject's hands should be placed on his knees.
Auscultation of the lungs begins from the anterior surface of the chest. Strictly symmetrical areas are listened to, starting from the supraclavicular fossa, gradually moving the phonendoscope down and to the sides to the mid-axillary line.
· Then listen to the back surface of the chest, starting from the suprascapular areas, moving to the interscapular space and subscapular region. In this case, the patient is asked to bring his arms together on his chest in order to “expose” the lung tissue in the interscapular space as much as possible.
· When auscultating the lungs, the main breath sounds are first assessed. In this case, the patient should breathe deeply and evenly, through the nose, not very forced.
· Only after this, against the background of deep breathing through the mouth, the presence of additional noises is determined - wheezing, crepitus, pleural friction noise. To better differentiate pathological noises, auscultation is repeated after coughing.
Basic breath sounds
1. Vesicular (alveolar) breathing. Normal pulmonary breathing, called vesicular (vesicula - inflated bubble) or alveolar, is formed as a result of vibration of the alveolar septa at the moment they are filled with air. Inhalation is active phase breathing, therefore the intensity of penetration of the air wave into the lungs exceeds the force of vibration of the alveolar wall during exhalation (passive phase of breathing). Therefore, membrane vibrations during inhalation will be stronger and longer than during exhalation. As a result of a decrease in the tension of the alveolar walls during exhalation, their vibrations quickly die out. In this regard, vesicular respiration has the following characteristic features: heard throughout the entire inhalation phase with gradual intensification towards the end of inhalation and the first third of exhalation. Vesicular breathing of the lungs is a blowing noise reminiscent of the sound of pronouncing the letter “F” when drinking tea from a saucer and sucking the liquid with your lips.
Under physiological conditions, vesicular respiration listens better on the anterior surface of the chest below the second rib, lateral to the parasternal line, in the axillary region and below the angle of the scapula. Bronchovesicular breathing is sometimes heard over the right apex of the lung, since the right bronchus is shorter and wider than the left.
The power of vesicular respiration varies depending on a number of factors of extrapulmonary origin:
1) the strength of respiratory movements;
2) the thickness of the subcutaneous fat and muscle layer of the chest;
3) proximity of the adjacent areas of the lungs.
Vesicular respiration can change both in the direction of weakening and strengthening. These changes are physiological and pathological.
Physiological weakening Vesicular breathing is observed when the chest thickens and the strength of respiratory movements weakens.
Physiological enhancement Vesicular breathing is observed in individuals with a thin chest. In children under 5-7 years of age, vesicular breathing is louder and is called puerile breathing, due to the thinness of the chest and the small lumen of the bronchi.
Saccaded breathing is characterized by intermittent inhalation (consists of individual short intermittent breaths with minor pauses between them) and normal exhalation. Intermittent breathing occurs when the respiratory muscles contract unevenly (nervous muscle tremors).
A physiological change in vesicular respiration is observed simultaneously on the right and left.
Changes in vesicular breathing (weakening, strengthening, saccadic breathing) in a limited area indicates pathology.
Increased vesicular respiration may concern one of its phases (exhalation) - the so-called vesicular breathing with prolonged exhalation, or two phases - hard breathing. When breathing hard, the exhalation is shorter than the inhalation, but rougher in timbre. Increased exhalation depends on the difficulty of air passing through the small bronchi when their lumen narrows ( inflammatory edema mucous membrane or the presence of bronchospasm). Hard breathing is similar to puerile breathing, but its mechanism is different. It is somewhat intermittent in nature and occurs with increased respiratory movements (forced exhalation, increased temperature, damage to the entire lung), with a sharp and uneven narrowing of the lumen of the small bronchi and bronchioles (bronchitis, bronchial asthma). In a limited area, hard breathing occurs in cases where small areas of infiltration alternate with normal lung tissue (focal pneumonia, pulmonary tuberculosis).
At weakening of vesicular respiration Inhalation and exhalation are shortened, so a short inhalation is practically audible and the exhalation is not audible at all. This is observed:
1) with a decrease in alveolar tissue (pulmonary emphysema, infiltration of the alveolar wall in the first stage lobar pneumonia, focus of pneumosclerosis);
2) if there is an obstacle to the passage of air through the bronchi (partial obstructive atelectasis caused by a large tumor or foreign body, which makes it difficult for air to pass into the alveoli);
4) if there is an obstacle to the conduction of sounds to the doctor’s ear (accumulation of liquid, air in pleural cavity).
Complete absence vesicular respiration observed with complete obstructive atelectasis, significant accumulation of fluid and air in the pleural cavity, and with the invasion of lung tissue by a massive lung tumor.
2. Bronchial (laryngo-tracheal) breathing is formed in the larynx when air passes through the glottis during inhalation and exhalation. Air, passing through a narrow glottis into a wider lumen, makes vortex, turbulent movements, but since in the exhalation phase the glottis is narrowed more than in the inhalation phase, the sound during exhalation becomes stronger, rougher and longer. Sound waves spread along the air column throughout the bronchial tree.
Distinctive Features bronchial breathing from vesicular : exhalation is louder, rougher and longer than inhalation: the timbre resembles the sound “ X" , inhalation and exhalation are clearly audible.
Normal it can be heard over the larynx, trachea and large bronchi. Anteriorly to the level of attachment of the manubrium to the body of the sternum and parasternal lines. Posteriorly in the interscapular space to the level of the III-IV thoracic vertebrae and paravertebral lines. In other parts of the lungs, bronchial breathing is not audible, since the powerful alveolar layer of the lungs muffles bronchial breathing like a pillow and prevents it from reaching the surface of the chest.
During development pathological processes the lungs above the chest can be heard in certain areas pathological bronchial breathing.
Basic reasons the appearance of pathological bronchial breathing.
- Compaction of a significant area of lung tissue (segment, lobe) - with inflammatory and tuberculous infiltrate, pulmonary infarction, massive area of pneumosclerosis. A necessary condition is open, unclogged large bronchi and their contact with the compaction of the lung tissue. It is known that thick fabric with preserved bronchial patency, it conducts breathing better from the bronchi. The best conditions arise for the occurrence of bronchial breathing if the compaction begins from lung root and extends to the parietal pleura, which is consistent with the anatomical structure of the segment and lobe of the lung. With large infiltration (lobar pneumonia), bronchial breathing will be loud and rough (infiltrative bronchial breathing).
- The presence in the lung of a cavity containing air and communicating with the bronchus (cavity, abscess, large bronchiectasis cavity) can lead to the appearance cavity bronchial breathing. If there are smooth walls of a cavity filled with air and connected to the wall of the bronchus, when air passes over it, bronchial breathing develops a special timbre - amphoric breathing. This sound is produced by blowing over the narrow neck of a bottle (an amphora is a vessel with a narrow neck). Over very large smooth-walled planes with a wide connection with the bronchus and with open pneumothorax, pathological bronchial breathing appears metallic shade. Bronchial breathing in this case is very loud and high-pitched (ringing like metal).
- Compression atelectasis (pressure of the lung towards the root) in the presence of fluid in the pleural cavity ( exudative pleurisy, hydrothorax). In this case, bronchial breathing is heard at the root of the lung. It is very quiet (it seems to come from afar).
In practice, sometimes we encounter mixed breathing . Mixed (bronchial-vesicular) breathing has features of vesicular and bronchial respiration. Typically, inhalation is vesicular and exhalation is bronchial. Normally, such breathing can be heard over the right apex. In pathology, it is observed in cases where foci of compaction alternate with normal lung tissue - with focal pneumonia, in stages I and III of lobar pneumonia, pneumosclerosis.
Adverse breath sounds
1. Wheezing (rhonchi)- additional respiratory sounds that occur in the trachea and bronchi during pathology.
According to the mechanism of formation and sound perception wheezing is divided into wet and dry.
Mechanism of occurrence dry wheezing :
Narrowing of the lumen of the bronchi (bronchospasm or swelling of the mucous membrane);
Fluctuations of viscous sputum in the lumen of the bronchi.
Mmethodology for studying lymph nodes.
In a healthy person, the lymph nodes are not visible and cannot be palpated. But given the widespread prevalence of various dental diseases among the population (caries, periodontitis, periodontal disease, etc.), we have to take into account the fact that in many people it is possible to palpate the submandibular lymph nodes without much difficulty, and due to minor, sometimes invisible injuries to the skin of the lower extremities, small (pea-sized) inguinal lymph nodes can be palpated. According to some authors, single small axillary nodes are also not a serious diagnostic sign.
Examination of the lymph nodes is performed by inspection and palpation.
During palpation, the size of the lymph nodes is determined: they are compared with the size of some round objects (the size of “a millet grain”, “the size of a lentil”, “the size of a small (medium, large) pea”, “the size of a hazelnut”, “the size of a pigeon egg” ", "about the size of a walnut", "about the size of a chicken egg").
The number of enlarged lymph nodes and their consistency (doughy, soft-elastic, dense) are specified; mobility, pain on palpation (a sign of inflammatory processes), cohesion with each other in conglomerates and cohesion with surrounding tissues, the presence of edema of the surrounding subcutaneous tissue and hyperemia of the corresponding area of the skin, the formation of fistula tracts.
Palpation of the lymph nodes is carried out with the tips of slightly bent fingers (usually the second - fifth fingers of both hands), carefully, carefully, with light, sliding movements (as if “rolling” through the lymph nodes).
Palpation of the lymph nodes is carried out in a certain sequence. First, the occipital lymph nodes, which are located in the area of attachment of the neck muscles to the occipital bone, are palpated, then they move on to palpation of the postauricular lymph nodes, which are located behind the auricle on the mastoid process of the temporal bone. In the area of the parotid salivary gland, the parotid lymph nodes are palpated.
Mandibular (submandibular) lymph nodes, which enlarge during various inflammatory processes in the oral cavity, are palpated in the subcutaneous tissue on the body of the lower jaw behind the masticatory muscles (during palpation, these lymph nodes are pressed against the lower jaw).
The mental lymph nodes are determined by moving the fingers from back to front near the midline of the chin area.
Superficial cervical lymph nodes are palpated in the lateral and anterior regions of the neck, respectively, along the posterior and anterior edges of the sternocleidomastoid muscles. Long term increase cervical lymph nodes, sometimes reaching significant sizes, are observed in tuberculous lymphadenitis, lymphogranulomatosis, lymphocytic leukemia. However, even in patients with chronic tonsillitis, chains of small dense lymph nodes can often be found along the anterior edges of the sternocleidomastoid muscles.
With stomach cancer in the supraclavicular region (in the triangle between the legs of the sternocleidomastoid muscle and the upper edge of the clavicle), a dense lymph node (“Virchow’s gland” or “Virchow’s gland - Troisier”) can be detected, which is a tumor metastasis.
When palpating the axillary lymph nodes, the patient's arms are slightly moved to the sides. The fingers of the palpating hand are inserted as deep as possible into the armpit, after which the patient’s abducted hand returns to its original position; in this case, the patient should not press it tightly to the body. Palpation of the axillary lymph nodes is carried out by moving the palpating fingers in the direction from top to bottom. Enlargement of the axillary lymph nodes is observed with metastases of breast cancer, as well as with any inflammatory processes in the upper extremities.
When palpating the ulnar lymph nodes, grab them with a brush own hand the lower third of the forearm of the patient's arm being examined and bend it at the elbow joint at a right or obtuse angle. Then, with the indicated and middle fingers of the other hand, the sulci bicipi medialis is felt with sliding movements just above the epicondyle of the shoulder.
The inguinal lymph nodes are palpated in the area of the inguinal triangle (fossa inguinalis) in a direction transverse to the pupart ligament.
The popliteal lymph nodes are palpated in the popliteal fossa of the leg bent at a right angle at the knee joint, with the knee placed on a solid support.
Mmuscle research methodology.
Initially, there are complaints of muscle weakness, muscle fatigue, involuntary twitching of individual muscle groups, limitation and complete absence of active (voluntary) movements.
With a decrease in muscle tone, passive flexion and extension of the corresponding limb occurs unusually easily, in the absence of the slight resistance that normally exists. With hypertonicity, muscle resistance is, on the contrary, increased. By raising and lowering the patient's head, you can assess the tone of the neck muscles.
Then muscle strength is assessed: according to the resistance that the patient is able to overcome. When researching muscle strength flexors, the doctor invites the patient to bend the arm at the elbow joint, the leg at the knee joint, the hand at the wrist joint, the foot at the ankle, etc., after which, asking the patient to provide resistance, he tries to straighten it. When examining the muscle strength of the shoulder extensors, the doctor tries to bend the patient's arm at the elbow joint, while the patient is holding it in an extended state. The study is carried out separately for the muscles of the right and left limbs, muscle strength is also determined using a dynamometer.
Methods for studying the skeletal system.
First, pay attention to the patient’s complaints of pain in the bones. Acute pain in the bones after injury may indicate bone fractures; dull, gradually increasing pain in the bones is often associated with some kind of inflammatory process; persistent, debilitating, often clearly localized pain occurs with bone metastases of malignant tumors.
Upon examination, the presence of various deformations of the bones of the skull, spine, chest, pelvis, and limbs is determined. There may be changes in the shape of the lower extremities in the form of X-shaped (genu valgum) or O-shaped (genu varum) legs, shortening of one of the limbs - with osteomyelitis, with acromegaly - enlargement of the fingers and toes, zygomatic bones, lower jaw; for congenital heart defects, infective endocarditis, liver cirrhosis, bronchiectasis - thickening of the terminal phalanges of the fingers in the form of drumsticks; with scleroderma, due to the destruction of the terminal phalanges, the fingers are shortened, taking the shape of a short sharpened pencil.
Palpation of the bones is performed strictly symmetrically. By palpation, it is possible to more accurately identify thickening of individual bones (for example, “rachitic rosary” of the ribs), determine the unevenness of their surface and pain (with periostitis), and detect pathological fractures.
Percussion is performed using the direct percussion method proposed by F.G. Yanovsky (with the end phalanx of the index or middle finger of the right hand) or L. Auenbrugger (strike 2-5 fingers with the ends of straightened and closed fingers), on flat bones (sternum, ribs, spine, ilium, shoulder blades, sacrum). In case of blood diseases (anemia, multiple myeloma), bone metastases of malignant tumors, pain in the flat bones is determined.
Research methodologyjoints
First, by questioning, they find out whether the patient has complaints of pain in the joints (constant or volatile), morning stiffness in the joints, limitation of movements in certain joints (stiffness), the presence of crunching (crepitus) when moving, etc.
The examination of the joints is performed strictly symmetrically on both sides. They start with the joints of the hand, then move on to the study of the elbow and shoulder joints, the temporomandibular joint, the cervical, thoracic and lumbar spine, the sacroiliac joints, the sacrum and coccyx, the hip and knee joints, and the joints of the feet.
The examination of the joints usually includes inspection and palpation, and possibly auscultation.
When examining, pay attention to changes in the configuration of the joints (for example, an increase in their volume, a spindle-shaped shape), smoothness of their contours, changes in the color of the skin over the joints (hyperemia, pigmentation, shine).
When palpating the joints, swelling is revealed due to effusion into the joint cavity, swelling of the periarticular tissues. The accumulation of free fluid in the articular cavity is confirmed by the appearance of the symptom of patellar balloting. To determine it, the patient is laid horizontally with the limbs extended as much as possible, the thumbs are placed on the patella, and the lateral and medial areas of the knee joint are compressed with the palms of both hands. Next, use your thumbs to push the patella towards the anterior surface of the joint. If there is free fluid in the cavity of the knee joint, the fingers feel a response weak push caused by the impact of the patella on the thigh bone. They also pay attention to the presence of pain in the joints when palpating them, an increase in skin temperature over the joint area (apply the back of the hand to the skin above the symmetrical joints; if both symmetrical joints are involved in the pathological process, then the skin temperature is assessed by comparison with the skin temperature above other unchanged joints). Using a measuring tape, measure the circumference of symmetrical joints.
Next, the volume of active and passive movements is determined, stiffness and pain during movement are identified. In this case, active movements are performed by the patient himself, and passive movements (flexion, extension, abduction, adduction of the limb) are performed by the doctor with complete relaxation of the patient’s muscles.
When performing a particular movement in the joints, a certain angle is formed, which, if necessary, can be measured using special goniometer devices.
To determine crunching (crepitus), the doctor’s palm is placed on the corresponding joint and movements (active or passive) are made in this joint.
Symptoms of “drumsticks” and “watch glasses” are flask-shaped thickening of the terminal phalanges of the fingers and toes and changes in the shape of the nails.
Diagnostic value of the symptom: observed with prolonged current diseases lungs (chronic suppurative processes), heart (subacute infective endocarditis, congenital heart defects), liver (cirrhosis).
