Respiratory system: auscultation of the lungs and determination of bronchophony. Bronchophony, determination method, diagnostic value

Normal bronchophony is the absence of a vague hum when listening to a person's chest during a conversation. In this case, the voice is heard at two symmetrical points on both sides equally. Most often, bronchophony is determined during a conversation in a whisper, and the words must contain the hissing sounds “sh” and “ch”. Let's consider the features of the disease and research methods.

What is bronchophony

You can determine the patency of the bronchi using a stethoscope while listening to the chest. In this case, breathing is observed at certain symmetrical points of the lungs. Often the doctor concludes: “bronchophony is normal.” This means that there is no hum when listening with the device. That is, the voice is carried unhindered through the air column of the bronchi. In this case, the patient is forced to pronounce words containing the sounds “r”, “sh” and “ch”, but in a whisper.

Bronchophony is similar to vocal tremors, but is determined by a different method. Most often, this indicator is an early, and sometimes the only factor that may indicate compaction of the lung tissue. It is this shell that is a good conductor of sounds, and when pronounced by the patient, they will be clearly audible. Experts note that pneumonia can be recognized in this way, since the hum appears before physical signs (fever, weakness and cough).

Types of bronchophony by shade:

• amphorophony - characterized by a loud and clear sound;
• pectorilkovia - sound with a metallic tint;
• egophony - nasal sound and rattling.

Methods for determining bronchophony

Are you wondering what it is - “normal bronchophony” - and how to determine it? The answer will be given directly by the therapist. He checks the patient with a stethoscope at two symmetrical points on the chest. The voice is formed in the upper part of the respiratory organs and, like bronchial breathing, is conducted to the chest. If the lung does not conduct sounds well, they will be inaudible or distorted, that is, words will not be understood.

An important condition for bronchophony is the conductivity of the bronchi. Any distortion of the voice, hum instead of words of different shades indicates the development of a certain pathology.

Bronchophony can be determined using a simple stethoscope, but it is better to use a phonendoscope. This is a newer device equipped with a membrane for good listening. Normally, whispering is heard where bronchial breathing is. If the sounds of air and liquid are detected simultaneously, this indicates hydropneumothorax.

Symptoms

Bronchophony can be determined (normal or not) by listening to both a loud voice and a whisper. In a healthy person, when pronouncing, for example, the phrase “cup of tea,” it is impossible to clearly understand the words; only incoherent speech will be heard. If words spoken in a whisper become audible or vocal tremors are heard, we can talk about the accumulation of fluid in the pleural cavity (pneumothorax) or obstructive atelectasis.

With the help of bronchophony, it is possible to diagnose at an early stage the processes of compaction of the lung tissue, through which all sounds pass quite clearly.

In general, in patients of the pulmonology department, that is, those who have problems with the respiratory system, bronchophonia does not normally appear in the medical history - the indicator either increases (with pneumonia, tuberculosis) or weakens (with pleurisy, pneumothorax). The test also looks at physiological parameters such as increased heart rate, elevated body temperature, wheezing cough or difficulty breathing.

Diagnostics

Due to the manifestation of the resonance effect, it can be heard above the formed cavities that contain air. Amphoric sound (crisp and clear) occurs when there is a resonant effect over an empty cavity. There may also be a metallic echo, which professionals call pectoriquia. A nasal tone and rattling sound above the highest border of the pleural whisper are heard during egophony.

How is the procedure performed?

To determine that bronchophony is normal, the therapist listens to the voice by placing a stethoscope on the right side in the area above the collarbone. The patient must pronounce words with hissing sounds in a whisper, and the doctor, meanwhile, moves the device to a symmetrical point on the left. After this, the results obtained are analyzed; normally, they should be the same.

If noises, wheezing, or whistling are heard, then additional examination in the form of x-rays, fluorograms or tests may be needed to clarify or confirm the diagnosis. If the patient has a cough and sputum comes out, it may be necessary to examine the contents to correctly prescribe therapy.

Examination of sputum allows one to determine the nature of the pathological process that has affected the respiratory organs. Most often it is taken in the morning before meals and even before rinsing the mouth. With tuberculosis, since sputum is produced in very small quantities, the patient can collect it for two days. The biomaterial is examined not only for bacterial content, but its character (color, consistency, smell) is also assessed.

Deciphering the results

The interpretation of the respiratory examination (that is, whether bronchophony is normal) is carried out directly by the attending physician. At home, due to ignorance of some deviations, it is difficult to determine, since wheezing and sounds conducted through the bronchi can have different shades.

For example, dry wheezing indicates bronchitis or bronchial asthma. Wet echoes indicate more serious pathologies such as tuberculosis, severe bronchitis or ARVI. During pneumonia, a whistle is heard.

Increased bronchophony may indicate compaction of the lung tissue (pneumonia, fibrosis, pulmonary infarction, infiltrative tuberculosis), air in the cavity that leads to the bronchi (open pneumothorax, abscess, cavity, bronchiectasis) and collapse of the lung tissue as a result of compression (compressive atelectasis) .

Weakening of bronchophony indicates blockage of the bronchus (obstructive atelectasis), fluid, air, connective tissue in the pleural cavity (exudative pleurisy, hemothorax, closed pneumothorax, hydropneumothorax, fibrothorax).

Ausculation

“Bronchophonia is normal, what is it?” - a frequently asked question regarding respiratory diseases. This indicator is determined by a listening method called auscultation. It does not include sounds that relate to coughing, sneezing, rumbling in the intestines, loud breathing, which are heard at a distance. Only those sounds that are heard inside our body using a device (stethoscope or phonendoscope) are heard.

Such sounds were noticed at the beginning of our era, but for a long time they were not used as a diagnostic method in the study of patients. Auscultation became a method for diagnosing pathologies related to the lungs only at the beginning of the 19th century. Around the same time, a stethoscope was invented, which made it possible to listen to internal sounds, evaluate their nature and determine pathology.

Auscultation methods:

• immediate (direct) - listening to internal sounds with the ear attached to the patient’s body;
• mediocre (instrumental) - carried out using a stethoscope and phonendoscope.

Auscultation is carried out in a warm room, where there are no extraneous sounds, on the patient’s bare chest. First, an assessment of the main sounds is formed and only then additional ones, in the form of echoes of different types and noises.

Irina Karkina from Samara asks:

Why is bronchophony determined at, and what can it be?

Our expert answers:

X-ray is the most objective research method that allows you to determine the inflammatory process in the lung tissue. But before sending the patient for an x-ray, the doctor conducts an objective examination, including inspection, palpation, percussion and auscultation. The results obtained during auscultation are the reason for referring the sick person for an instrumental examination.

Auscultation is carried out using a phonendoscope, which allows you to listen. Bronchophony (chest talk) is one of the listening methods. Using this method, the specialist is able to identify areas of compaction in the respiratory organ, which is characteristic of pneumonia.

During the procedure, the patient is asked to whisper phrases and individual words containing hissing sounds. The most frequently spoken words include:

• Cup of tea;
• sixty six;
• cone;
• fur coat.

Using a phonendoscope, the specialist listens to the lungs, determining in which areas the voice conduction is enhanced. Normally, there is no bronchophony, that is, the doctor hears indistinct sounds merging with each other.

How is the result deciphered?

The following types of chest talk are distinguished:

• negative (if there is no pathological process);
• reinforced;
• weakened.

When sound conduction is enhanced, words are heard clearly, which indicates the presence of compactions in the lung tissue, which are a good conductor of sounds. This result is possible with the following pathologies:

• inflammation of the lung tissue;
• pulmonary infarction;
• abscess;
• other conditions characterized by the formation of compactions and cavities in the respiratory organ.

Sound conduction may not be enhanced if the pathological formation is small or located too deep from the surface of the body.

When chest talk weakens, words spoken by the patient in a whisper are not audible at all. This is possible in the following cases:

• with accumulation of exudate, air or gases in the pleural cavity;
• with the development of obstructive atelectasis;
• with emphysema.

Sound conductivity decreases not only with pneumonia. This condition is observed in people who are overweight or have a well-developed shoulder girdle.

This examination technique is often the only possible way to diagnose the disease at an early stage, when its main manifestations are absent.

Details

Clinical diagnosis:

Main disease: Acute respiratory viral infection of moderate severity

Complications of the underlying disease: Acute bronchitis. Acute right-sided sinusitis

I. Passport part

Last name, first name: S.N.

Female gender

Age: 21 years old

Permanent place of residence: Moscow

Date of receipt: 13/12/2010, 16:45

Date of supervision: 20-22/12/2010.

II.Complaints

At the time of supervision, he makes no complaints.

At the time of receipt of the complaint about general weakness, increased body temperature to 38.5º C, headache, cough with a small amount of white-yellow sputum, nasal congestion and yellow nasal discharge, radiating to the upper jaw.

III. History of present illness (anamnesis morbi)

He considers himself sick since December 1, 2010, when, after hypothermia suffered the day before (November 29 and 30), nasal congestion, a feeling of general weakness, and a dry paroxysmal cough appeared. On December 3, a constant low-grade fever appeared (in the period from December 3 to 8, there was a daily increase in body temperature to 37 in the morning, to 37.5ºC in the evening), the cough persisted (gradually became productive, with the release of a small amount, up to 25 ml, of white-yellow sputum), general weakness, nasal congestion. On December 2-3, nasal discharge appeared, first transparent, then yellow. The patient did not go to the doctor, took Coldrex several times, used Nazivin drops, with a short-term effect; continued to go to work every day. On December 9, the body temperature increased to 37.5 (in the morning) - 38.0ºС (in the evening), on December 10 - to 38.0ºС (in the morning) - 38.5ºС (in the evening), pain appeared in the area of ​​the right zygomatic bone, radiating to the upper jaw, severe headache; nasal discharge has become more abundant; The cough persisted. She took paracetamol, with a temporary effect (decrease in temperature to 37.0ºC). In connection with these complaints, on December 13, 2010, the patient was urgently hospitalized in the 2nd infectious diseases department of the Central Clinical Hospital of the UPD of the Russian Federation.

IV. Life history (Anamnesis vitae)

Brief biographical information: Born in 1989 in Moscow. She grew and developed normally. Higher education. Single.

Meals: regular, three times a day, high-calorie, varied.

Epidemiological history: works as a producer's assistant; due to the nature of her work, hypothermia is sometimes possible (working on a film set in the autumn-winter period). Lives in Moscow, in a comfortable apartment, living conditions are good. At the beginning of November 2010, I went to Egypt for 10 days (tourism). Denies contacts with infectious patients and contacts with animals. Denies parenteral manipulations of a medical or non-medical nature over the past 6 months.

Past illnesses: Childhood infections (chickenpox, rubella). ARVI 1-2 times/year.

Gynecological history: menstruation from the age of 12, regular, heavy, moderately painful, lasting 6-7 days. There were no pregnancies. Last examination by a gynecologist in February 2009.

Allergic history: There are no allergic diseases. Denies intolerance to foods, medications, vaccines, serums.

Family history: not burdened. Denies endocrine and mental diseases, hemorrhagic diathesis in close relatives.

Bad habits: smokes 3-4 cigarettes a day.

V. Present state (status praesens)

GENERAL INSPECTION

General state– moderate severity, consciousness- clear, position- active, body type- normosthenic, height- 168 cm, body mass- 57 kg, posture– correct.

Body temperature- 37.6 O C, facial expression- calm

Skin pale pink color. There are no pigmentations, depigmentations, exanthemas, enanthems, or hemorrhages. There are no trophic changes in the skin or visible tumors. The skin is dry, turgor is preserved, hair growth is of the female type. There are no changes in the nail plates.

Subcutaneous fat moderately developed, its deposition is uniform. There is no swelling.

The lymph nodes: The submandibular lymph nodes are palpated on the right and left in the form of elastic, painless, easily removable, round formations, 1.0 x 1.0 cm in size. The skin over the lymph nodes is not changed. The occipital, parotid, supra- and subclavian, axillary, ulnar, and inguinal lymph nodes are not palpable.

Muscles are developed satisfactorily, tone is preserved, there is no pain or hardness on palpation.

Bones not deformed, no pain when beating.

Joints not deformed, no defiguration, the range of active and passive movements is within the physiological norm.

RESPIRATORY SYSTEM

O S M O T R

Rib cage cylindrical in shape, normosthenic, supra- and subclavian fossae are pronounced, the shoulder blades are at the same level and fit tightly to the chest, the epigastric angle is straight, the width of the intercostal spaces is moderate. The chest is symmetrical, there is no curvature of the spine.

Chest circumference with quiet breathing - 76 cm, with a deep breath - 80 cm, with maximum exhalation - 72 cm. Excursion of the lower edge of the lung along the posterior axillary line: 4 + 4 = 8 cm.

Breath chest type, there is no lag of one half of the chest during breathing, auxiliary muscles are not involved in breathing. The number of respiratory movements is 18 per minute at rest. Breathing is deep and rhythmic.

P A L P A T I O N

The chest is painless and elastic. Voice tremor in symmetrical areas is carried out in the same way.

P E R K U S S I A

Comparative percussion: the same clear pulmonary percussion sound is detected in symmetrical areas of the chest.

Topographic percussion.

Upper border of the lungs:

Lower border of the lungs:

A U S C U L T A T I O N

Breath sounds: hard breathing and a small amount of scattered dry bass rales are heard in symmetrical areas of the chest.

Bronchophony: identical on both sides over symmetrical areas of the chest.

CIRCULAR SYSTEM

O S M O T R

Neck examination: neck vessels are not changed; There is no positive venous pulse, no “carotid dancing”.

Examination of the heart area: the heart hump is not detected, there is no visible pulsation.

P A L P A T I O N

Apex beat palpated in the 5th intercostal space 1.5 cm medially from the left midclavicular line, not intensified, not diffuse.

Heart beat not determined.

Epigastric pulsation not defined

Trembling in the area of ​​the heart at the apex, at the base of the heart not determined. There is no palpation tenderness in the precordial area.

P E R K U S S I A

Relative dullness of the heart.

Borders of relative dullness of the heart: right - IV intercostal space, 1 cm outward from the right edge of the sternum; left - 5th intercostal space, 1.5 cm medially from the midclavicular line, upper - at the level of the 3rd rib.

The diameter of the relative dullness of the heart is 10 cm, the width of the vascular bundle is 4 cm, the configuration of the heart is normal.

Absolute dullness of the heart.

The boundaries of absolute dullness of the heart: right - along the left edge of the sternum, left - 1 cm medially from the left border of relative dullness, upper - at the level of the IV rib.

A U S C U L T A T I O N

Heart sounds rhythmic, the number of heartbeats is 74 per minute, heart sounds are not changed. There are no additional tones. Noises are not listened to.

RESEARCH

Study of arteries. The pulsation of the temporal, carotid, radial, popliteal arteries and arteries of the dorsum of the foot is preserved. Aortic pulsations in the jugular fossa are not detected, double Traube tone, double Vinogradov-Durozier murmur on the femoral arteries are not heard.

The arterial pulse on the radial arteries is the same on the right and left, satisfactory filling and tension, 74 per minute.

Blood pressure - 120/70 mm Hg. on both hands.

Vein examination. There is no dilatation of the veins of the chest, abdominal wall, or limbs.

DIGESTIVE SYSTEM

GASTROINTESTINAL TRACT

Appetite preserved, no aversion to any products.

Chair regular, once a day, decorated, brown.

Signs of bleeding: vomiting blood, coffee grounds, black tarry stools, no blood in the stool.

O S M O T R

Oral cavity: the tongue is red-pink in color, moist, the papillary layer is preserved, there are no plaques, cracks, or ulcers. The teeth are sanitized and preserved. The gums, soft, hard palate are pale pink in color, there are no hemorrhages or ulcerations.

Stomach regular shape, symmetrical, actively involved in the act of breathing; There is no visible peristalsis and no venous collaterals. Abdominal circumference at the navel level is 72 cm.

P E R K U S S I A

A tympanic percussion sound is detected over the entire surface of the abdomen; no free or encysted fluid is detected in the abdominal cavity.

P A L P A T I O N

Superficial indicative palpation: the abdomen is soft, painless, discrepancies of the rectus muscles, hernias, and palpable tumor-like formations are not determined. Shchetkin-Blumberg and Mendel's symptoms are negative.

Methodical deep sliding palpation according to Obraztsov-Strazhesko. The sigmoid colon is palpated in the left iliac region in the form of a smooth, dense, painless cylinder with a diameter of about 2 cm, easily displaced, and does not rumble. The cecum is palpated in the right iliac region in the form of a smooth, soft, elastic consistency, painless cylinder with a diameter of about 3 cm, easily displaces, and rumbles.

The transverse colon, ascending, and descending colon are not palpable. The lower border of the stomach is determined by ausculto-percussion 3 cm above the navel. The greater curvature of the stomach and the pylorus are not palpable.

A U S C U L T A T I O N

Live peristalsis is heard over the entire surface of the abdomen, 1-2 peristaltic sounds per 1 second. No peritoneal friction sounds or vascular sounds are heard.

LIVER AND GALL BLADDER

O S M O T R

There is a bulge in the right hypochondrium; there is no restriction in breathing in this area.

P E R K U S S I A

Boundaries of the liver according to Kurlov:

The upper limit of absolute dullness of the liver along the right midclavicular line is at the level of the VI rib.

The lower limit of absolute dullness of the liver: along the right midclavicular line - at the level of the edge of the costal arch,

along the midline - at the point separating the upper and middle thirds of the distance from the xiphoid process to the navel

along the left costal arch - at the level of the parasternal line.

Ortner's sign is negative.

P A L P A T I O N

Liver edge palpated along the right mid-clavicular line at the level of the costal arch, along the midline - at the point separating the upper and middle thirds of the distance from the xiphoid process to the navel, pointed, soft-elastic, smooth, painless.

Liver dimensions according to Kurlov:

along the right midclavicular line - 9 cm,

along the anterior midline - 8 cm,

along the left costal arch - 7 cm

Gallbladder not palpable. Kera's symptom, Lepene's, and phrenicus-symptom are negative.

A U S C U L T A T I O N

There is no peritoneal friction noise in the area of ​​the right hypochondrium.

SPLEEN

There is no pain in the left hypochondrium. There is a bulge in the left hypochondrium; there is no restriction in breathing in this area.

The longitudinal size of the spleen along the X rib is 6 cm,

The transverse size of the spleen is 4 cm.

There is no peritoneal friction noise in the left hypochondrium.

PANCREAS

There is no pain in the upper abdomen, including girdling pain.

URINARY SYSTEM

There is no pain in the lumbar region, urination problems, or swelling.

There is no swelling, bulging, hyperemia of the skin, or asymmetry of the lumbar and suprapubic region.

Lumbar region: Tapping in the lumbar region is painless.

Suprapubic region: a tympanic percussion sound is detected above the pubis.

Kidneys: The kidneys are not palpable in a standing or lying position.

Bladder: not palpable.

Pain during palpation along the ureter and at the costovertebral point is not detected.

ENT ORGANS

Nose: the shape of the nose is not changed, breathing through the nose is difficult, there is hyperemia of the visible mucous membranes of the nose. The nasal discharge is yellow. In the projection of the right maxillary sinus there is pain with pressure and tapping.

Mucous membranes of the oropharynx hyperemic, tonsils without features. Enantem, there are no raids.

Larynx: There is no deformation or swelling in the larynx area. There is no hoarseness or aphonia.

EYES

Eyelids not edematous, no ptosis. There is no lacrimation. Conjunctiva pale pink in color, no hemorrhages. Pupils D=S, pupillary reflexes preserved. The cornea is transparent. There are no visual impairments.

NERVOUS SYSTEM AND SENSE ORGANS

There are no dizzinesses, sleep disturbances, motor dysfunctions, or sensitivity.

Consciousness is not impaired, oriented in the surrounding environment, place and time. Intelligence preserved.

Severe neurological symptoms: diplopia, asymmetry of nasolabial folds, swallowing disorders, tongue deviation are not detected. There are no meningeal symptoms, the Romberg position is stable, there are no changes in muscle tone and symmetry.

Sensitivity is preserved.

VI. Preliminary diagnosis and its rationale

Preliminary diagnosis - - placed on the basis

- medical history

- patient complaints an increase in body temperature to a maximum of 38.5ºC, cough (at first dry, then with the release of a small amount, up to 25 ml, of white-yellow sputum), discharge from the nose, headache, general weakness

- objective examination data: fever 37.6°C; hyperemia of the mucous membranes of the oropharynx, hyperemia and swelling of the mucous membranes of the nose, discharge from the nose

Diagnosis mild acute bronchitis

- patient complaints

- objective examination data

Diagnosis based on:

- medical history

- complaints

Data

It is necessary to carry out differential diagnosis between the following respiratory viral diseases:

With influenza, the disease begins more acutely, and intoxication is more pronounced. The temperature is usually above 38°C, maximum in the first 24-36 hours; severe weakness and muscle aches are noted; intense headaches localized in the frontal and supraorbital areas, symptoms of tracheitis - a feeling of rawness behind the sternum, sore throat.

A very characteristic symptom of parainfluenza is damage to all parts of the upper respiratory tract, especially the larynx. Characterized by intense cough, hoarseness, hoarseness, and sore throat. Enlargement and pain in peripheral lymph nodes (submandibular, posterior cervical, axillary) are often observed.

Rhinovirus infection is characterized by pronounced local manifestations on the mucous membrane of the respiratory tract. The main symptom is watery rhinorrhea, which is accompanied by redness and maceration of the external nasal passages, difficulty in nasal breathing, lacrimation and swelling of the eyelids.

Adenoviral infections are characterized by involvement of lymph nodes in the pathological process (enlargement, thickening), sequential appearance of symptoms, possible damage to the conjunctiva and cornea; longer incubation period (5-6 days, sometimes 9-11 days).

With coronavirus infection, the main symptom is rhinitis, a short course of the disease (several days), paroxysmal severe cough and dry wheezing.

Respiratory syncytial infection is characterized by a temperature predominantly up to 38°C, slight rhinitis, dry paroxysmal cough, and a feeling of heaviness in the chest. Restoration of normal breathing usually occurs after 7-10 days (the disease can drag on for up to three weeks). In the lungs, against the background of hard breathing, dry, scattered wheezing is heard. Thus, in this patient, the possible causative agent can be considered the MS virus. To make an accurate diagnosis, serodiagnosis is required, but this is not decisive in the selection of therapy.

Focal pneumonia can be excluded by the absence of signs of focal lung damage, i.e. increased vocal tremors and bronchophony, dullness of percussion sound, bronchovesicular breathing, moist small and medium bubble rales; A chest x-ray is necessary.

VII. Examination plan:

General clinical blood test

General clinical urine analysis

Blood chemistry

X-ray of the chest and paranasal sinuses

Consultation with an otorhinolaryngologist

Physiotherapist consultation

VIII. Data from laboratory and instrumental research methods, consultations with specialists:

General clinical blood test

General clinical urine analysis

The rhythm is sinus, 74 beats per minute. Normal position of the EOS. There are no pathological changes.

Chest X-ray (12/14/10)

A plain X-ray of the chest in the direct and left lateral projection shows an increase in the pulmonary pattern in the hilar and most in the medial sections on both sides due to the bronchovascular component, against the background of which no focal and infiltrative changes were detected. The roots are intact. The diaphragm is positioned normally. The sinuses are free. There is no fluid in the pleural cavity. The mediastinal shadow is not expanded. The heart is not enlarged in size, with a smoothed waist. The aorta is without features. Conclusion: the picture in the lungs corresponds to the signs of bronchitis.

Consultation with an otorhinolaryngologist (12/14/10)

Purpose of consultation: inspection

Complaints: nasal congestion and yellow nasal discharge, pain in the area of ​​the right zygomatic bone radiating to the upper jaw, general weakness, increased body temperature to 37.2ºС

Objectively:

- nose: breathing is somewhat difficult, the mucous membrane is swollen, hyperemic; in the common passages there is a moderate amount of mucopurulent discharge. In the projection of the right maxillary sinus there is pain, aggravated by pressure and tapping

- ears: Ad et As: Mt gray, clear outlines

- pharynx: the mucous membrane is moderately hyperemic; tonsils without features, no plaques

- larynx: mucous membrane of normal color; The glottis is wide, the ligaments are mobile

Diagnosis: acute right-sided sinusitis

Conducted puncture of the right maxillary sinus according to standard methods

Rinse

Naphthyzin in the nose 2 times a day

Puncture of the right maxillary sinus and culture of sinus contents

Culture of the contents of the right maxillary sinus

Staphylococcus aureus (scanty growth)

Group C hemolytic streptococcus (heavy growth)

Physiotherapist consultation

Detoxification therapy: S. Glucosae 5% - 200 ml + S. Acidi ascorbinici 5 ml IV drip

Antibiotic therapy: S.Claforani 1.0 – 4 times a day IM (III generation cephalosporin antibiotic. Acts bactericidal, disrupting the synthesis of the cell wall of microorganisms. Has a wide spectrum of action). Antibiotic therapy is indicated due to the occurrence of acute bronchitis, presumably of bacterial-viral etiology, as well as acute sinusitis of bacterial etiology. It is indicated for obvious signs of bacterial damage to the bronchi (production of mucopurulent sputum and an increase in its quantity, increasing signs of intoxication).

Symptomatic therapy: S. Naphtizini – into the nasal passages, 3 drops 2 times a day. Naphthyzin is an alpha-adrenergic stimulating agent that has a rapid, pronounced and long-lasting vasoconstrictor effect on the vessels of the mucous membranes (reduces swelling, hyperemia, exudation). Facilitates nasal breathing.

Due to the absence of severe bronchial obstruction, the prescription of bronchodilators is not indicated.

Physiotherapy: UV irradiation, electrophoresis on the area of ​​the maxillary sinuses

X. Clinical observation of the patient:

12/20/10 – condition of moderate severity, stable. At the time of inspection he makes no complaints. Notes positive dynamics (since hospitalization) - breathing through the nose is not difficult, a small amount of mucous discharge. Cough and pain in the area of ​​the right maxillary sinus do not bother me. The mucous membranes of the oropharynx are not hyperemic; slight hyperemia of the nasal mucosa. Body temperature is normal. In the lungs there is symmetrical vesicular breathing, no wheezing. BH 17/min. Heart sounds are of normal sonority, the rhythm is correct. Heart rate 72/min. Blood pressure 120/68 mmHg. The abdomen is soft, painless on palpation in all parts. There is no swelling. The abdomen is soft, painless; the stool is regular and formed. Diuresis is adequate to the water load, there are no dysuric phenomena.

12/21/10 - satisfactory condition. At the time of inspection he makes no complaints. Breathing through the nose is not difficult, there is a small amount of serous discharge. There is no pain in the area of ​​the right maxillary sinus. The mucous membranes of the oropharynx and nose are not hyperemic. Body temperature is normal. In the lungs there is symmetrical vesicular breathing, no wheezing. BH 16/min. Heart sounds are of normal sonority, the rhythm is correct. Heart rate 68/min. Blood pressure 110/70 mmHg. The abdomen is soft, painless on palpation in all parts. There is no swelling. The abdomen is soft, painless; the stool is regular and formed. Diuresis is adequate to the water load, there are no dysuric phenomena.

On December 22, 2010, the patient was discharged from the hospital with improvement (general condition is satisfactory, regression of clinical manifestations, positive dynamics of general clinical blood and urine tests). It is recommended to consult a general practitioner at your place of residence to clarify the cause of anemia.

XI. Final diagnosis:

Preliminary diagnosis - acute respiratory viral infection of moderate severity- placed on the basis

- medical history: acute onset of illness after hypothermia

- patient complaints an increase in body temperature to a maximum of 38.5ºC, cough (at first dry, then with the release of a small amount, up to 25 ml, of white-yellow sputum), discharge from the nose, headache, general weakness

- objective examination data: fever 37.6°C; hyperemia of the mucous membranes of the oropharynx, hyperemia and swelling of the mucous membranes of the nose, discharge from the nose

- laboratory data: neutrophilic leukocytosis, increased ESR (according to a general blood test)

Diagnosis acute bronchitis– can be placed on the basis of:

- medical history: acute onset of the disease, presence of a risk factor (smoking)

- patient complaints for paroxysmal cough (at first it was dry, after a few days it became productive with the release of a small amount, up to 25 ml, of white-yellow sputum)

- objective examination data: upon auscultation of the chest, hard breathing and a small amount of scattered dry bass rales are heard in symmetrical areas of the chest

- laboratory and instrumental research data: neutrophilic leukocytosis, increased ESR (according to a general blood test); absence of infiltrative-focal changes according to chest radiography

Diagnosis acute right-sided sinusitis based on:

- medical history– change in the nature of nasal discharge a few days after the onset of the disease (transparent → yellow)

- complaints the patient has difficulty in nasal breathing, yellow discharge from the nose, pain in the area of ​​the right zygomatic bone radiating to the upper jaw.

Data direct examination patient: in the projection of the right maxillary sinus, pain with pressure and tapping; hyperemia and swelling of the visible mucous membranes of the nose, yellow discharge from the nose

- result of consultation with an otorhinolaryngologist

EXAMPLE OF DESCRIPTION OF AN OBJECTIVE STUDY OF THE RESPIRATORY ORGANS IN THE EDUCATIONAL HISTORY OF A DISEASE

BRONCHOPHONIA

Bronchophony is one of the methods for studying the respiratory organs, which consists of analyzing the conduction of whispered speech on the surface of the chest.

Bronchophony is the equivalent of a palpable vocal tremor. The mechanisms of bronchophony and vocal tremor are the same. However, bronchophony has advantages before vocal tremor, which is not always felt by the hand, in weakened patients with a quiet voice, in people with a high voice, most often in women, and does not change with a small magnitude of the cytological process. Bronchophony is more sensitive.

Technique The definition of bronchophony is as follows: the cut of the phonendoscope is applied to the chest in strictly symmetrical areas (where auscultation is performed). After each application, the patient is asked to whisper words containing hissing sounds (for example, “cup of tea” | “sixty-six”).

NB! Normally, bronchophony is negative. The whisper is transmitted very weakly to the chest (the words are indistinguishable and are perceived as an unclear hum), but equally on both sides at symmetrical points.

\/ Reasons for increased (positive) bronchophony the same as vocal tremors: compaction of the lung tissue, a cavity in the lung communicating with the bronchus, open pneumothorax, compression atelectasis.

Upon examination The chest is regular in shape and symmetrical. The supraclavicular and subclavian fossae are moderately pronounced. The course of the ribs is normal, the intercostal spaces are not widened. Respiration rate is 16-20 per minute, breathing movements are rhythmic, of medium depth. Both halves of the chest participate evenly in the act of breathing. Abdominal (difficult in women) or mixed type of breathing predominates. The ratio of the duration of the inhalation and exhalation phases is not disturbed. Breathing is silent, without the participation of auxiliary muscles.

On palpation The chest is elastic and pliable. The integrity of the ribs is not damaged, pain in the ribs and intercostal spaces is not detected. Voice tremors are moderately expressed, the same in symmetrical areas of the chest.

With comparative percussion A clear pulmonary sound is detected over the entire surface of the lungs.

(If changes in percussion sound are detected, indicate their nature and location).

With topographic percussion:

a) the lower borders of the lungs along the midclavicular lines pass along the VI rib (not determined on the left), along the anterior axillary - along the VII rib, along the middle axillary -
along the VIII rib, along the posterior axillary - along the IX rib, along the scapular - along the X rib, along the paravertebral - at the level of the spinous process of the XI thoracic vertebra;

b) excursion of the lower pulmonary edge along the middle axillary lines - 6-8 cm on both sides;

c) the height of the apices of the right and left lungs in front - 3-4 cm above the collarbones, in the back - at the level of the spinous process of the VII cervical vertebra;

d) the width of the apices of the lungs (Krenig's fields) is 4-7 cm on both sides.

On auscultation Visicular breathing is detected above the lungs on both sides (laryngo-tracheal breathing can be heard in the upper part of the interscapular space to the level of the IV thoracic vertebra). Adverse respiratory sounds (crepitation, pleural friction noise) are not heard.

Bronchophony negative on both sides. (If pathological auscultatory phenomena are detected, it is necessary to indicate their nature and location).

X-ray research methods are widely used in the diagnosis of respiratory diseases.

X-ray And radiography allow us to determine the airiness of the lungs, detect foci of shading (inflammation, tumor, pulmonary infarction, etc.), cavities in the lungs, fluid in the pleural cavity and other pathological conditions (Fig. 83). X-ray can determine the nature of the fluid in the pleural cavity: if the fluid is inflammatory (exudate), the upper limit of the darkening is located along an oblique line (from the side down to the mediastinum); if it is a transudate, the top level of darkening is horizontal.

Rice. 83. Radiographs:

a - right-sided upper lobe pneumonia, b- bronchogenic lung cancer, V- left-sided exudative pleurisy

Tomography allows you to determine the exact localization (depth) of the pathological process, which is of particular importance before surgery.

bronchography used to study the bronchi and makes it possible to identify dilations, protrusions of the bronchi in bronchiectasis (Fig. 84), a bronchial tumor, its narrowing, a foreign body, etc.

Fluorography carried out for the primary detection of lung pathology.

Endoscopic methods are used to diagnose bronchitis, bronchiectasis, bronchial tumors, central lung abscess, erosions, ulcers of the bronchial mucosa (bronchoscopy), as well as for examining the layers of the pleura, separating adhesions between them (thoracoscopy), taking material for biopsy, etc. Functional methods for diagnosing the respiratory system (spirometry, spirography, pneumotachometry, peak flowmetry) make it possible to identify respiratory failure at the onset of its first symptoms, as well as evaluate the effectiveness of the therapy.

Laboratory research methods have a great banner in the diagnosis of respiratory pathology.

UAC is carried out for all patients and makes it possible to detect signs of various pathological processes:

V leukocytosis with a shift to the left, increased ESR - with pneumonia, chronic bronchitis, suppurative lung diseases;

V leukocytosis, lymphopenia, monocytosis, increased ESR during tuberculosis;

V anemia - with lung cancer;

V leukopenia and increased ESR - with influenza pneumonia;

V erythrocytosis, increase in hemoglobin and slowdown of CO") ■
with emphysema.

Analysis of sputum, pleural fluid contains a lot of useful information about the patient’s illness. The interpretation of the data from these studies was given in Chap. 3.

An objective research method based on listening to natural sound phenomena that occur in the body and are inaudible at a distance.

This method was discovered by René Laennec in 1816. He also invented the stethoscope.

In Russia, the method was put into practice in the 60s of the 20th century. Filatov offered a stethoscope.

Auscultation methods:

• Direct
• Mediocre (using a stethoscope)

Stethoscopes: hard (used in obstetrics) and soft.

Conditions observed during auscultation

• Silence
• Temperature (18-24)
• Exposing the patient to the waist
• Moisten the chest hair in men
• Comfortable vertical position of the doctor and the patient, supporting the patient with his left hand
• Auscultation is performed during quiet breathing (with the mouth closed)
• Maintaining the sequence (from the healthy side to the sick side, or from right to left, front to back)

Places of auscultation of the lungs

Above the collarbones

Under the collarbones

2nd intercostal space along the midclavicular lines

4th intercostal space by 1 cm. outward from the midclavicular line

Laterally in the depths of the axillary fossae

4th intercostal space along the mid-axillary lines

6th intercostal space along the mid-axillary lines

Behind – all the same points as during percussion

Main and secondary breath sounds

Basic:

• Vesicular or alveolar respiration
• Bronchial or laryngotracheal

Side effects:

• Wheezing
• Crepitus
• Pleural friction rub

The main breath sounds are heard during quiet breathing. A healthy person has vesicular breathing throughout the entire surface of the lungs. It is formed in the alveoli as a result of the rapid straightening of their walls. When air enters and begins to collapse on exhalation. Heard throughout the entire inhalation and the initial third of the exhalation

The sound is reminiscent of a soft blowing noise, reminiscent of pronouncing the letter “f” while inhaling.

The standard for auscultation is the 2nd intercostal space along the midclavicular line and below the angles of the scapulae.

Varieties of vesicular breathing: weakened, increased (puerile), hard, intermittent (saccade) breathing.

Weakening of vesicular respiration is normal: with a thickening of the subcutaneous fat layer and a well-developed muscle layer.

In patients without lung pathology: in weakened individuals, with chest pain, with elevation of the diaphragm (ascites, flatulence).

For respiratory pathology:

1. With a decrease in air flow into the alveoli (swelling of the larynx, vocal cords, narrowing of the trachea and main bronchus);
2. When the lungs lose their elasticity – pulmonary emphysema;
3. In case of inflammation of the alveolar septa (focal pneumonia, the initial stage of lobar pneumonia);
4. With the accumulation of fluid and air in the pleural cavity;
5. With obstructive atelectasis;

Increased vesicular respiration

• During physical and muscular work
• In asthenics, with poor development of the subcutaneous fat layer and muscle layer
• In children under 3 years of age - puerile

In case of pathology: with the development of a pathological process on one side, it is heard from the healthy lung (exudative pleurisy, lobar pneumonia)

Hard breathing:

Coarser, harder breathing, with exhalation being ½ or more of the exhalation phase (bronchitis, bronchopneumonia)

Intermittent (saccade) breathing:

The inhalation is uneven, intermittent, the exhalation is uniform.

Bronchial breathing

• Formed in the larynx and trachea when air passes through the glottis
• Bronchial breathing spreads along the bronchial tree, but is not normally carried out to the chest. The auscultation point is not normally audible. Heard throughout the entire inhalation and exhalation phase
• Reminds me of pronouncing the letter “x” while exhaling
• Normally, you can listen above the larynx and trachea, that is, in the places of their projection: the jugular fossa in front, at the level of the spinous process of the 7th cervical vertebra, and 3-4 thoracic vertebrae in the back

Pathological bronchial breathing

Conditions of occurrence: lung diseases in which the lung tissue becomes denser, but the patency of the conducting bronchus is preserved (stage 2 lobar pneumonia, pulmonary tuberculosis, pulmonary infarction); with compensated atelectasis; if there is an air cavity in the lung communicating with the bronchus (abscess, cavity in the lung); with open pneumothorax.

Types of bronchial breathing:

• Amphoric breathing (cavity in the lungs)
• Quiet bronchial breathing (with compression atelectasis);
• Methodical breathing (open pneumothorax);
• Stenotic breathing (with narrowing of the trachea or large bronchus) resembles the sound of a saw.

Adverse breath sounds:

Wheezing, crepitus, pleural friction noise.

Wheezing is divided into dry and wet. Wheezing is heard in both phases of breathing.

Dry wheezes - are formed only in the bronchi and are divided depending on the diameter of the bronchus into whistling (narrow-channel) and phase (low-channel) - formed in large and medium bronchi.

Whistling (treble)

The main condition is a narrowing of the lumen of the bronchi.

Reasons for narrowing:

1. Smooth muscle spasm
2. Swelling of the bronchial mucosa due to inflammation
3. Accumulation of viscous sputum in the lumen of the bronchi: located parietally, in the form of strands, threads.

Bass (low-pitched, buzzing)

They are formed in large and medium-sized bronchi due to the accumulation of viscous sputum in the lumen of the bronchi, which in the form of cords and threads vibrates like strings.

Occurs in bronchitis, bronchopneumonia, bronchial asthma, pneumosclerosis.

Wheezing heard at a distance - remote (during an attack of bronchial asthma). In cardiac asthma - moist rales - boiling samovar syndrome.

Wet wheezing

They are formed in the bronchi, trachea and cavities when liquid secretions accumulate in them.

Depending on the caliber of the bronchi in which they are formed, they are distinguished:

— fine-bubble

— Medium bubble

- large bubble

Depending on sonority:

- sonorous (consonant) - abscess, bronchopneumonia

- silent - for bronchitis, pulmonary edema.

Crepitus

Crepitus - "crackling" sound. It occurs in the alveoli when there is a small amount of secretion in them (secretion of surfactant decreases) and during exhalation the walls of the alveoli stick together. On inspiration - crepitus.

If the alveoli are completely filled with secretion, then crepitus does not form.

It resembles the sound of rubbing a strand of hair over your ear. Crepitation is heard only on inspiration.

It is observed with lobar pneumonia in the initial and final stages, with infiltrative tuberculosis.

In older people without lung diseases, during the first deep breaths after lying in bed.

Distinctive signs of crepitus from fine bubbling moist rales.

• Crepitus is heard only during inspiration, and wheezing is heard in both phases.
• Moist rales intensify or disappear after coughing, but the crepitus does not change.
• Crepitus is always homogeneous, wheezing is heterogeneous.

Pleural friction rub

More often it resembles the crunch of snow underfoot, or the rustling of silk fabric. Normally, the pleural layers move without noise, because smooth and moistened with a small amount of transudate. Sometimes this noise can be felt by the hand. It is heard along the axillary and scapular lines.

Reason for formation: with dry pleurisy, the presence of adhesions of pleural leaves (fibrin deposition), in the initial stage of effusion pleurisy, or dryness of the leaves with dehydration, with uremia.

Difference between friction noise and fine bubbling rales.

• When coughing, wheezing may disappear or change its character, but the pleural friction noise does not disappear or change.
• With strong pressure with a stethoscope, the pleural friction noise intensifies, but wheezing does not.
• Test for imaginary breathing: close the mouth and nose, ask the patient to inhale and then exhale, the pleural friction noise remains, and other noises disappear.
• More often, pleural friction noise is accompanied by pain.

Inflammatory lung infiltration syndrome.

Includes inflammatory infiltration syndrome, focal compaction syndrome of pulmonary tissue, obstructive atelectasis, compression atelectasis syndrome, emphysema syndrome, bronchial obstruction disorders, lung cavity syndrome, pneumothorax syndrome.

Syndromes associated with compaction of lung tissue.

Inflammatory infiltration syndrome - manifests itself against the background of lobar pneumonia, occurs in 3 stages: 1. Flushing (exudation); 2. Hepatization (gray-red); 3. Permissions.

Pathogenesis. As a result of the inflammatory process, exudative fluid rich in fibrin enters the alveoli - the stage of tide. Which is organized during the hepatization stage, the lung becomes dense. As a result of the production of proteolytic enzymes, fibrin dissolves, partially coughs up, and partially resolves (resolution stage).

Clinic syndrome. Hot flash stage – complaints of a dry cough or discharge of a small amount of fibrinous sputum, high temperature, chest pain on the affected side, aggravated by deep breathing and coughing. On general examination, herpetic rashes on the lips and wings of the nose, feverish blush on the affected side. Examination of the chest: tachypnoe, lag of the affected side in the act of breathing, palpation confirms the lag, vocal tremor on the affected side is somewhat stronger, excursion of the chest is limited.

Comparative percussion: dull tympanic sound in the affected area.

Topographic percussion: limited mobility of the lower edge of the lung on the affected side. The affected area corresponds to the lobe of the lung.

Auscultation: weakened vesicular breathing and silent crepitus in the affected area, bronchophony increased.

Diagnostic value of bronchophony data.

Bronchophony - determination of the conduction of a sound wave from the vocal cords to the surface of the chest, determined by a phonendoscope, while asking you to pronounce hissing sounds.