Internalmedicine Sub Ans

1.Rules and questions of patient survey?
Be attentive. “Listen completely and attentively. ...
Ask open questions.
Be curious.
Summarise throughout.
Involve friends and family.
Use the right tone.
Be aware of your patient's situation.
Get help from colleagues.
First, always introduce yourself and state your name and title. Next, make sure to speak clearly
and slowly. It is also important to make eye contact and to smile. Finally, ask the patient how
they are doing and if there is anything you can do for them.
2. What condition must be observed for a general examination?

General examination is actually the first step of physical examination and key component of
diagnostic approach.
Inspection is the major method during general examination, combining with palpation,
auscultation, and smelling.
Aims to...
Assess patient's general condition
Detect manifestations of internal & systemic diseases
3 components:
History taking - Clues are the symptoms
Physical exam - Clues are the signs
Investigations - Clues are test results

The components of a physical exam include:
Inspection. Your examiner will look at, or "inspect" specific areas of your body for normal color,
shape and consistency. ...
Palpation.
Percussion.
Auscultation.
The Neurologic Examination:
3.Types of patient position and their characteristics.

.Active position - the patient can move freely and easily.
• Passive position - in the case of impossibility of active movements of patients (in a state of
unconsciousness, severe weakness).
• Forced position - the patient is taken to reduce the severity of symptoms...
Active position indicates on absence of severe functional disorders in case of trauma,

compensatory adjustments (adaptation) in orthopedic patients.
■ - Passive position indicates on the severity of trauma, shock. It may be caused by fractured
bones or paralysis.
■ - Forced extremity or trunk attitude may be result of dislocation, inflammation, etc. After
reposition of dislocation, reduction of
4.What is forced position of the patient? Give example of forced position of

patient and explain it.
Forced postures are postures in which the body is not in a natural position and in which tension
is caused in different parts of the body.
Example of Forced position
• Disease - abdominal pain.

.Forced position. <<The fetal position>> - patient lies on his side, hands and feet pressed against
the abdomen. In the result the pressure is decreasing in the stomach. Severity of pain is
reduced...
Example of Forced position.
• Disease - bronchial asthma. The main manifestation - dyspnea and asphyxia.
• Forced position. Patient sits, leans with hands. In the result the auxiliary respiratory muscles
are involved in the process of breathing. Severity of dyspnea is reduced.
5.Tyoes of consciousness of a patient and its characteristics.

Level of
consciousness Description-
Awake
Alert, responds immediately and fully to commands may or may not be fully oriented
The inability to think rapidly and clearly. There is
impaired judgment and decision making.
Confused
Disoriented-This is the beginning of loss of consciousness. There is disorientation in place,

impaired memory and a loss of recognition of self which is the last to deteriorate..
Drowsy, sleeps a lot, but is easily aroused with minimal stimuli, i.e. voice, and then responds,
but may not be oriented in time, place or person
Stupor-This is a condition of deep sleep or unresponsiveness.. The patient can only be aroused
or caused to make a motor or verbal response by vigorous and repeated extemal stimulation
(painful). The response initiated is often withdrawal or grabbing at stimulus..
Coma-There is no motor response to the external environment or to any stimuli, even deep
pain or suctioning. There is no arousal to any stimulus. Reflexes may be present, abnormal
movement (posturing) to pain may be present
Lethargic
6.What is coma? Its types and characteristics.
A coma is a prolonged state of unconsciousness. During a coma, a person is unresponsive to
their environment. The person is alive and looks like they are sleeping. However, unlike in a
deep sleep, the person cannot be awakened by any stimulation, including pain.
Different Categories of Comas
Toxic-Metabolic Encephalopathy. -When the kidneys or other organs fail, the body fails to
dispose of any toxins correctly.
Cerebral Hypoxia. -heart attacks and strokes can deprive the brain of oxygen, leading to
cerebral hypoxia. Cerebral hypoxia is a medical emergency. It can cause permanent brain injury.
If the brain goes too long without oxygen, brain death and coma can occur...
Persistent Vegetative State (PVS) -profound or deep state of unconsciousness. Persistent

vegetative state is not brain-death. An individual in a state of coma is alive but unable to move
or respond to his or her environment...
Locked-In Syndrome-Locked-in syndrome (LiS) is a rare and serious neurological disorder that
happens when a part of your brainstem is damaged, usually from a stroke. People with LiS have
total paralysis but still have consciousnes..
Brain Death- also known as brainstem death is when a person on an artificial life support
machine no longer has any brain function.
Medically Induced Coma- this is a type of temporary coma, or deep state of unconsciousness, is
used to protect the brain from swelling after an injury- and allows the body to heal.
7. Diagnostic value of face examination, give example of diagnostic faces and

their characteristics.
Examination of the face involves inspection for blepharochalasia (eyelid sagging), excess
wrinkling, or redundancy of skin in various areas of the chin, neck, upper neck, and face.
Regional inspection of the face should be made to document skin lesions such as keratoses,
moles, or scars...
Inspect the skull and face.

Inspect the skin and scalp.
Palpate skull (especially if patient complains of tenderness or recent trauma).
Assess facial sensation and motor function
8.Types of constitution. Their characteristics.

person's inherited and acquired physical, mental and emotional composition, personality and
temperament.
basic physiological tendency that is believed to contribute to personality, temperament, and

the etiology of specific mental and physical disorders. Examples of this factor include hereditary
predispositions and physiological characteristics (circulatory, musculoskeletal, glandular, etc.).
9. The patients body temperature, the norms when it is measured and the
measurement rules.
Normal Body temperature-37'C
Ways to Take a Temperature
Rectal. The thermometer is placed in the child's bottom. ...
Oral. The thermometer is placed in the mouth under the tongue. ...
Axillary. The thermometer is placed in the armpit.
Tympanic. The thermometer is placed in the ear.
Temporal artery. The thermometer scans the surface of the forehead...
10.Types of fever and their characteristics.

Types of fever
• Intermittent
⚫ Temperature returns to normal at least once every 24 hours!

It is commonly associated with conditions such as gram- negative positive sepsis, abscesses, and
acute bacterial endocarditis;
• Remittent
Temperature does not return to normal and varies a few degrees in either direction;
It is associated with viral upper respiratory tract, legionella, and
mycoplasma infections; •
Sustained or continuous
Temperature remains above normal with minimal variations;
It is seen in persons with drug fever;
• Relapsing
There is one or more episodes of fever, each as long as several days, with one or more days of
normal temperature between episodes;
It may be caused by a variety of infectious diseases, including tuberculosis, fungal infections,

Lyme disease, and malaria.
Hectic fevers, because of wide swings in temperature, are often associated with chills and
sweats. This pattern is thought to be very suggestive of an abscess or pyogenic infection such as
pyelonephritis and ascending cholangitis, but may also be seen with tuberculosis,
hypernephromas, lymphomas, and drug reactions...
Reverse..
Hyperthermia differs from fever in that the body's temperature set point remains unchanged. .
The opposite is hypothermia, which occurs when the temperature drops below that required to
maintain normal metabolism.
11.Types of fever and their characteristics.

Same as question 10.
12. What type of fever is called permanent?

Persistent (chronic) fevers are typically defined as fevers lasting more than 10 to 14 days.
A fever can mean a lot of different things, but most low-grade and mild fevers are nothing to
worry about. Most often, an increase in body temperature is a normal response to an infection,
like a cold or the flu. But there are many other less common causes of a persistent low-grade
fever that only a doctor can diagnose.
13.What type of fever is called laxative

Constipation and fever can occur at the same time, but that doesn’t necessarily mean that the
constipation caused your fever. The fever may be caused by an underlying condition that’s also
related to constipation.
For example, if your constipation is caused by a viral, bacterial, or parasitic infection, that
infection may result in fever. The cause of the fever is the infection, not the constipation, even
though they occur simultaneously.
14. What type of fever is called intermittent?

With intermittent fever, the temperature is elevated but falls to normal (37.2°C or below) each
day, while in a remittent fever the temperature falls each day but not to normal. In these two
patterns the amplitude of temperature change is more than 0.3°C and less than 1.4°C.
15.What type of fever is called debilitating or hectic?

Hectic fevers, because of wide swings in temperature, are often associated with chills and
sweats. This pattern is thought to be very suggestive of an abscess or pyogenic infection such as
pyelonephritis and ascending cholangitis, but may also be seen with tuberculosis,
hypernephromas, lymphomas, and drug reactions.
16.What type of fever is called reverse?

The concentration of researchers on the cellular and humoral processes in snails means that
relatively little is known of the ability of snails to generate non-specific reactions, analogous to
fever, which may follow a similar course in all animals. Independent of the systematic position,
many ectotherms developed a behavioural mechanism for changing body temperature,
involving moving to warmer or cooler microhabitats.The condition for thermo-behavioural
response is the ability to perceive thermal stimuli. Snails possess this ability, as the observation.
Depending on the intensity and direction of the thermal stimulus these animals react
behaviourally, increasing or decreasing exposure to specific temperature conditions
17.What type of fever is called incorrect?

Feeling feverish or hot may be one of the first signs of having a fever. However, it’s also possible
to feel feverish but not be running an actual temperature. Underlying medical conditions,
hormone fluctuations, and lifestyle may all contribute to these feelings.
While an occasional feverish feeling isn’t necessarily a cause for concern, ongoing, or chronic,
feelings of having a fever without an elevated body temperature could signify an undiagnosed
medical condition
18.The main complaint of pulmonary patients with the explanation of their

mechanism of occurrence.
Main problems are in pulmonary are most common lung diseases include: Asthma. Collapse of
part or all of the lung (pneumothorax or atelectasis) Swelling and inflammation in the main
passages (bronchial tubes) that carry air to the lungs (bronchitis)
Main symptoms
increasing breathlessness – this may only happen when exercising at first, and you may
sometimes wake up at night feeling breathless.
a persistent chesty cough with phlegm that does not go away.
frequent chest infections.
persistent wheezing.
Mechanism how pulmonary disease occur :
Over time, exposure to irritants that damage your lungs and airways can cause chronic
obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema. The
main cause of COPD is smoking, but nonsmokers can get COPD too.
19.What is cough? Its types, mechanism and cause of occurrence.
Cough;
Appears as protective reaction at a congestion of mucus in respiratory ways or
intaken foreign body. It can be dry-without sputum discharge, moist with sputum discharge
with various quantity and quality.
1..The constant cough is observed at inflammation larynx, bronchial tubes, cancer of lung and
sometimes at tuberculosis of lung.
2.Periodic cough - influenza,andar sharp catarrh, pneumonia, TB of lung, chronic bronchitis, is

especial in a stage of intensification. Strong and long cough sharply raise intrathoracic pressure
and cause short-term expansion of neck veins, cyanosis and puffiness of face. At whooping
cough, at the end of a strong and long attack of cough, vomiting reflex can appear due
transferring of an irritation from the cough centre to the close located vomiting centre
(children).
Regards to loudness and timbre distinguish: loud, «barking» cough - at whooping cough,
tumour of larynx, hysteria; silent cough or slight cough in the first stage croupous pneumonia,
at dry pleurisy, in an initial stage of lung tuberculosis.
Blood spitting (haemoptysis) - discharge of blood with sputum during cough Sputum with
containing blood is observed in a number of lung illness (tuberculosis, multiple bronchiectasis
illness, degeneration of tumor,, lung abscess, virus pneumonia, laryngitis and tracheitis caused
by virus, actinimicosis of lung)) Sputum with containing blood is observed also in a number of
heart-vessel diseases ((some heart valvular defect (mitral stenosis), stagnation in a small blood
circle, thrombosis or embolism of pulmonary artery with further developed lung infarction,
damage of small vessels.)) Blood discharged during cough with sputum, can be freshen, scarlet,
or changed. Scarlet blood in sputum can be observed at tuberculosis of lung, bronchial cancer,
multiple bronchiectasis illness crawfish, actinimicosis of lung. Rusty color of blood in sputum (<<
rusty sputum »>) is observed during II stages of croupous pneumonia due to disintegration of
red blood cells and formation of a pigment heamosidirin. At infarction of lung during first 2-3
days blood in sputum is freshen, scarlet, and in subsequent 7-10 days - it changed.
20. Mechanism of occurrence of chest pain in patients with respiratory diseases
and in which respiratory disease does chest pain occur?
Pain in chest
It is necessary to determine localization, character, intensity, duration and irradiation,

connection with the process of breath, cough and position of body. The pains can appear in
case of development of pathological process in chest, pleura, heart and aorta, sometimes, as
irradiation of pain at diseases of abdominal cavity organs.
Pain in case of disease of respiratory apparatus is
connected with irritation of pleura-costal and diaphragmatic, in which the sensitive nervous
endings. The damage of pleura is possible during it's inflammation (dry pleurisy), at croupous
pneumonia, abscess, tuberculosis), lung infarction, tumour process, trauma (spontaneous
pnumathorax, wound, fracture of rib), under diaphragmatic abscess and acute pancreatitis.
21.Respiratory rate. Norms and rules of respiration.

Age Respiratory rate (breaths/minute)
6 to <8 years 18 to 24
8 to <12 years 16 to 22
12 to <15 years 15 to 21
15 to 18 years 13 to 19
>18 years 12 to 25
Respiration is normally unconscious and automatic. its rate is tightly controlled and determined
by blood levels of carbon dioxide as determined by metabolic rate. The respiratory process
should have relatively constant rate and inspiratory volume that together constitutes a normal
respiratory rhythm.
22.What types of breathing are normal and who has it?

Normal ventilation is an automatic, seemingly effortless inspiratory expansion and expiratory
contraction of the chest cage. This act of normal breathing has a relatively constant rate and
inspiratory volume that together constitute normal respiratory rhythm. Anyone who has a
respiratory rate of 12-25 breaths per minute while resting has normal breathing.
23.What is dyspnea? Types of dyspnea.

Shortness of breath, often described as an intense tightening in the chest, air hunger, difficulty
in breathing, breathlessness or a feeling of suffocation.
Types of dyspnea:
Excertional dyspnea, positional dyspnea, paroxysmal dyspnea, acute dyspnea(acute pulmonary

edema, inspiratory dyspnea , expiratory dyspnea, subjective and objective dyspnea.
24.What is inspiratory dyspnea? Mechanism of its occurrence, and the list of

respiratory diseases in which it occurs.
Inspiratory dyspnea implies a lesion in the respiratory tract outside the thorax. Patients with
isolated nasal problems are able to breath normally when the mouth is open. Presence of
abnormal sound may help to localize the problem.
disease: congestive heart failure, Pneumonia, Copd, stenotic nares, rhinitis, pharyngeal polyps,
laryngeal edema, tracheal collapse, tracheobronchitis etc.
25. What is respiratory dyspnea? The mechanism of its occuresnce and list of
diseases in which it occurs.
Three types of dyspnea are differentiated by the
prevalent breathing phase: inspiratory dyspnea, expiratory dyspnea and
Dyspnea mixed dyspnea when both expiration and inspiration become difficult.
Expiratory dyspnea is difficulty with the expiratory phase of breathing, often due to obstruction
in the larynx or large bronchi, such as by a foreign body or due to intrathoracic airway diseases.
It can be caused by obstruction of the respiratory ducts, contraction of the respiratory surface
of the lungs due to their compression by liquid or air accumulated in the pleural cavity,
decreased pneumatization of the lung in pneumonia, atelectasis, infarction or decreased
elasticity of the lungs. These conditions are associated with decreased total (vital) lung capacity
and ventilation, which causes increased carbon dioxide content of blood, and acidosis of tissues
due to accumulation in them of incompletely oxidized metabolites.respiratory .
26. What is mixed dyspnea, the mechanism of its occurrence , an list of
respiratory diseases in which it occurs.
Mixed dyspnea is when there is difficulty in both the inspiratory and expiratory phase.it is
caused by fixed obstruction in the extra-thoracic airways, eg neoplasia. There is an
inappropriate degree of effort in breathing with changes in rate, rhythm and character of
respiration.
It occurs in diseases including cardiac and pulmonary diseases (congestive heart failure, acute
coronary syndrome, pneumonia, chronic obstructive pulmonary diseases) and many other
conditions like anemia and mental disorders.
27.what is objective dyspnea. In what diseases does it occur?

Objective symptoms are those evident to the observer and called physical signs. Examples of
such physical signs are temperature, pulse rate and rhythm, respiratory rate and character,
temperature, posture, edema, gait. Faint cardiac murmurs and pulmonary rales are pure
objective signs.
28.What is subjective dyspnea and it occurs in which diseases?

Dyspnea is a subjective symptom reported by patients. It is always a sensation expressed by
the patient and should not be confused with rapid breathing (tachypnea), excessive breathing
(hyperpnea), or hyperventilation.
29.normal forms of chest and what forms of chest occurs in diseases?

Normosthenic (conical) chest in subjects with normosthenic
constitution resembles a truncated cone whose bottom is formed by welldeveloped muscles of

the shoulder girdle and is directed upward. The
anteroposterior (sternovertebral) diameter of the chest is smaller than the
lateral (transverse) one, and the supraclavicular fossae are slightly
pronounced. There is a distinct angle between the sternum and the
manubrium (angulus Ludowici); the epigastric angle nears 90°. The ribs are
moderately inclined as viewed from the side; the shoulder blades closely fit
to the chest and are at the same level; the chest is about the same height as the
abdominal part of the trunk.
Hypersthenic chest in persons with hypersthenic constitution has
the shape of a cylinder. The anteroposterior diameter is about the
same as the transverse one; the supraclavicular fossae are absent (level
with the chest). The manubriosternal angle is indistinct; the epigastric angle
exceeds 90°; the ribs in the lateral parts of the chest are nearly horizontal,
the intercostal space is narrow, the shoulder blades closely fit to the chest,
thoracic part of the trunk is smaller than the abdominal one.
Asthenic chest in persons with asthenic constitution is elongated,
narrow (both the anteroposterior and transverse diameters are smaller than
normal); the chest is flat. The supra- and subclavicular fossae are distinctly
pronounced. There is no angle between the sternum and the manubrium:
the sternal bone and the manubrium make a straight "plate". The epigastric
angle is less than 90°. The ribs are more vertical at the sides, the tenth ribs
are not attached to the costal arch (costa decima fluctuens); the intercostal
spaces are wide, the shoulder blades are winged (separated from the chest),
the muscles of the shoulder girdle are underdeveloped, the shoulders are
sloping, the chest is longer than the abdominal part of the trunk.
30.types of normal and pathological curvature of spine?

.Spine deformities
The chest may be abnormal in subjects with various deformities of the
spine which arise as a result of injuries, tuberculosis of the spine, rheumatoid
arthritis (Bekhterev's disease), etc. Four types of spine deformities are
distinguished: (1) lateral curvature of the spine, called scoliosis; (2)

excessive-forward and backward curvature of the spine (gibbus and kyphosis,
respectively); (3) forward curvature of the spine, generally in the lumbar
region (lordosis); (4) combination of the lateral and forward curvature of the
spine (kyphoscoliosis).
Scoliosis is the most frequently occurring deformity of the spine. It
mostly develops in schoolchildren due to bad habitual posture.
Kyphoscoliosis occurs less frequently. Lordosis only occurs in rare cases.
Curvature of the spine, especially kyphosis, lordosis, and kyphoscoliosis
cause marked deformation of the chest to change the physiological position
of the lungs and the heart and thus interfere with their normal functioning.
31. what is evaluated during the examination of chest?

This is done by examining the patient posteriorly, placing the examiner's thumbs together at
the midline at the level of the tenth rib with hands grasping the lateral rib cage; both visual and
tactile observations are made both during tidal volume breathing and during deep forceful
inhalation.The physical examination of the chest is composed of inspection, palpation,
percussion, and auscultation.
32.what is determined by palpation of heart?

Palpation includes assessing the arterial pulse, measuring blood pressure, palpating any thrills
on the chest, and palpating for the point of maximal impulse. Arterial pulse: When palpating
the arterial pulse, the examiner should be able to gather the rate, rhythm, and
characteristics.Palpation provides useful information to assess and evaluate findings related to
temperature, texture, moisture, thickness, swelling, elasticity, contour,
lumps/masses/deformities, consistency/density, organ location and size, vibration, pulsatility,
crepitation, and presence of pain. The front of your fingers are used to perform light
palpation, deep palpation, light ballottement and deep ballottement.
33.what is vocal tremor and condition of it carrying it to the periphery?

VOCAL TREMOR:--. Vocal tremor is a rhythmic, involuntary vibration of the larynx (voice
box) that causes the vocal cords to open and shut during speech. Chronic inflammatory
polyneuropathy, or peripheral neuropathy, which affects nerves outside of the brain and spinal
cord, can lead to a host of problems, such as difficulty walking, facial weakness, numbness in
the hands and feet, difficulty swallowing, and hoarseness or changes in the voice.
34.Causes of strengthening and weakening of vocal tremor?

It happens when the nerve impulses to your voice box (larynx) are disrupted. This results in
paralysis of the vocal cord muscles. Vocal cord paralysis can make it hard to speak and even
breathe. That's because your vocal cords, also called vocal folds, do more than just produce
sound. Increasing subglottal pressure is primarily responsible for vocal intensity increase
but also leads to significant increase in noise production and an increased fundamental
frequency. Increasing AP stiffness significantly increases the fundamental frequency and slightly
reduces noise production.
35.what is percussion? By whome and when was it proposed, its physical

foundation.
Percussion is a method of tapping body parts with fingers, hands, or small instruments as part
of a physical examination. It is done to determine: The size, consistency, and borders of body
organs. The presence or absence of fluid in body areas.Leopold Auenbrugger (1722-1809), the
inventor of percussion, joins René Laennec as the father of modern physical examination.
Origins of percussion instruments: Among the earliest known examples of percussion
instruments are idiophones made from mammoth bones found in present-day Belgium. These
instruments are thought to date from 70,000 B.C. and are idiophones, which means they
produce sound via the vibration of the entire instrument in physical foundation.
36.Types of percussion sounds and their characteristics.

Broadly classifying, there are four types of percussion sounds: resonant, hyper-resonant, stony
dull or dull. A dull sound indicates the presence of a solid mass under the surface. A more
resonant sound indicates hollow, air- containing structures. Tymphany. Loud, high pitched
sound heard over abdomen.
• Resonance. Heard over normal lung tissue.
Hyper resonance. Heard in over inflated lungs as in emphazema.
• Dullness. Heard over liver.
Flatness. Heard over bones and muscle.
37.characteristics of pulmonary percussion sound.

Percussion produces sounds on a spectrum from flat to dull depending on the density of the
underlying tissue. Areas of well-aerated lung will be resonant, or tympanic, to percussion.
Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation.
Crackling or bubbling noises (rales) made by movement of fluid in the tiny air sacs of the lung.
Dull thuds heard when the chest is tapped (percussion dullness), which indicate that there is
fluid in a lung or collapse of part of a lung.
38. characteristics of dull percussion sound.

Dullness is typically considered an abnormal sound if elicited with percussion over the lungs or
the intestines, stomach, or bladder. In this case, it could represent intestines that are filled with
stool, indicating constipation, a bowel obstruction, or some sort of mass. Dullness to
percussion of the chest suggests reduced air in the chest due to fluid or soft tissue. Dullness
is a soft, muffled, thud-like tone heard when percussing over a solid body organ like the liver.
Flatness is a soft, short tone heard when percussing over solid tissue like muscle and bone.
Resonance is a low- pitched, hollow tone heard when percussing air-filled tissue like the lungs.
39. characteristics of tympanic percussion sound.

Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the
stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate
excessive air in the chest, such as may occur with pneumothorax. Fluid filled with a mixture of
air and contents (e.g., intestines, bladder, stomach). Fluid results in a tympanic sound (like a
drum, usually high pitched with a long duration). Normal findings on percussion include
tympany over the stomach, epigastric area, and upper midline, and dullness over the liver, a full
bladder, a pregnant uterus and the left lower quadrant over the sigmoid colon (if the patient is
ready to have a bowel movement).
40.characteristics of box percussion sound.

cajon has been, since the 19th century, a key component in traditional Afro-Peruvian music.
Named with the Spanish word for "box," the cajon was first invented to replace the African
drums used by slaves in colonial Peru. which were eventually banned by the slaves' masters. A
cajon is a box-like instrument that the percussionist sits on and uses their hands, palms, and
inches tall and 12 inches wide. fingertips to create sound. The instrument is relatively 18
41. General rules of percussion?

GENERAL RULES OF PERCUSSION
Percussion is a method of tapping body parts with fingers, hands, or small instruments as
part of a physical examination. It is done to determine:
 The size, consistency, and borders of body organs
 The presence or absence of fluid in body areas
 The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it
with a firm object.
 The pleximeter,usually middle finger,must be firmly applied to the chest wall.

 The plessor is kept at right angle.
 The percussion stroke must be sudden, the plessor finger must be withdrawn
immediately after the stroke,to prevent damping of the note,
 When percussing,the patient head must be slightly tilted forward,the arms crossed on
the chest.
42. The purpose and rules of comparative percussion?

 Comparative percussion of the lungs is used to determine the nature of the pathological
changes in the lungs and pleural cavity and used for diagnosis of bronchopulmonary
disorders.
 The purpose of comparative percussion is to compare the percussion sounds over the
lungs on the opposite part of chest,
 The patient should be in a comfortable position and relaxed.
 The best position is standing or sitting.patients with graves disease must be percussed in
lying position.
 The room should be warm and protected from external noise.
 Comparative percussion helps to determine whether the underlying tissue is air filled,
fluid filled or solid.
43.The purpose and rules of topographic percussion?
 Topographic percussion of the lungs reveals the boundaries of an

organ or a detected pathological formation
 The count of the ribs is made from the front, beginning with the
second rib (the place of attachment to the sternum is between the
sternum's handle and its body), the first rib corresponds to the
collarbone.
 The lower edge of the lung is located on the right and left at the same level
 The displacement of the lower border of the lungs is revealed primarily in emphysema
 Light/superficial percussion is preferred over heavy/deep percussion. heavy percussion is
used only when the superficial tissues are thick. heavy percussion is not needed for
purposes of outlining organs.
 Kronigs area- extends across trapezius muscle on each side of neck corresponding to apex
of lungs. Its measures around 5cm.contraction of this zone denotes disease of lung apex.
 Traube’s semilunar space-bounded above by lower border of left lung,below by
spleen,internally by the left lobe of liver, and externally by the coastal margins.,it contains
the fundus of the stomach .and gives tympanic sound on percussion. When the stomach is
filled with food, the tympanic sound is decreased or disappears .the sound is also decreased
or disappeared in case of pericardial effusion or left pleural effusions.
44. The reason for the appearance of a dull percussion sound over the chest
instead of a clear pulmonary one?
 Dullness is typically heard when fluid or solid tissue replaces air-containing lung tissues, as
occurs with pneumonia, pleural effusions, or tumors.
 Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation.
Once an abnormality is detected, percussion can be used around the area of interest to
define the extent of the abnormality. Normal areas of dullness are those overlying the liver
and spleen at the anterior bases of the lungs.
 Causes of Dull Percussion Note

 Pleural effusion, pneumonia, pulmonary edema, lung cancer
45.The reasons for aapearence of tympanic percussion sounds over the chest
instead of pulmonary one?
 Tympany is typically heard over air-filled structures such as the small intestine and the
large intestine.
 Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over
the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest
indicate excessive air in the chest, such as may occur with
Pneumothorax
46.The reasons for the appearance of blunted type percussion sound over the
chest instead of clear pulmonary sound?
47.the reason for appearance of box percussion sound over the chest instead of
clearly pulmonary sound?
48.where is the upper border of the lung normally located in front and where is
the back and the method of determining it?
49. @4. Non-pulmonary and pulmonary causes of the upper border of the lungs
shifting upwards?
50. @4. Non-pulmonary and pulmonary causes of the upper border of the lungs
shifting downwards?
51. How to determine the lower border of the lungs and where is it located
normally?
The lower border of the right lung is first determined anteriorly along the parasternal and the
medioclavicular lines, then laterally along the anterior, medial and posterior axillary lines, and
posteriorly along the scapular and paraspinal lines. The lower border of the left lung
determined only laterally, by the three axillary lines, and posteriorly by the scapular and
paraspinal lines. The lower border of the left lung is not determined anteriorly because of the
presence of the heart. The pleximeter finger is placed in the interspaces, parallel to the ribs,
and the plexor finger produces slight and uniform strokes over it.
Normal Lower Border of the Lungs
Topographical lines Position of lower border of the lungs

Lin. parasternalis dextr. the upper edge of 6-th rib
Lin. medioclavicularis dextr. the inferior edge of 6-th rib
Lin. axillaris anterior dextra et sinistra the inferior edge of 7-th ribs
Lin. axillaris media dextr. et sin. the inferior edge of 8-th ribs
Lin. axillaris posterior dextr. et sin. the inferior edge of 9-th ribs
Lin. scapularis dextr. et sin. the inferior edge of 10 ribs
Lin. paravertebralis dextr. et sin. the level of the spinous T11
52.Non-pulmonary and pulmonary causes of the displacement of the lower border of the
lungs upwards?
The elevation of the lower border of the lungs is usually unilateral and occurs in
(1) restriction of the lung due to development of connective tissue (pneumosclerosis)
(2) complete obstruction of the lower-lobe bronchus by a tumour which causes gradual collapse
of the lung, atelectasis
(3) accumulation of fluid or air in the pleural cavity which displace the lung upwards and
medially toward the root
(4) marked enlargement of the liver (cancer, echinococcosis), or of the spleen (chronic
myeloleukaemia).
Bilateral elevation of the lower borders of the lungs occurs in the presence of large amounts of
fluid (ascites) or air in the abdomen due to an acute perforation of gastric or duodenal ulcer, and
also in acute meteorism.
53. Non-pulmonary and pulmonary causes of the displacement of the lower border of the
lungs downwards?
Unilateral lowering of the lower border of the lungs can be due to vicarious (compensatory)
emphysema of one lung with inactivation of the other lung (pleurisy with effusion, hydrothorax,
pneumothorax, hemiparesis of the diaphragm).
Bilateral lowering of the lower border of the lungs can occur in acute and chronic dilation of the
lungs (attack of bronchial asthma and emphysema of the lungs, respectively) and also in
sudden weakening of the tone of the abdominal muscles and lowering of the abdominal viscera
(splanchnoptosis).
54.How to determine the mobility of the lower pulmonary edge and what are its normal
indicators?
The respiratory mobility of the lungs is determined as follows.

The lower border of the lungs in normal respiration is first determined and marked by a
dermograph. Further the patient is asked to make a forced inspiration and to keep breath at the
height. The pleximeter finger should at this moment be held at the lower border of the lung
(determined earlier). Percussion is now continued by moving the pleximeter downwards to
complete dullness, where the second mark should be made by a dermograph at the upper edge
of the pleximeter finger. Next the patient is then asked to maximum air from the lungs and to
keep breath again. The percussion is now continued in the downward direction from starting
point until the clear vesicular resonance disappears. The third dermographic mark should be
made at the point where relative dullness is heard. The distance between the extreme marks is
measured). It corresponds to the maximum respiratory mobility.
Active respiratory mobility of the lower border of normal lungs
Topographical lines Active respiratory mobility(sm)

Lin. medioclavicularis dextr. 4-6
Lin. axillaris media dextr. et sin. 6-8
Lin. scapularis dextr. et sin. 4-6
55. Causes of decreased mobility of the lower pulmonary margin
Respiratory mobility of the lower border of the lungs is diminished in inflammatory infiltration or
congestive plethora of the lungs, decreased elasticity of the pulmonary tissue (emphysema),
profuse pleural effusion, and in pleural adhesion or obliteration.
56. What is auscultation, types, by whom and when was it proposed?
Auscultation (L auscultare to listen) means listening to sounds inside the body.

Auscultation is immediate (direct) when the examiner presses his ear to the patient's body, or
mediate (indirect, or instrumental) by using stethescope. Auscultation was first developed by the
French physician Laennec in 1816.
57. Rules of lung auscultation
● Patient must be in upright position or laying down.

● Warm,quiet and calm environment.
● Patient’s chest is bare ( clothes taken off).
● Patient is breathing evenly.
● Phonendoscope is tightly clasped to the chest.
● Listen to 2-3 breathing cycles in each auscultation point.
Positions:
● Front side of the chest: supra and subclavian areas,f.Mohrenheim,2nd intercostal
space
● Lateral sides of chest: f. Axillaris,4th and 6th intercostal spaces
● Back of chest: suprascapularis, “alarming zone”, interscapularis (3 points),
Subscapularis (either 6 & 8 or 7 & 9 intercostal spaces).
During ausculation, we listen to basic sounds:

● Vesicular Respiration
● Bronchial Respiration
58. What are the main respiratory noises, their types and mechanism of occurrence?
The main respiratory noises are vesicular (alveolar) breathing which is heard over the
pulmonary tissues, and bronchial (laryngotracheal) breathing which is heard over the larynx,
trachea, and large bronchi.
Respiratory sounds known as vesicular respiration arise due to vibration of the elastic
elements of the alveolar walls during their filling with air in inspiration. Therefore, the
summation of the great number of sounds produced during vibration of the alveolar walls gives
a long soft (blowing) noise that can be heard during the entire inspiration phase, its intensity
gradually increasing. This sound can be simulated by pronouncing the sound “T” during
inspiration.Alveolar walls still vibrate at the initial expiration phase to give a shorter second
phase of the vesicular breathing, which is heard only during the first third of the expiration
phase, because vibrations of elastic alveolar walls are quickly dampened by the decreasing
tension of the alveolar walls.
In case of bronchial breathing, air is inhaled, it passes through the vocal slit to enter a wider
trachea where it is set in vortex type motion. Sound waves thus generated propagate along the
air column throughout the entire bronchial tree. Sounds generated by the vibration of these
waves are harsh. During expiration, air also passes through the vocal slit to enter a wider space
of the larynx where it is set in a vortex motion. But since the vocal slit is narrower during
expiration, the respiratory sound becomes louder, harsher and longer.
Q59. Bronchial respiration: definition, mechanism of occurrence, characteristics, places
of listening are normal.
Respiratory sounds known as bronchial or tubular breathing arise in the larynx and the
trachea as air passes through the vocal slit. As air is inhaled, it passes through the vocal slit to
enter wider trachea where it is set in vortex type motion. Sound waves thus generated
propagate along the air column throughout the entire bronchial tree. Sounds generated by the
vibration of these waves are harsh. During expiration, air also passes through the vocal slit to
enter a wider space of the larynx where it is set in a vortex motion. But since the vocal slit is
narrower during expiration, the respiratory sound becomes louder, harsher and longer. This type
of breathing is called laryngotracheal (by the site of its generation).
Bronchial breathing is well heard in physiological cases over the larynx, the trachea, and at
points of projection of the tracheal bifurcation (anteriorly, over the manubrium sterni, at the point
of its junction with the sternum, and posteriorly in the interscapular space, at the level of the 3rd
and 4th thoracic vertebrae). Bronchial breathing is not heard over the other parts of the chest
because of large masses of the pulmonary tissue found between the bronchi and the chest wall.
Q60. Vesicular respiration: definition, mechanism of occurrence, characteristics, places

of listening are normal.
Respiratory sounds known as vesicular respiration arise due to vibration of the elastic
elements of the alveolar walls during their filling with air in inspiration. Therefore, the
summation of the great number of sounds produced during vibration of the alveolar walls gives
a long soft (blowing) noise that can be heard during the entire inspiration phase, its intensity
gradually increasing. This sound can be simulated by pronouncing the sound “T” during
inspiration.Alveolar walls still vibrate at the initial expiration phase to give a shorter second
phase of the vesicular breathing, which is heard only during the first third of the expiration
phase, because vibrations of elastic alveolar walls are quickly dampened by the decreasing
tension of the alveolar walls.
Normal vesicular breathing is better heard over the anterior surface of the chest, below the 2nd
rib, laterally of the parasternal line, and also in the axillary regions and below the scapular
angle, i.e. at points where the largest masses of the pulmonary tissue are located. Vesicular
breathing is heard worse at the apices of the lungs and their lowermost parts, where the masses
of the pulmonary tissue are less abundant.
61. @4. What is pathological bronchial respiration and the causes of its
occurrence?
Pulmonary causes!
Pathologically decreased vesicular respiration can be:
~ due to a significantly diminished number of the alveoli;
due to inflammation and swelling of the alveoli walls in a part of the lung;
decreased also in insufficient delivery of air to the alveoli through the air ways;
due to obstructed conduction of sound waves from the source of vibration (alveolar walls) to
the chest surface.
Non.. Pulmonary causes
Changes in vesicular breathing
Physiological weakening - with thickening of the chest in athletes, obesity, etc.;
Physiological strengthening - in children, asthenic physique, in hyperventilation;
Pathological enhancement (hard breathing)
62. @4. Non-pulmonary and pulmonary causes of weakening of vesicular

respiration.
Increase vesicular breath
Increased
Increased movement of respiration
Exercise, fever, anemia, metabolic acidosis, compensation (single lung)
Vibrations of the vocal cords caused by turbulent flow through the larynx
> Transmitted along trachea, bronchi to chest wall
> Rustling quality
➤ Inspiration continuous with expiration Intensity increases during inspiration & fades during
first 1/3rd expiration
63. @4. Non-pulmonary and pulmonary causes of increased vesicular

respiration.
Increase vesicular breath
Increased movement of respiration
Exercise, fever, anemia, metabolic acidosis, compensation (single lung)
Vibrations of the vocal cords caused by turbulent flow through the larynx
> Transmitted along trachea, bronchi to chest wall
> Rustling quality
➤ Inspiration continuous with expiration
Intensity increases during inspiration & fades during first 1/3rd expiration
64. @4. What are additional respiratory noises and their types?
These may be high pitched or low pitched and are continuous sounds associated with airway
narrowing due to a variety of causes, including bronchoconstriction and excessive secretions.
Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person
breathes in (inhales). ...
Rhonchi. Sounds that resemble snoring. ...
Stridor. Wheeze-like sound heard when a person breathes. ...
Wheezing. High-pitched sounds produced by narrowed airways.
Normal Breath Sounds
Vesicular
■ Found over lung periphery. Low pitched, soft breezy sound.
■ Inspiration > Expiration by 2 ½ times.
Bronchovesicular
Found on either side of sternum and between scapula on back. Moderate intensity.
■ Inspiration = Expiration
Bronchial
Found over the trachea and above manubrium. Loud, harsh, high pitched, blowing sound.
■ Inspiration < Expiration by 2.
Absent breath sound
65. @4. What is dry wheezing, types, mechanism of occurrence, characteristic,

diagnostic value?
Dry wheezing..
a physical obstruction, such as a tumor or a foreign object that's been inhaled...conditions can
lead to wheezing: Allergies. Anaphylaxis (a severe allergic reaction, such as to an insect bite or
medication...
More specifically, a barking cough occurs when the larynx (the vocal cord area) is affected. It is
also known as a characteristic sign of croup, a viral infection that causes swelling in this region.
This is more common in children but can develop in adults.
Other potential causes of dry cough can include:
laryngitis
sore throat
croup
tonsillitis
sinusitis
asthma
allergies
gastroesophageal reflux disease (GERD)
medications, especially ACE inhibitors
exposure to irritants such as air pollution, dust, or smoke..

Diagnosis..
Moisturize the air. Use a humidifier, take a steam ...
Drink fluids. Warm liquids can relax the airway and loosen up sticky mucus in your throat...
Avoid tobacco smoke. ...
Take all prescribed medications
66. @4. What is wet wheezing, types, mechanism of occurrence, characteristic,

diagnostic value?
wet cough, also known as a productive cough, is any cough that produces mucus (phlegm). It
may feel like you have something stuck in your chest or the back of your throat. Sometimes a
wet cough will bring mucus into your mouth....
Occurence..
The following conditions can cause a wet cough:
common cold or the flu
pneumonia
chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema
acute bronchitis
asthma..
Characteristics..
runny nose
postnasal drip, or the excess mucus that drips from your nose down into your throat
fatigue
Wet coughs sound wet because of the moisture present when mucus comes up from your
respiratory system...
Diagnosis. ..
Additional testing may include:
chest X-rays
lung function tests
bloodwork
sputum analysis, a microscopic look at phlegm
pulse oximetry, which measures the amount of oxygen in your blood
arterial blood gas, which tests a blood sample from an artery to show the amount of oxygen
and carbon dioxide in your blood, along with your blood chemistry
67. @4. What is small-bubble wheezing, mechanism of occurrence,

characteristic, diagnostic value?
Mucus that contains bubbles and is foamy is commonly referred to as frothy sputum. Frothy
sputum can sometimes be a sign of: chronic obstructive pulmonary disease (COPD)
gastroesophageal reflux disease (GERD)..
Coughing up white mucus can indicate several conditions, including upper respiratory tract
infections (URTIs), asthma, bronchitis, and chronic obstructive pulmonary disease (COPD).
Mucus from the chest is responsible for protecting against microbes, and is often white or clear
in color when it is healthy....
Increasing your fluid intake, using a cool-mist humidifier, and using saline nasal sprays can help
thin the mucus and make it easier to clear. Lozenges (cough drops) can also help relieve
symptoms. If you have bronchitis, asthma, or COPD, your doctor might prescribe inhaled
respiratory medications.
68. @4. What is medium-bubbly wheezing, the mechanism of occurrence,

characteristic, diagnostic value?
69. @4. What is large-bubble wheezing, the mechanism of occurrence,

characteristics, diagnostic value?
70. @4. What is crepitation, types, mechanism of occurrence, characteristic,

diagnostic value?
Crepitation in the lungs refers to the sound and sensation associated with subcutaneous
emphysema, a condition in which air is trapped under the skin. It is characterized by the
palpable or audible popping, crackling, grating, or crunching sensation that can occur when air
is pushed through the soft tissue in the chest..
Types.. Fine are typically late inspiratory and coarse are usually early inspiratory.
Medium crackles are high pitched, very brief and soft. It sounds like rolling a strand of hair
between two fingers. ...
Coarse crackles are louder, more low pitched and longer lasting...
Occurence...
When air leaks out of the lungs, like with a collapsed lung, the air can collect in the
subcutaneous tissues of the neck and chest, causing subcutaneous emphysema. Crepitus occurs
when pressure is applied to the affected area, causing the trapped air to produce popping
sounds or a crackling sound...
Diagnosis..
using lung auscultation, which involves listening to lungs sounds with a stethoscop....
The healthcare provider will palpate, or apply pressure to the affected area, and a crackling
sound can sometimes be heard or felt.
71. What is pleural friction noise, mechanism of occurrence, characteristic,
diagnostic value?
Ans– the noise generated when the visceral and parietal layers of the pleura rub against each
other is known as pleural friction noise . It occurs due to the pathological changes which may
alter the physical properties of the pleural surfaces and the friction against one another
resulting in pleural rub noises.It may be caused by pleuritis , tuberculosis ,dry pleurisy ,pleurisy
with effusion and in the case of acute dehydration and also uremic intoxication After a short
time after coughing pleural friction sound does not change .When a stethoscope is pressed
tighter against the chest, the pleural friction sound is intensified. Pleural friction sound is heard
during both inspiration and expiration .if a patient moves his diaphragm in and out while his
mouth and nose are closed, the sound produced by the friction of the pleura due to the
movement of the diaphragm can be heard.
72. How to distinguish wheezing, crepitation and pleural friction noise among
themselves .
Ans – Wheezing is a high-pitched whistling sound produced by the fluttering of the airways
walls and fluid together.wheezes are heard all over the chest. wheeze is expiratory in nature,
but it can be inspiratory also.
Crepitation originates in the alveoli.and is the sound produced by many alveoli during their
simultaneous reinflation. It is a slight crackling sound that can be imitated by rubbing a lock of
hair. Crepitation is only heard during the height of inspiration. it does not change after
coughing.
Pleural friction noise is the noise generated when the visceral and parietal layers of the pleura
rub against each other. If a patient moves his diaphragm in and out while his mouth and nose
are closed, the sound produced by the friction of the pleura can be heard when the diaphragm
moves up and down with. A short time after coughing, the pleural friction sound does not
change. Pleural friction sound is heard during both inspiration and expiration.
73.What is a syndrome, list the main syndromes in respiratory diseases
Ans – a group of symptoms which consistently occur together, and are characterized by a set of
associated symptoms are known as syndromes.
In respiratory diseases syndromes are of 5 types mainly

1. Syndromes of bronchial LESIONS (bronchitic syndrome, bronchial obstruction syndrome,
bronchospasm syndrome; bronchiectatic syndrome, atelectasis syndrome)
2. SYNDROMES of the RESPIRATORY LUNG syndrome (focal seal lung tissue, massive syndrome
seal lung tissue, syndrome of disseminated lung lesions; syndrome of cavity in the lung
syndrome, emphysema)
3. SYNDROMES lesions of the PLEURA (dry pleurisy, syndrome of hydrothorax, pneumothorax

syndrome, syndrome hydropneumothorax)
4. SYNDROMES lesions of the VESSELS of the LUNGS (hemoptysis the syndrome, the syndrome
of lung hemorrhage)
5. SYNDROMES CHARACTERIZING the functional state of the LUNGS (respiratory failure

syndrome, pulmonary heart syndrome)
74.What are the complaints and what is revealed during examination,

palpation, percussion and auscultation in the syndrome of focal pulmonary
tissue compaction?
Ans – decrease in airiness of the tissue along with complaints of constant fever , dry cough,
rusty sputum , short breath and pain in the chest.during physical examination acrocyanosis ,
hyperemia of the face , forced position and affected part of chest is behind in breathing.on
palpation vocal fremitus and resistance is observed on affected part. Percussion sounds are dull
tympanic and auscultation reveals pleural friction rub and crepitation .
75.What are the complaints and what is revealed during the examination
(general and chest) in the first stage of the syndrome of lobular compaction of
lung tissue?
Ans -In the first stage or stage of onset an increased respiratory rate accompanied with pain
and affected side shows a lag or delay. It may be caused due to extensive serous exudation ,
vascular engorgement and rapid bacterial proliferation.
76.What are the complaints and what is revealed during examination (general
and chest) in stage II of the syndrome of lobular compaction of lung tissue
Ans – the second stage also known as stage of consolidation(lobar pneumonia)may show signs
of cough with a sharp pain affected side along with rusty sputum.cyanosis of lips and fingers is
present on examination and during high fever the face is flushed and patients nostril dilates on
inspiration. Dyspnea is present and the respiratory movements are diminished on the affected
side. Caused due to vascular congestion ,accumulation of fibrin and alveolar spaces filled with
inflammatory exudate.
77.What are the complaints and what is revealed during examination (general
and chest) in stage III of the syndrome of lobular compaction of lung tissue?
Ans -in the last stage the cyanosis and dyspnea disappears and the patient looks more
comfortable and the affected lung expands again.the resorption of the exudate occurs in the
stage of resolution.
78.What is revealed by palpation in the first stage of the syndrome of lobular

compaction of lung tissue?
Ans –on palpation pleural rub may be present and the fremitis may be slightly decreased or
normal
79.What is revealed by palpation in stage II of the syndrome of lobular

compaction of lung tissue?
Ans – on palpation diminished respiratory excursions , pleural rub is present . tactile fremitus is
increased.
80.What is revealed by palpation in the III stage of the syndrome of lobular

compaction of lung tissue ?
Ans - on palpation the tactile fremitus becomes less marked and and the findings become
normal like normal respiration and the absence of the pleural
81. @4. What is revealed during percussion in the first stage of the syndrome of
lobular compaction of lung tissue?
The amount of air in the lungs decreases incompression of the pulmonary tissue by the pleural
fluid (compression
atelectasis) above the fluid level; complete obstruction of the large
bronchus with a tumour and gradual resorption of air from the lungs below
the closure of the lumen (obstructive atelectasis). Clear pulmonary sounds

become shorter and higher (i.e. duller) in the mentioned pathological
conditions. If these conditions are attended by decreased tension in the elastic
elements of the pulmonary tissue, e.g. in the presence of compression or
obstructive atelectasis, the sound over the atelectatic zone becomes dull with
a tympanic tone. This sound can also be heard during percussion of a patient
with acute lobar pneumonia at its first stage, when the alveoli of the affected
lobe, in addition to air, contain also a small amount of fluid.A complete absence of air in the
entire lobe of the lung or its part
(segment) is observed in the following cases: (a) acute lobar pneumonia at
the consolidation stage, when the alveoli are filled with the inflammatory
exudate containing fibrin; (b) formation in the lung of a large cavity, which is
filled with the inflammatory fluid (sputum, pus, echinococcous cysts, etc.), or
heterogeneous airless tissue (tumour); (c) accumulation of fluid in the pleural
cavity (transudate, exudate, blood
82. @4. What is revealed during percussion in the II stage of the pulmonary
lobular compaction syndrome?
83. @4. What is revealed during percussion in the III stage of the pulmonary
lobular compaction syndrome?
84. @4. What is revealed during auscultation in the first stage of the syndrome
of lobular compaction of lung tissue?
85. @4. What is revealed during auscultation in the II stage of the lobular
compaction syndrome?
Decreased vesicular breathing can be due to inflammation and swelling
of the walls in a part of the lung and decreased amplitude of their vibration
during inspiration, which is characteristic of early acute lobar pneumonia.
During the second stage of this disease, the alveoli of the affected part of the
lung become filled with effusion and vesicular breathing becomes inaudible
over this region. Vesicular breathing can be decreased also in insufficient
delivery of air to the alveoli through the air ways because of their mechanical
obstruction (e.g. by a tumour). Air admission to the alveoli can be decreased
in patients with a markedly weakened inspiration phase (as a result of
inflammation of the respiratory muscles, intercostal nerves, rib fracture,
extreme asthenia of the patient and adynamia).
Vesicular respiration decreases also due to obstructed conduction of
sound waves from the source of vibration (alveolar walls) to the chest
surface, as, for example, in thickening of the pleural membranes or
accumulation of air or fluid in the pleural cavity. If the amount of fluid or air
in the pleural cavity is great, respiratory sounds are not heard. Conduction of
sound to the surface of the chest may be absent in atelectasis of the lung due
to complete obstruction of the lumen in the large bronchus.
86. @4. What is revealed during auscultation in stage III of the syndrome of
lobular compaction of lung tissue?
87. @4. What is compression and obturation atelectasis and the mechanism of
their occurrence.
•Compressive atelectasis is when fluid, air, blood or a tumor presses on alveoli from the
outside. Resorptive atelectasis happens when no new air can move into the alveoli (for
instance, there's a blockage). Contraction atelectasis is the result of lung scarring
•Compressive atelectasis may result after a diaphragmatic hernia, when a part of an organ from
the abdominal cavity goes into the chest cavity, near the lungs. Additionally, compressive
atelectasis may occur when there is fluid or air in the lungs, also known as pleural effusion or
pneumothorax.
•Obturative atelectasis (segmental or lobar).
Causes:
• closure of airing bronchus lumen by endobronchial tumour, foreign body,
compression from outside
Sings:
Dyspnea.
Asymmetric chest motions in respiration.
Weakened or disappearance of vocal fremitus in consolidation area.
At the initial stage of atelectasis (hypoventilation stage) when a small amount of
aired alveoli in the collapsed area is still kept, diminished vesicular breath sound may
be defined. In obturative atelectasis at the complete bronchus closure stage no breath
sounds are heard above airless zone. No breath sounds are also heard above tumour.
Bronchophony reveals sound transmission increase above pulmonary consolidation area
88. @4. What are the complaints and what is revealed during the examination
(general and chest) in the syndrome of obturation atelectasis?
Obturative atelectasis (segmental or lobar).
Causes:
Sings:
Dyspnea.

Bronchophony reveals sound transmission increase above pulmonary consolidation
89. @4. What is revealed by palpation in the syndrome of obturation

atelectasis?
90. @4. What is revealed in percussion with obturation atelectasis syndrome ?

complete obturation of the bronchial lumen a resorption atelectasis arises in the parenchyma
of the lungs consisting, as the name indicates, in resorption of the remaining air and collapse of
the parenchyma.
Causes:
Sings:
Dyspnea.
Bronchophony reveals sound transmission increase above pulmonary consolidation area
complete obstruction of the large
bronchus with a tumour and gradual resorption of air from the lungs below
the closure of the lumen (obstructive atelectasis). Clear pulmonary sounds
become shorter and higher (i.e. duller) in the mentioned pathological
conditions. If these conditions are attended by decreased tension in the elastic
elements of the pulmonary tissue, e.g. in the presence of compression or
obstructive atelectasis, the sound over the atelectatic zone becomes dull with
a tympanic tone. This sound can also be heard during percussion of a patient
with acute lobar pneumonia at its first stage, when the alveoli of the affected
lobe, in addition to air, contain also a small amount of fluid.
•Dullness to percussion over the involved area
•Elevation of lower border of lung unilaterally in obstructive atelectasis
91. @4. What is revealed during auscultation in the syndrome of obturation

atelectasis?
Obturative atelectasis:
Causes:
+closure of airing bronchus lumen by endobronchial tumour, foreign body, compression

from outside.
Symptoms:
+Dyspnea.
+Asymmetric chest motions in respiration.
+Weakened or disappearance of vocal fremitus in consolidation area.
At the initial stage of atelectasis (hypoventilation stage) when a small amount of aired alveoli in
the collapsed area is still kept, diminished vesicular breath sound may be defined. In obturative
atelectasis at the complete bronchus closure stage no breath
+Bronchophony reveals sound transmission increase above pulmonary consolidation

area
92. @4. What are the complaints and what is revealed during examination
(general and chest) with compression atelectasis syndrome?
Compressive atelectasis:
Causes:
• pneumothorax
•
pleural effusion syndrome
Signs:
• Dyspnea.
• Asymmetric chest motions in respiration.
• Increased vocal fremitus in consolidation area.
• The tympanic
compressive atelectasis development when alveoli still contain air and
communication with adductor bronchus is kept. Further, upon complete air resorption
percussion note becomes flat.
• Vesicular breath
bronchophony increase
extending on periphery through consolidated drawn in pulmonary area (in the case of
compressive atelectasis, e.g. lung compression from outside
93. @4. What is revealed by palpation in compression atelectasis syndrome?
94. @4. What is revealed in percussion with compression atelectasis syndrome?

Percussion ofcompression atelectasis syndrome:
Dullness to percussion over the involved area. Diminished or absent breath sounds.
Reduced or absent chest excursion of the involved hemithorax. Deviation of trachea and heart
toward the affected side.
95. @4. What is revealed during auscultation in compression atelectasis

syndrome?
Compressive atelectasis (pulmonary [lung] collapse) syndrome.
Causes:
• pneumothorax
• pleural effusion syndrome
Sings:
• Dyspnea.
• Asymmetric chest motions in respiration.
• Increased vocal fremitus in consolidation area.
• The tympanic
communication with adductor bronchus is kept. Further, upon complete
air resorption percussion note becomes flat.
• Vesicular breath
bronchophony increase
extending on periphery through consolidated drawn in pulmonary area (in
the case of compressive atelectasis, e.g. lung compression from outside)
Fig.5. Compressive atelectasis at the left side (lung compression from outside by
28
pleural effusion syndrome

fremitus in consolidation area.
percussion note is defined at the initial stage of
air resorption percussion note becomes flat.
Vesicular breath sound changes into bronchial breat
bronchophony increase: patent bronchus passes bronchial breath sound
extending on periphery through consolidated drawn in pulmonary area (in
the case of compressive atelectasis, e.g. lung compression from outside)
Compressive atelectasis at the left side (lung compression from outside by
the fluid – exudates).
percussion note is defined at the initial stage of
bronchial breath sound
96. @4. What are transudate and exudate and how do they differ from each
other?
Transudates:
• Malfunctioning membranes causes fluid accumulates in the body
cavities.
• This fluid is referred to as a transudate.
• Regulation of amount of fluid in these cavities is done by the

lymphatic system.
• Malfunctioning of membranes cause transudate formation due to a
disease process in an organ or the lymphatic sysem.
• Mechanism- disrupt the balance between the formation and its
uptake by the lymphatic system causing fluid accumulation in one
side of the membrane.
Exudates:
• An exudate is a fluid with a high content of protein and cellular debris
which has escaped from blood vessels and has been deposited in
tissues.
• Cellular material-tumour cells or foreign materials such as bacteria,
viruses, parasites, fungi.
• Infection/ cancer- inflammatory response recruit large number of
white blood cells to the site.
• As a result exudate forms. Thus, cells (both leukocytes and foreign
material) and their metabolites fill the cavity in the organ.
(general and chest) with pneumothorax syndrome?
Pneumothorax Syndrome:
A pneumothorax is a collapsed lung. A pneumothorax occurs when air leaks into the
space between your lung and chest wall. This air pushes on the outside of your lung and makes
it collapse. A pneumothorax can be a complete lung collapse or a collapse of only a portion of
the lung.
+A pneumothorax can be caused by a blunt or penetrating chest injury, certain medical
procedures, or damage from underlying lung disease. Or it may occur for no obvious reason.
Symptoms usually include sudden chest pain and shortness of breath. On some occasions, a
collapsed lung can be a life-threatening event.
+Treatment for a pneumothorax usually involves inserting a needle or chest tube between
the ribs to remove the excess air. However, a small pneumothorax may heal on its own.
+In general, men are far more likely to have a pneumothorax than women are. The type
of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20
and 40 years old, especially if the person is very tall and underweight.
Other risk factors:
Smoking -The risk increases with the length of time and the number of cigarettes smoked, even
without emphysema.
Genetics - Certain types of pneumothorax appear to run in families.
Previous pneumothorax - Anyone who has had one pneumothorax is at increased risk of
another.
98. @4. What is revealed during palpation with pneumothorax syndrome?

Percussion of pneumothorax :
An area of hyperresonance on one side of the chest may indicate a pneumothorax.

Tympanic sounds are hollow, high, drumlike sounds
99. @4. What is revealed by percussion in pneumothorax syndrome?

Percussion of pneumothorax:
The percussion sound on the affected side has an exaggerated, resonant and booming
quality. The percussion note is exaggerated partly because a stethoscope is used and partly
because, in the supine patient, air localizes upwards to the anterior thorax
100. @4. What is revealed during auscultation in pneumothorax syndrome?

A pneumothorax can be defined as air in the pleural cavity.This occurs when there is a breach of
the lung surface or chest wall which allows air to enter the pleural cavity and consequently
cause the lung to collapse
(101)What are the complaints and what is revealed during examination(general

and chest) with fluid accumulation syndrome in the pleural cavity?
Pleural effusion is an abnormal, excessive collection of this fluid in the pleural cavity.
There are two types of pleural effusion:
Transudative pleural effusion is caused by fluid leaking into the pleural space. This is from
increased pressure in the blood vessels or a low blood protein count. Heart failure is the most
common cause.
Exudative effusion is caused by blocked blood vessels or lymph vessels, inflammation, infection,
lung injury, or tumors.
Complaints
Chest pain, usually a sharp pain that is worse with cough or deep breaths
Cough
Fever and chills
Hiccups
Rapid breathing
Shortness of breath
Restrictive types of ventilation disorders occurs due to the decrersed ability of lung to expand
and collapse.
Examination
*Physical findings are signs of volume gain, reduced tactile vocal fremitus, dullness on
percussion, shifting dullness, and diminished or absent breath sounds. Shifting dullness will be
absent with massive and loculated effusions. Massive pleural effusions present with respiratory
embarrassment and signs of mediastinal shift. Other findings may be related to associated
systemic disease.
*The topographic percussion of lungs reveals unilateral lowering of lower border of lungs.The
accumulation of fluid in pleural cavity can displace the lungs upwards and medially towards the
root.
*Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen
carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation,
originating from lung which is compressed by the fluid pushing up from below.Breath sound
decreased or absent;bronchial breath sounds and bronchophony,egophony and whispered
pectoriloquy may be heard over the area of the lung that is compressed near the effusion.
*Pathological bronchial respiration occurs in such cases.
(102)What is revealed during palpation with fluid accumulation syndrome in the

pleural cavity?
During the accumulation of fluid in the pleural cavity of lungs, palpation is performed as a part
of examination which reveals:
*tactile fremitus decreased or absent.
*chest expansion decreased on the affected side.
*tracheal shift away from affected side
*Massive pleural effusions present with respiratory embarrassment and signs of mediastinal
shift. Other findings may be related to associated systemic disease.
*palpable liver or spleen due to diaphragmatic depression
*Protrusion of the intercostal spaces,assymetry of clavicles and shoulder blades and unilateral
thoracic lagging can be observed.
*Rigidity of chest.
*Vocal fremitus become weaker
(103)What is revealed by percussion in the syndrome of accumulation of fluid in

the pleural cavity?
Percussion of lungs in pleural effussion shows:
*unilateral lowering of lower border of lungs.
*The accumulation of fluid in pleural cavity can displace the lungs upwards and medially
towards the root.
*Dullness to percussion up to the level of the scapula and axilla.
*Dullness to percussion over the entire hemithorax.
*Mild bulging of intercostal spaces.
(104)What is revealed during auscultation with syndrome of accumulation of

fluid in the pleural cavity?
*Auscultation over a pleural effusion will produce a very muffled sound
*If you listen carefully to the region on top of the effusion, you may hear sounds suggestive of
consolidation, originating from lung which is compressed by the fluid pushing up from below.
*Breath sound decreased or absent
*bronchial breath sounds and bronchophony,egophony and whispered pectoriloquy may be

heard over the area of the lung that is compressed near the effusion.
*Decreased or absent fremitus posteriorly and laterally.
*Hyppocratic sound and gutta cadens can be heard in some cases due to fluid accumulation.
(105)What are the complaints and revealed during examination(general and

chest) with lung cavity syndrome?
A lung cavity or pulmonary cavity is an abnormal, thick-walled, air-filled space within the lung.
[1] Cavities in the lung can be caused by infections, cancer, autoimmune conditions, trauma,
congenital defects
[2] Due to pulmonary embolism.
[3] The most common cause of a single lung cavity is lung cancer.
[4] Bacterial, mycobacterial, and fungal infections are common causes of lung cavities.
[5] Globally, tuberculosis is likely the most common infectious cause of lung cavities.
[6] Less commonly, parasitic infections can cause cavities.[5] Viral infections almost never cause
cavities.
[7] The terms cavity and cyst are frequently used interchangeably; however, a cavity is thick
walled (at least 5 mm), while a cyst is thin walled (4 mm or less).
[8] The distinction is important because cystic lesions are unlikely to be cancer, while cavitary
lesions are often caused by cancer.
Main complaints can be
[1]recent onset of fever and productive cough suggest an infection, while a chronic cough,
fatigue, and unintentional weight loss suggest cancer or tuberculosis.
[2] Symptoms of a lung cavity due to infection can include fever, chills, and cough.
[3] Knowing how long someone has had symptoms for or how long a cavity has been present on
imaging can also help to narrow down the diagnosis.
[4] If symptoms or imaging findings have been present for less than three months, the cause is
most likely an acute infection; if they have been present for more than three months, the cause
is most likely a chronic infection, cancer, or an autoimmune disease.
The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation
of respiratory sounds, normally first carried out from the back of the chest.
Physical exam findings are unequal breath sounds, hyperresonance with percussion over the
chest wall, and decreased wall movement on the affected side of the chest.
The chest wall should be palpated and any crepitance or signs of trauma should be noted.
vital sign abnormalities may include tachycardia, tachypnea, hypoxia and hypotension,
depending on the severity .
A chest x-ray should be ordered early in the evaluation of a patient .
If the patient is unstable, however, and a tension pneumothorax is suspected, proceed directly
to treatment without waiting for the radiograph.
When unidentified for a long time can lead to pneumothorax.

(106)What is revealed during palpation with lung cavity syndrome?
A lung cavity or pulmonary cavity is an abnormal, thick-walled, air-filled space within the lung.
Cavities in the lung can be caused by infections, cancer, autoimmune conditions, trauma,
congenital defects.
Palpation with lung cavity syndrome shows:
*tactile fremitus decreased or absent.
*tracheal shift to the unaffected side of the chest.
*chest expansion decreased on the affected side.
*The chest wall when palpated shows crepitance or signs of trauma.
*Protrusion of the intercostal spaces,assymetry of clavicles and shoulder blades and unilateral
thoracic lagging can be observed.
*Vocal fremitus become weaker
(107)What is revealed by percussion with lung cavity syndrome?

The organs lying below the percussed area begins vibrating ang transmit the vibrations as
sound waves.
*When filled with air, loud sounds can be heard.These sounds may differ in strength,pitch and
tone.
*Resonant or clear sound can be heard during the percussion of a healthy lungs.
*If lung contain excess air, it gives bandbox sound.
*Tympanic sound resemble the sound of a drum,which can be heard in lung cavity syndrome.
*Tympanic sound can be dull or loud depending on the amount of air filled in the cavity.
*Unilateral elevation of lower border of lungs.
*Decrease in the respiratory mobility of lower border of lungs.
(108))What is revealed by auscultation with lung cavity syndrome?

Auscultation of the lung is an important part of the respiratory examination and is helpful in
diagnosing various respiratory disorders.
Amphoric Breath Sound
*It is a low pitch bronchial breath sound with high pitch overtones.
*It has a metallic character.
*Amphoric breathing can be produced by blowing over the mouth of an empty glass or clay jar.
*Greek word amphoreus means jar so it is called amphoric breathing.
*It occurs in the presence of a superficial large cavity (not less than 5-6 cm in diameter) with
patent bronchi and open pneumothorax.
*Smooth wall is also a requirement as it is capable of reflecting sound.
*High pitch overtones occur because of strong resonance of sound waves within cavity wall or
pleural cavity.
Decreased vesicular breathing can be heard as walls become incapable of quick distension.
Pathological bronchial breathing of cavitary type heard due to cavity in lungs.
In complications, metallic respiration can be heard.It is a loud and high sound, resemble sound
of metal when struck.
(109))What are the complaints and what is revealed during examination(general

and chest) with hyper airiness syndrome in the lungs?
Hyperinflated lungs occur when air gets trapped in the lungs and causes them to overinflate.
Hyperinflated lungs can be caused by blockages in the air passages or by air sacs that are less
elastic, which interferes with the expulsion of air from the lungs.
Hyperinflated lungs are often seen in people with chronic obstructive pulmonary disease
(COPD) — a disorder that includes emphysema. Certain lung problems, such as asthma and
cystic fibrosis, also can cause hyperinflation.
Hyperinflated lungs complaints;
Difficulty inhaling
Struggling to breath
Shortness of breath
Fatigue
Low energy
Examination includes involves a physical exam, a review of your medical history, and imaging
tests.
As part of the physical exam, the doctor will listen for strange breath sounds with a
stethoscope, including those indicating valve regurgitation or a heart murmur. A person with
hyperinflated lungs may also have a "barrel chest" in which the chest appears inflated all the
time.
Lung hyperinflation can be detected with imaging tests, including:
Chest X-rays, which provide detailed images of the lungs, heart, and airways
Computed tomography (CT) scan, which composites multiple X-ray images to create three-
dimensional "slices" of the chest cavity
Echocardiogram, use to check for problems with the heart.
(110)what is revealed during palpation with hyper airiness syndrome in the

lungs?
When examining the chest by the method of palpation:
Emphysematous type of chest is determined
Barrel shape
Expansion of intercostal spaces
Clearly defined the angle of Louis
The epigastric angle is obtuse
The ribs in horizontal direction
The breath is actively involved auxilary respiratory muscles

Vocal fremitus is decreased
On examination of chest with a stethoscope, it will be noted that there is either decreased or
absent breath sound over the area of affected lung ,which may indicate that the lung is not
inflated in the particular area
111. @4. What is revealed with percussion in the syndrome of hyper-airiness of

the lungs?
Syndrome of increased airiness of lung tissue (emphysema)
REASONS: It occurs in COPD, bronchial asthma; as a result of involutional changes; the outcome
of many chronic lung diseases; emphysema
SYMPTOMS:Dyspnea of an expiratory character, patients exhale with closed lips, puffing out
their cheeks (puff - "pink puff");Cyanosis, puffiness of the face ("blue swelling");The chest is
barrel-shaped;The amplitude of the respiratory excursion of the lungs is reduced. Often,
auxiliary muscles are involved in the act of breathing;The weakening of voice trembling and
increased resistance of the chest are palpated;In comparative percussion - box sound;With
topographic percussion, the expansion of the boundaries of the lungs, both up and down,
restriction of respiratory excursion of the lungs;Difficulties in determining the percussion
boundaries of the heart, reducing the zone of absolute dullness of the heart.Tachycardia (in
response to hypoxia);During auscultation, weakened vesicular, so-called "cotton" breathing is
heard. The nature of breathing changes depending on the disease leading to emphysema or a
concomitant process;Radiologically determined increased transparency of the pulmonary fields,
decreased diaphragm mobility, low diaphragm position, horizontal position of the ribs;A
spirographic study reveals: a decrease in lung capacity (VC) and maximum pulmonary
ventilation (MLV), as well as an increase in residual volume
112. @4. What is revealed with auscultation in the syndrome of hyper-airiness

of the lungs?
Succusion (Hippocratic) sound. This is the splashing sound heard in
the chest of a patient with hydropneumothorax, i.e. when serous fluid and air
are accumulated in the pleural cavity. The sound was first described by
Hippocrates, hence the name. The sound can be identified by auscultation:

the physician presses his ear against the chest of the patient and then shakes
the patient suddenly. The splashing sounds are sometimes heard by the
patient himself during abrupt movements.
The so-called falling-drop sound (gutta cadens) can be heard by
auscultation. It can occur in large cavities of the lungs or at the base of the
pleural cavity which contain liquid pus or air as the patient changes his
posture from recumbent to upright position or vice versa. Tenacious liquid
containing pus sticks to the surface of the cavity and as the patient changes
his position it gathers in drops which fall one after another into the liquid
(sputum or pus) accumulated at the bottom.On auscultation the diminished vesicular breath
sounds are determined
113. @4. What are the main complaints made by patients with diseases of the
cardiovascular system?
Patients with diseases of the heart usually complain of dyspnea, i.e.
distressing feeling of air deficit. Dyspnea is a sign of the developing circula-
tory insufficiency, the degree of dyspnea being a measure of this
insufficiency.
Attacks of asphyxia, which are known as cardiac asthma, should be
differentiated from dyspnea. An attack of cardiac asthma usually arises
suddenly, at rest, or soon after a physical or emotional stress, sometimes
during night sleep. It may develop in the presence of dyspnea
Patients often complain of palpitation. They feel accelerated and
intensified heart contractions. Palpitation is determined by the increased
excitability of the patient's nerve apparatus that controls heart activity.
Palpitation is a sign of affection of the heart muscle in cardiac diseases such

as myocarditis, myocardial infarction, congenital heart diseases, etc.,
Some patients complain of intermissions (escaped beats) which are
due to disorders in the cardiac rhythm. Intermissions are described by the
patient as the feeling of sinking, stoppage of the heart.
Pain in the heart region is an important and informative sign. The
character of pain is different in various diseases of the heart. The physician
should determine (by questioning) the location of the pain, the cause or
condition under which it develops .Pain often develops due to acute insufficiency of the
coronary circulation, which results in myocardial ischemia. This pain
syndrome is called stenocardia or angina pectoris.
Patients with heart diseases often complain of cough which is due to
congestion in the lesser circulation. The cough is usually dry; sometimes a
small amount of sputum is coughed up. Dry cough is also observed in aortal
aneurysm because of the stimulation of the vagus nerve.
Patients with cardiovascular pathology often have dysfunction of the
central nervous system, which is manifested by weakness, rapid fatigue,
decreased work capacity, increased excitability, and deranged sleep.
Complaints of headache, nausea, noise in the ears or the head are not
infrequent in essential hypertension patient
114. @4. Causes of pain in the heart region?

Pain in the heart region is an important and informative sign. The
character of pain is different in various diseases of the heart. Pain often develops due to acute
insufficiency of the
coronary circulation, which results in myocardial ischemia. This pain

syndrome is called stenocardia or angina pectoris. In angina pectoris pain is
retrosternal or slightly to the left of the sternum; it most commonly radiates to
the region under the left scapula, the neck, and the left arm. Pain is especially intense in
myocardial infarction and, unlike in angina
pectoris, it persists for a few hours, and sometimes for several days. It does
not abate after vasodilatory preparations are given. Pain in dissecting
aneurysm of the aorta is piercing (like in myocardial infarction). Unlike in
myocardial infarction, pain radiates usually to the spinal column, and moves
gradually along the course of the aorta. Myocarditis is characterized by
intermittent and pressing pain; it is dull, mild, and is intensified during
exercise. Pain in pericarditis is located at the middle of the sternum or
throughout the entire cardiac region; the pain is stabbing or shooting, and is
intensified during movements, cough, even under the pressure of a
stethoscope; the pain may persist for several days or arise in attacks.
Permanent pain behind the manubrium sterni that does not depend on
exercise or emotional stress (the so-called aortalgia) occurs in aortitis.
Stabbing pain at the heart apex that arises in emotional stress or fatigue is characteristic of
cardioneurosis. It should be remembered that pain in the
cardiac region may arise due to affections of intercostal muscles, nerves,
pleura, or the-adjacent organs (diaphragmatic hernia, cholecystitis, ulcer,
gastric cancer)
115. @4. Causes of palpitations.

Patients often complain of palpitation. They feel accelerated and
intensified heart contractions. Palpitation is determined by the increased
excitability of the patient's nerve apparatus that controls heart activity.

Palpitation is a sign of affection of the heart muscle in cardiac diseases such
as myocarditis, myocardial infarction, congenital heart diseases, etc., it may arise as a reflex in
diseases of some other organs, in fever, anemia, neurosis,
hyperthyroidism, and after administration of some medicinal preparations
(atropine sulphate, etc.). Palpitation may also occur in healthy persons under
heavy physical load, during running, emotional stress, smoking or coffee
abuse. Patients with serious heart diseases may feel palpitation constantly, or
it may arise in attacks of paroxysmal tachycardia
116. @4. What is "heart failure" when they appear and the mechanism of their
occurrence?
Heart failure — sometimes known as congestive heart failure — occurs when the heart muscle
doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can
build up in the lungs, causing shortness of breath.
Certain heart conditions, such as narrowed arteries in the heart (coronary artery disease) or
high blood pressure, gradually leave the heart too weak or stiff to fill and pump blood properly.
Heart failure can be ongoing (chronic), or it may start suddenly (acute).
Heart failure signs and symptoms may include:
Shortness of breath with activity or when lying down
Fatigue and weakness
Swelling in the legs, ankles and feet
Rapid or irregular heartbeat.
Heart failure often develops after other conditions have damaged or weakened the heart.
However, heart failure can also occur if the heart becomes too stiff.
In heart failure, the main pumping chambers of the heart (the ventricles) may become stiff and
not fill properly between beats. In some people, the heart muscle may become damaged and
weakened. The ventricles may stretch to the point that the heart can't pump enough blood
through the body.
Over time, the heart can no longer keep up with the typical demands placed on it to pump
blood to the rest of the body.
Any of the following conditions can damage or weaken your heart and can cause heart failure.
1. Coronary artery disease and heart attack.
2.High blood pressure.
3. Faulty heart valves.
Mechanism
Heart failure begins after an index event produces an initial decline in pumping capacity of the
heart. After this initial decline in pumping capacity of the heart, a variety of compensatory
mechanisms are activated, including the adrenergic nervous system, the renin-angiotensin
system, and the cytokine system.
117. @4. Types of shortness of breath, causes and mechanism of its occurrence
in diseases of the cardiovascular system.
Types of shortness of breath or dyspnoea -
1. Orthopnea - it is the sensation of dyspnoea in the recumbent position, relieved by sitting or

standing.
2. Paroxysmal nocturnal dyspnea (PND) - it is a sensation of dyspnoea that awakens the patient,
often after 1 or 2 hours of sleep, and is usually relieved in the upright position.
3. Trepopnea - it is a sensation of dyspnoea that occurs in one lateral decubitus position as

opposed to the other.
4. Platypnea - it is a sensation of dyspnoea that occurs in the upright position and is relieved
with recumbency.
Cardiac causes of shortness of breath include -
1. Cardiac arrhythmias
2. Acute and chronic heart failure
3. Acute coronary syndrome
4. Valvular disease
5. Cardiomyopathy
6. Constrictive pericarditis
Mechanism of shortness of breath -
Increase in pulmonary venous pressure due to cardiac diseases leads to increase in hydrostatic
pressure leading to leakage
of fluid into the interstitium. This causes first interstial edema,
and in more severe cases to frank pulmonary edema causing respiratory distress, leading to
dyspnoea
118. @4. Causes and mechanism of cough and hemoptysis in heart diseases.
The reason for cardiac cough is the heart failure, which is typical of many cardiovascular
system’s diseases and pathological conditions like -
Heart attack
angina pectoris
ischemic heart disease
hypertension
various arrhythmias
myocarditis
heart defects
Mitral valve disease

In heart failure, the heart doesn't pump blood efficiently. It's often tied to a cardiac cough.
Heart failure causes fluid retention, which can lead to a buildup of fluid in the lungs. This fluid
triggers a cough as the body tries to clear it out.
Of the cardiovascular causes of haemoptysis, the most important is the chronic
pulmonary congestion secondary to mitral stenosis. In such a case, the
haemoptysis may vary from blood-stained sputum to a profuse haemorrhage. Aneurysm of the
ascending aorta may also cause haemoptysis by pressure and
ultimately weeping through a bronchus but such cases are rarely seen
119. @4. What can be seen in pathology during a general examination in

diseases of the cardiovascular system?
Cyanotic skin is a common sign of heart diseases. In patients with
circulatory disorders, cyanosis is more pronounced in parts of the body that
are farther remoted from the heart, i.e. the fingers and toes, the tip of the
nose, the lips, and the ear lobes. This phenomenon is known as acrocyanosis.
It depends on the increased content of reduced hemoglobin in the venous
blood because of excessive oxygen absorption by tissues in slow blood
circulation.
The colour of the skin is important for diagnosis of some heart
diseases. Mitral stenosis can be diagnosed by the violet-red colour of the
patient's cheeks, mildly cyanotic colour of the lips, nose, and extremities
("facies mitralis").
The skin and visible mucosa of patients with aortal heart diseases are
usually pale. Cyanosis in combination with paleness (pallid cyanosis) is

characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis
of the pulmonary artery. Icteric colour of the sclera and skin is characteristic
of grave circulatory insufficiency. The skin of patients with persisting septic
endocarditis has a peculiar colour resembling that of coffee with milk.
Edema frequently attends heart diseases. If the patient stays out of bed,
edema is localized mainly in the malleolus, the dorsal side of the feet, and the
shins, where a pressure of fingers leaves slowly leveling impressions. If the
patient lies in bed, edema is localized in the sacrolumbar region.
Local edema sometimes develops in cardiovascular pathology. When
the superior vena cava is compressed, for example in exudative pericarditis or
aneurysm of the aortal arch, the face, neck, and the shoulder girdle can be
affected by edema (“the collar of Stokes”).
The shape of the nails and distal phalanges of the fingers is
informative. Drum-stick (Hippocratic) fingers are characteristic of subacute
septic endocarditis and some congenital heart diseases
120. @4. What types of forced situations can be observed in diseases of the
cardiovascular system?
. Complications of heart failure -
1. Renal failure is caused by poor renal perfusion due to low cardiac output.
2. Hypokalemia or hyperkalemia, hyponatremia
3. Impaired liver function is caused by hepatic venous congestion and poor atrial perfusion.
4. Thromboembolism, due to low cardiac output and enforced immortality.
5. Atrial and ventricular arrhythmias due to electrolyte changes and pro-arrhythmic effect of
sympathetic activation.
121. @4. How and when can the color of the skin change in diseases of the
cardiovascular system
The vagotonic reflexes:
1) Goltz reflex - a slight tapping on the frog's stomach and intestines causes the arrest or a
slowdown in heart contractions.

2) Ashner's (ocular-cardiac )reflex: decrease in heart rate by 10-20 beats per minute after
pressing on the eyeballs.
122. @4. Revealing features of cardiac edema and the mechanism of their
occurrence
The sympathicotonic reflex:

Bainbridge reflex - increasing of pressure in the right atrium or in the vena cava leads to
excitation of mechanoreceptors . Volleys of afferent impulses from these receptors lead to the
activation of neurons in the sympathetic division of the ANS and tachycardia occurs due to high
impact of sympathetic nerve on the heart.
. 123. @4. What can be seen in the norm and what about pathology when
examining the heart area?
Tone of cardiac nerve centers:
When transection of the vagus nerve, there is an increase in heart rate from 70-80 beats / min
to 130-140 beats / min.
This result indicates that the nucleus of the vagus nerve has a tone, that is in constant
excitation.
When the sympathetic nerve is transected the heart rate remains practically unchanged.
This result indicates that the center of the sympathetic nerve of the heart does not have tone. A
newborn child has no vagus tone, so his heart rate reaches 140 beats / min
124. @4. What is a heart hump, the causes and mechanism of its occurrence?
Tachycardia (tak-ih-KAHR-dee-uh) is the medical term for a heart rate over 100 beats a minute.
Many types of irregular heart rhythms (arrhythmias) can cause tachycardia.
Tachycardia can also be caused by an irregular heart rhythm (arrhythmia).
A fast heart rate isn't always a concern. For instance, the heart rate typically rises during
exercise or as a response to stress.
Symptoms:
Sensation of a racing, pounding heartbeat or flopping in the chest (palpitations)
Chest pain
Fainting (syncope)
Lightheadedness
Rapid pulse rate
Shortness of breath
Causes:
Fever
Heavy alcohol use or alcohol withdrawal

High levels of caffeine
High or low blood pressure
Imbalance of substances in the blood called electrolytes — such as potassium, sodium, calcium
and magnesium
Medication side effects
Overactive thyroid (hyperthyroidism)
Prevention;
1.Get regular exercise
2.Eat a healthy diet.
3.Maintain a healthy weight.
4.Keep blood pressure and 5.cholesterol under control
6.Don't smoke.
7.If you drink, do so in 8.moderation
9.Manage stress.
10.Go to schedule checkup
125. @4. What is a heart attack when it happens normally, the reasons for its
appearance in pathology?
Bradycardia (brad-e-KAHR-dee-uh) is a slow heart rate. The hearts of adults at rest usually beat
between 60 and 100 times a minute. If you have bradycardia, your heart beats fewer than 60
times a minute.
Bradycardia can be a serious problem if the heart rate is very slow and the heart can't pump
enough oxygen-rich blood to the body. If this happens, you may feel dizzy, very tired or weak,
and short of breath. Sometimes bradycardia doesn't cause symptoms or complications.
Symptoms:
A slower than typical heartbeat (bradycardia) can prevent the brain and other organs from
getting enough oxygen, possibly causing these signs and symptoms:
Chest pain
Confusion or memory problems
Dizziness or lightheadedness
Easily tiring during physical activity
Fatigue
Fainting (syncope) or near-fainting
Shortness of breath
Causes
A typical heartbeat
Typical heartbeatOpen pop-up dialog box
Bradycardia can be caused by:
Heart tissue damage related to aging
Damage to heart tissues from heart disease or heart attack
A heart condition present at birth (congenital heart defect)
Inflammation of heart tissue (myocarditis)
A complication of heart surgery
An underactive thyroid gland (hypothyroidism)

Prevention;
1.Get regular exercise
2.Eat a healthy diet.
3.Maintain a healthy weight.
4.Keep blood pressure and 5.cholesterol under control
6.Don't smoke.
7.If you drink, do so in 8.moderation
9.Manage stress.
10.Go to schedule checkup
126. @4. What is the apical shock, its properties and their characteristics are
normal?
Asynchronous is muscle that contracts more than once per nerve impulse. Asynchronous
muscle appears in an insect's flight muscles as the wings need to flap at high frequencies.
Despite these disadvantages, asynchronous muscles are beneficial for high frequency
oscillations. They are more efficient than synchronous muscles because they do not require
costly calcium regulation. This allows for changes in their macroscopic structure for increased
force production
Some isometric exercises develop tension by holding the body in a certain position, while
others may involve holding weights. Holding the muscle contraction allows the muscle tissue to
fill with blood and create metabolic stress on the muscle. This can help improve strength and
endurance
127. @4. What is the "Musset symptom", the mechanism of occurrence and the
cause of occurrence?
The aorta is a compression chamber because it is an important drive for diastolic perfusion. To
keep the blood flowing constantly, and not only during systole (as would be the case with a
rigid aorta), the high elasticity of the aortic walls allows it to dilate as a consequence of the high
systolic pressure. This allows the aorta to accumulate blood in its proximal part, which is then
propelled by the passive elastic contraction of the aorta during diastole.
128. @4. Cardiac and non-cardiac causes of displacement of the apical shock to
the left and down.
Basal vascular tone is regulated by the complex balance between endogenous vasodilators and
vasoconstrictors. A blunted response to vasoconstrictors, therefore, could also contribute to
vasodilation and, subsequently, hyperdynamic flow.
Ion channels in the plasma membrane of vascular muscle cells that form the walls of resistance
arteries and arterioles play a central role in the regulation of vascular tone.
129. @4. The causes of the displacement of the apical push up and to the left,
down and to the right
Vascular tone, the contractile activity of vascular smooth muscle cells in the walls of small
arteries and arterioles, is the major determinant of the resistance to blood flow through the
circulation.
. 130. @4. Types of changes in the area of the apical shock and the causes of
their occurrence
Blood pressure is measured using two numbers: The first number, called systolic blood
pressure, measures the pressure in your arteries when your heart beats. The second number,
called diastolic blood pressure, measures the pressure in your arteries when your heart rests
between beats.
Normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a
diastolic pressure of less than 80.6 days ago
131. Cardiac tremor, definition, method of definition, mechanism of

occurrence, types.
 Cardiac tremor are feeling of having a fast beating, fluttering or pounding
heart.
 Stress, exercise, medication or rarely a medical condition can trigger them.
 It can be a symptom of heart arrhythmia, that might require treatment.
 It can be defined as hear beating too fast, flip- flopping, flittering rapidly,
pounding or skipping beats.
 It maybe felt in the throat or neck as well as the chest.
 They can occur during activity or rest.
 The three common description of heart palpitation are flip flopping, often
caused by premature contraction of the atrium or ventricle.
 Rapid fluttering in the chest suggest supraventricular or ventricular
arrhythmias and irregular fluttering suggest atrial fibrillation, atrial flutter or
tachycardia with variable block.
 Pounding in the neck is due to canon A waves in the jugular venous,
pulsation that occurs when the right atrium contracts against a closed
tricuspid valve.
132.Rules of percussion of HEART.

 cardiac percussion is performed starting at the very left of the chest and
percussing from resonance towards cardiac dullness in the 3rd, 4th and 5th
and perhaps 6th interspaces, from left axillary to right axillary lines.
 Normal cardiac percussion should show dullness to percussion from the
sternum to approximately 6cm lateral to the left of the sternum.
 Percussion is especially useful when the point of maximal impulse (pmi),
also known as the apical impulse, cannot be felt where the apex of the
heart is located.
 The pmi will best be located with a patient in the supine position, near the
5th or possibly 4th interspace along the mid clavicular line.
 The pmi if felt will be accentuated in the left lateral decubitus position
since this position displaces the apical impulse towards the left.
 Location, amplitude and duration of the impulse should be noted at this
point.
 When the apical points cannot be palpated percussion can be a useful
option.
 Under these circumstances, cardiac dullness can occupy a large area,
especially if there is a large pericardial effusion making the impulse
undetectable.
 The order of percussion is aortic, pulmnic, tricuspid and mitral.
133. what is relative dullness of heart(RDH). The boundries of RDH.

 RDH is the projection of the anterior surface onto the chest.
 The relative cardiac dullness is displaced due to the dilation of the
chambers of the heart.
 Rdh is related to the percussion of the heart.
 Defining of the borders of relative cardiac dullness: at first the right, left,
and upper borders of relative cardiac- dullness are defined.
 The right border of RDH , formed by the right atrium is found by percussing
one rib above the found lower lung border(usually in the 4th inter costal
space), moving vertically placed pleximeter finger strictly along the inter
costal space. Normally it is situated at the right sternum edge or 1 cm
laterally.
 The left border of RDH:formed by the left ventrical is defined after the
preliminary palpitation of the apical impulse usually at the v inter costal
space, moving from the anterior axillary line towards the heart. Normally it
is situated medial to the mid clavicular line for 1-2 cm.
 The upper border of RDH:formed by auricle of left atrium and pulmonary
artery trunk is defined by percussing from top to bottom, 1 cm lateral from
sternal line( but not along left para sternal line). Normally it is situated at
the third rib level.
134. what is absolute dullness of heart(ADH). ADH borders

 Absolute dullness of heart is the projection of the anterior surface of the
heart, which is not covered by the lungs on to the chest.
 Normal border of absolute cardiac dullness: right- in the 4th inter costal
space along the left edge of the sternum
 The upper-level of the lower edge of 4th rib. At the left parasternal line.
 Left- 1-2 cm medially from the left border of relative cardiac dullness In the
5th intercostals space.
 Right- in the 4th inter costal space along the left edge of the sternum, the
upper level of the lower edge 4th rib.
 The boundry of ADH decreases due to low diaphragm level, pulmonary
emphysema, left sided pneumothorax.
 It increases due to pregnancy, high diaphragm level, midiastinal tumors,
hypertrophy/ dilation of the right ventrical.
135. Where is the normal and which part of the heart forms the right
border of the relative dullness of the heart.
 On topographic percussion, the right border of the heart is determined in
the 4th intercostal space 1.5 cm outwards of the right edge of the sternum.
 Upper border is determined in the third intercostal space on the left of the
para sternal line
 The left border is determined in the 5th intercostals space 1-2 cm medially
from the left midclavicular line.
 Vascular bundle width is 6 cm
 Diameter of heart is 13 cm, this is the normal configuration of the heart.
laterally.
136. Where is the norm and which part of the heart forms the upper
limit of the upper limit of the relative dullness of the heart?
para sternal line
laterally.
137.Where is the normal and which part of the heart forms the left
border of the relative dullness of the heart?
para sternal line
 The left border of RDH:formed by the left ventrical is defined after the
preliminary palpitation of the apical impulse usually at the v inter costal
space, moving from the anterior axillary line towards the heart. Normally it
is situated medial to the mid clavicular line for 1-2 cm.
138.Where is the normal and which part of the heart forms the right
part of the absolute dullness of the heart?
para sternal line
 Right- in the 4th inter costal space along the left edge of the sternum, the
upper level of the lower edge 4th rib.
 139. Where is the norm and which part of the heart forms the
upper limit of absolute dullness of heart?
para sternal line
The upper-level of the lower edge of 4th rib. At the left parasternal line.
140. @4. Where is the left border of absolute dullness of the heart in the
norm and by what department of the heart is formed?
Heart contours refers to the outline of the heart as seen on frontal and lateral chest
radiographs and forms part of the cardiomediastinal contour.
left heart contour consist of left lateral border of left ventricle.Right heart contour
consist of right lateral border of right atrium.
In order to definition of right contour of the heart the finger-pleximeter is located in the
3-d and 2-d intercostals spaces at the level of midclavicular line parallel to a sternum.
percussion with medium strength is continued by moving the pleximeter finger
gradually along the interspace toward the heart until the percussion sound dulls.Further
the points recieved at a percussion in the 4-th , 3-d,2-d intercostal space are connected
among themselves to representation of a right contour of heart.the right heart contour
of heart is formed at the 2-d to 3-d intercostals space by right auricle.
Definition of the left contour of heartbegins with definiton of localization of the apex
beat.Further the left border of relative dullness of the heart is determined.next the
pleximeter finger is raised on one intercostals space above,the pleximeter
-finger position in the 4-th intercostals space is parallel to sternum at the level of
anterior axillary line.percusiion in the 3rd intercostal space is performed by same
rules.later the left border of heart vascular bundle in the 2-d intercostal is defined by
percusiion note on a dulled sound.the points recieved by means of percusiion in the 5-
th,4-th 3-d ,2-d intercostal space are connected and represents about left contour of
heart
141. @4. What are the contours of the heart, how many of them and how
are they formed?
142. @4. The width of the vascular bundle, the norms and how it is
formed? The vascular bundle of heart is formed on the right by venacava vein and an
ascending part of an aortic arch on the left by a pulmonary artery and a part of an aortic
arch. The vascular bundle of heart can be determined by percusiion of the borders of
relative heart dullness in 2nd intercostal space on the right and left.
The borders of the vascular bundle are determined by quiet percussion in the second
intercostal space,to right and left from the midclavicular line,toward sternum.
When the percusiion sound dulls ,a mark should be made by the outer edge of the
finger. The right and left borders of vascular dullness are normally found along the
edges of the sternum;the transverse length of dullness is 5-6 cm
143. @4. What is the length and diameter of the heart? Norms in men
and women.
The heart is often defined as the size of fist: 12cm in length,8cm in wide, and 6cm in
thickness The heart is located in the chest between the lungs behind the sternum and
above the diaphragm. Its centre is located about 1.5cm to the left of the midsaggital
plane. By ratio women heart and some of its chambers are smaller.A women's heart
pumps faster than a man's,but a man's heart ejects more blood with each pump .
144. @4. Non-cardiac and cardiac causes of displacement of the right
border of relative dullness of the heart to the right?
In hypertrophy and dilation of right auricle and right ventricle(in stenosis and
incompletence of tricuspid valve,stenosis of ostium of pulmonary artery,development of
pulmonary artery,sclerosis of pulmonary artery),the borders of the heart are displaced
to right. As a
result of hypertrophy and dilation of left ventricle(in arterial hypertension,stenosis of
ostium of aorta,incompletence of aortal valves,aneurysm of left ventricle),the borders of
the heart are displaced to left.
145. @4. Non-cardiac and cardiac causes of displacement of the upper
border of relative dullness of the heart up?
As a result of hypertrophy of left auricle (mitral stenosis and incompletence of mitral
valve )the borders of heart are displaced upwards
146. @4. Non-cardiac and cardiac causes of displacement of the left
border of relative dullness of the heart to the left?
As a result of hypertrophy and dilation of left ventricle(in arterial hypertension,stenosis of
ostium of aorta,incompletence of aortal valves,aneurysm of left ventricle),the borders of the
heart are displaced to left.
147. @4. Reasons for reducing the area of absolute dullness of the heart.
.obesity
swelling of subcutaneous tissue
narrow intercostal space
pulmonary emphysema
148. @4. The reasons for the increase in the area of absolute dullness of
the heart.
hypertrophy
dilation of heart
pericardial effusion
thin chest
wrinkling the bottom edge of the left lung
enlarged intercostal space
tumour of mediastinum
149. @4. Pathological configurations of the heart, types and causes of
their occurrence.
pathological conditions when the chambers of heart are dilated there are 2
configurations mitral configuration
aortic configuration
The angle formed by the vascular bundle and the left contour of heart becomes more
significant when the left ventricle is enlarged. Since it is more pronounced in aortic
incompetence and aortic stenosis, this configuration of heart is known as "aortic
configuration ".
The left atrium is enlarged and the pressure in the pulmonary artery increases in mitral
incompetence and mitral stenosis. In this connection waist of heart becomes smooth.
This configuration of the heart is known as "mitral configuration"
150. @4. Rules and points of auscultation of the heart, the activity of which
valves is heard at these points?
Rules of auscultation of heart
- The heart is usually auscultated by a stethoscope or a phonendoscope, but direct (immediate)

auscultation is also used.
- The condition of the patient permitting the heart sounds should be heard in various postures
of the patient: erect, recumbent, after exercise (e.g. after repeated squatting).
- Sounds associated with the mitral valve pathology are well heard when the patient lies on his
left side, since the heart apex is at its nearest position to the chest wall; aortic valve defects are
best heard when the patient is in the upright posture or when he lies on his right side.
- The heart sounds are better heard if the patient is asked to inhale deeply and then exhale
deeply and keep breath for short periods of time so that the respiratory sounds should not
interfere with auscultation of the heart.
- The valve sounds should be heard in decreasing order of their affection frequency. The mitral
valve should be heard first (at the heart apex); next follows the aortic valve (in the second
intercostal space to the right of the sternum), the pulmonary valve (in the second intercostal
space, to the left of the sternum), tricuspid valve (at the base of the xiphoid process), and finally
the aortic and mitral valve again at the Botkin-Erb point The
auscultatory areas (points) are as follows:
(1) area of the apex beat - for the mitral valves because the vibrations are well transmitted by
the firm muscle of the left ventricle and the cardiac apex is at the nearest distance to the
anterior chest wall during systole;
(2) lower part of the sternum near its junction with the xiphoid process (the right-ventricular
area) - for the tricuspid valves;
(3) valves of the pulmonary trunk are best heard at its anatomical projection onto the chest, i.e.
in the second intercostal space, to the left of the sternum;
(4) aortic valves are best heard in the second intercostal space, to the right of the sternum
where the aorta is the nearest to the anterior chest wall;
(5) heart sounds which are associated with the contractions of aortic and mitral valves or which
develop during its affections can be heard to the left of the sternum at the 3-rd and 4-th
costosternal joints (the so-called fifth listening post at the Botkin-Erb point
151. @4. True projections of the heart valves on the anterior wall of the chest?
Heart tones characteristic and phase of occurrence:-

True projection of heart valve on anterior wall of chest:-
Projections of the valves on the anterior chest wall are very close to one another: - mitral valves
projects to the left of the sternum at the 3-rd costosternal joint; - tricuspid valve - on the
sternum midway between the 3-rd left and 5th right costosternal joints; -valves of the
pulmonary trunk are projected in the 2-nd intercostal space, to the left of the sternum; -aortic
valves are projected in the middle of the sternum at the level of the 3-rd costosternal joint.
Since all heart valves are projected on a small area of the chest, it is difficult to decide which of
them is damaged if the valves are auscultated at sites of their actual projections. Perception of
sounds generated in the heart depends on the distance from the valve to its projection on the
chest wall and on sound conduction by the course of the blood flow. It is therefore possible to
find certain sites on the chest where sounds of each valve can be better heard
152. @4. Heart tones: characteristics, phase of occurrence.

The sounds produced by a working heart are called heart sounds. Two sounds can be well heard
in a healthy subject; the first sound, which is produced during systole and the second sound,
which occurs during diastole. A mechanism by which the heart sounds are produced connects
with the phases of the cardiac cycle. The heart contraction begins with the systole of the atria,
which is followed by contraction of the ventricles. During the early systole the following phases
are distinguished: (1) asynchronous contraction; the myocardium is involved only partly and the
intraventricular pressure does not increase; (2) isometric contraction; it begins when the main
mass of the myocardium is involved; atrioventricular valves are closed during this phase and the
intraventricular pressure markedly increases; (3) ejection phase; the intraventricular pressure
increases to level with that in the main vessels; the semilunar valves open. As soon as the blood
has been ejected, the ventricles relax (diastole) and the semilunar valves close. The ventricles
continue relaxing after the closure of the atrioventricular and semilunar valves until the
pressure in them is lower than in the atria (isometric relaxation phase). The atrioventricular
valves then open to admit blood into the ventricles. Since the difference between pressures in
the atria and the ventricles is great during the early diastole, the ventricles are quickly filled
(ventricle rapid filling phase). The blood flow then slows down (flow filling phase). Atrial systole
begins, and the cardiac cycle
153. @4. Mechanism of formation and duration of I tone.

Mechanism of formation and period of first tone:-
The first sound is produced by several factors. One of them is the valve component, i.e.
vibrations of the cusps of the atrioventricular valves during the isometric contraction phase,
when the valves are closed. The second component is muscular, and is due to the myocardial
isometric contraction. The intensity of myocardial and valves vibrations depends on the rate of
ventricular contractions: the higher the rate of their contractions and the faster the
intraventricular pressure grows, the greater is the intensity of these vibrations. The first heart
sound will thus be more resonant. The third component of the first heart sound is the vascular
one. This is due to vibrations of the nearest portions of the aorta and the pulmonary trunk
caused by their distention with the blood during the ejection phase
154. @4. Mechanism of formation and duration of II tone.

Mechanism of formation and duration of second tone:-
The second sound is generated by vibrations arising at the early diastole when the semilunar
cusps of the aortic valve and the pulmonary trunk are shut (the valve component) and by
vibration of the walls at the point of origination of these vessels (the vascular component). Both
sounds can be heard over the entire precordium but their strength changes depending on the
proximity of the valves involved in the formation of the first or second sound
155. @4. The mechanism of formation of III and IV heart tones

Mechanism of formation of third tone:-
The third sound is caused by vibrations generated during quick passive filling of the ventricles
with the blood from the atria during diastole of the heart; it arises in 0.15-1.12 s from the
beginning of the second sound.
Mechanism of formation of fourth tone :-
The fourth sound is heard at the end of ventricular diastole and is produced by atrial
contractions during quick filling of the ventricles with blood.
156. @4. The valve component of the formation of the I tone.
157. @4. Valve component of tone II formation.
158. @4. Vascular and muscular components of the formation of the I tone.
159. @4. Vascular and muscular components of tone II formation.
160. @4. The differences of the I tone from the II tone?
161. @4. Non-cardiac and cardiac causes of the amplification of both heart
tones?
162. @4. Non-cardiac and cardiac causes of weakening of both heart tones?
163. @4. What determines the strength of the 1st tone, the reasons for its
strengthening and weakening?
.The first sound is produced during systole, after a long pause. It is best
heard at the heart apex since the systolic tension of the left ventricle is more
pronounced than that of the right ventricle. The first sound is longer and louder than the
second heart sound
●The first sound increases at the heart apex if the left ventricle is not adequately filled with
blood during diastole. The first sound often becomes louder in stenosis of the left
atrioventricular orifice, when less than normal amount of blood is discharged from atrium to
the ventricle during diastole. The muscle of the left ventricle is therefore less distended by the
blood by the start of systole; it is more relaxed and therefore contracts more rapidly and
energetically to intensify the first sound. The first sound increases in stenosed
right atrioventricular orifice at the base of the xiphoid process. This sound is
also intensified during extrasystole (premature contraction of the heart) due to inadequate
diastolic filling of the ventricles.
●Intensity of the first heart sound diminishes in the mitral and aortic
valve insufficiency. The cusps of the affected mitral valve fail to close
completely the left atrioventricular orifice during systole. Part of the blood is
thus regurgitated to the left atrium. The pressure of the blood is below norm
against the ventricular walls and the cusps of the mitral valve, and the
valvular and muscular components of the first heart sound markedly
diminish. The period of closed valves is absent also during systole in the
aortic valve insufficiency. It means that the valves and muscle components of
the first heart sound will also diminish significantly.
●In tricuspid and pulmonary valve failure, the diminution of the first
heart sound will be better heard at the base of the xiphoid process due to the
diminution of the muscular and valves components of the right ventricle.

●The first sound can be diminished at the heart apex in stenotic aortal orifice because systolic
tension of the myocardium grows slowly when the
blood flow from the left ventricle is obstructed and it is overfilled with blood;
the amplitude of the sound vibrations decreases. In diffuse affections of the
myocardium (due to dystrophy, cardiosclerosis or myocarditis), the first heart
sound only may be diminished because its muscular component also
diminishes in these cases.
164. @4. "The rhythm of the quail": definition, when determined, the
conditions of occurrence.
165. @4. "Gallop rhythm": definition, mechanism of occurrence, types.

if the ventricular myocardium is much weakened, these sounds can be revealed by
auscultation. Intensification of one of these sounds gives a three-sound
rhythm, known as the gallop rhythm (because it resembles the galloping of horse).
The sounds of the gallop rhythm are usually soft and low, always
attended by a thrust, for which reason they are best heard on direct
auscultation; the gallop rhythm can also be heard in auscultation with a
phonendoscope, but the patient should lie on the left side after a mild
exercise. Protodiastolic (at the beginning of diastole), mesodiastolic (in the
middle of diastole), and presystolic (at the end of diastole)
gallop rhythms are
distinguished by the time of appearance of the extra sound in diastole. Gallop
rhythm is also classified as ventricular or atrial, according to its origin

166. @4. Differences of the "gallop rhythm" from the normal 3rd and 4th heart
tones?
Both the third and the fourth heart sounds can intensify significantly in
grave myocardial affection, but in tachycardia they sum up to give a
mesodiastolic or summation gallop rhythm. Gallop rhythm is an important
sign of myocardial weakness, and it has a great diagnostic and prognostic
value. It develops in severe heart affections in patients with myocardial
infarction, essential hypertension, myocarditis, chronic nephritis, decompen-
sated heart diseases
167. @4. What are heart murmurs? The causes and mechanism of their
occurrence?
168. @4. Classification of cardiac murmurs?.

169. @4. Causes of organic systolic heart murmurs and the place where they are
listened to?
According to the time of appearance, murmurs are classified as systolic
and diastolic.
○ Systolic murmur occurs in cases when, during systole,
blood moves from one chamber of the heart to another or from the heart to the main vessels
and meets an obstacle. Systolic murmur is heard in the
stenotic orifice of the aorta or the pulmonary trunk because blood ejected
from the ventricles meets a narrowed vessel (ejection murmur).
○ Systolic murmur is also heard in cases with mitral and tricuspid incompetence
(regurgitation murmur). Generation of systolic murmur is explained by

regurgitation of blood which is not completely expelled into the aorta and
pulmonary trunk during the ventricular systole, but is partly returned to the
atrium through an incompletely closed mitral or tricuspid orifice. Since this partly closed orifice
is actually a narrow slit, murmur is generated as blood passes through it.
170. @4. Causes of organic diastolic heart murmurs and the place where they
are listened to?
. Diastolic murmur occurs if blood meets a narrowed passage during
diastole (ejection murmur). ○This murmur is heard in a stenosed left or right
atrioventricular orifice, since blood meets a narrow passage in its flow from
the atria into the ventricles. Diastolic murmur also occurs in aortic or
pulmonary valve incompetence. Murmur is generated when blood flows back from the vessels
into the ventricles through a slit formed by incomplete
171. @4. Organic non-valvular heart murmurs, types, causes and mechanism of
their occurrence, listening places?
Organic murmurs are caused by structural abnormalities of the heart or circulation, such as a
stenotic valve or a communication from one chamber or vessel to another (such as a ventricular
septal defect). Heart murmurs are classified based on when they happen in a heartbeat:
Systolic: This type of murmur occurs when your heart muscle contracts (tightens).
Diastolic: This type of murmur occurs when your heart muscle relaxes.
Continuous: A continuous heart murmur happens during both contraction and relaxation of
your heart muscle.
Diastolic and continuous murmurs are more likely related to heart disease.
A murmur is caused by turbulent or abnormal blood flow across your heart valves.
If blood is flowing more rapidly than normal, it can cause an innocent heart murmur (also called
normal or physiologic). This type of murmur is common during:
Childhood.
Exercise.
Growth spurts.
Pregnancy.
The first few days after a baby is born.
Innocent heart murmurs can disappear and reappear. They may get louder when your heart
beats faster. They often go away eventually, but some last a lifetime. Innocent heart murmurs
don’t indicate a problem with your heart.
Location refers to where the heart murmur is usually heard best. There are four places on the
anterior chest wall to listen for heart murmurs. Each location roughly corresponds to a specific
part of the heart.[4] Health care providers listen to these areas with a stethoscope.
Region Location Heart Valve Association
Aortic 2nd right intercostal space -Aortic valve
Pulmonic 2nd left intercostal spaces -Pulmonic valve
Tricuspid 4th left intercostal space -Tricuspid valve
Mitral 5th left mid-clavicular intercostal space - Mitral valve
172. @4. Causes of valvular and non-valvular functional noises?
173. @4. What is Flint noise, the mechanism of its occurrence and the place of
listening?
174. @4. What is the Graham-Still noise, the mechanism of its occurrence and
the place of listening?
175. @4. How do organic noises differ from inorganic noises?
176. @4. Differences between intracardiac and extracardiac noises?

177. @4. Characteristics of pericardial friction noise and pleuropericardial
noise?
The following signs can be used for differentiation between pericardial
friction sounds and intracardiac sounds:
(1) there is no complete synchronism of pericardial friction sounds
with systole and diastole; friction sounds are often continuous, their intensity
increasing during systole or diastole;
(2) friction sounds can be heard for short periods during various phases
of the heart work, either during systole or during diastole;
(3) pericardial friction sounds are not permanent and can reappear at
intervals;
(4) friction sounds are heard at sites other than the best auscultative
points; they are best heard in the areas of absolute cardiac dullness, at the
heart base, at the left edge of the sternum in the 3rd and 4th intercostal
spaces; their localization is inconstant and migrates even during the course of
one day;
(5) friction sounds are very poorly transmitted from the site of their
generation;
(6) the sounds are heard nearer the examiner's ear than endocardial
murmurs;
(7) friction sounds are intensified if the stethoscope is pressed tighter to
the chest and when the patient leans forward, because the pericardium layers
come in closer contact with one another.
Pleuropericardial friction murmurs arise in inflammation of the pleura

adjacent to the heart and are the result of friction of the pleural layers
(synchronous with the heart work). As distinct from pericardial friction
sounds, pleuropericardial friction is always heard at the left side of relative
cardiac dullness. It usually combines with pleural friction sound and changes
its intensity during the respiratory phases: the sound increases during deep
inspiration when the lung edge comes in a closer contact with the heart and
decreases markedly during expiration, when the lung edge collapses
178. @4. Pathogenetic mechanisms of formation of pericardial friction noise.
179. @4. What changes in hemodynamics occur with mitral stenosis?

The hemodynamic consequence of mitral stenosis (MS) is an increased impedance or
resistance to transmitral flow.Mitral Stenosis attenuates the atrial contribution to left
ventricular filling and it also poses a hydraulic opposition or resistance to early filling.
• Diastolic tremor in the region of the apex of the heart is observed in mitral stenosis.
• Mitral configuration of the heart is formed.
• Pulsation of pulmonary artery is observed.
• Pulse difference is note
180. @4. What changes in hemodynamics occur with mitral valve insufficiency?
Mitral insufficiency, the most common form of valvular heart disease, occurs when the mitral
valve does not close properly, allowing blood to flow backwards into the heart. As a result, the
heart cannot pump efficiently, causing symptoms like fatigue and shortness of breath.If not
treated, it can lead to: atrial fibrillation – an irregular and fast heartbeat. pulmonary
hypertension – high blood pressure in the blood vessels that supply the lungs. heart failure –
where the heart cannot pump blood around the body properly.
181. @4. What changes in hemodynamics occur with aortic stenosis?

Aortic stenosis causes obstruction of blood flow from the left ventricle (LV) to the aorta. As a
result, there is a systolic pressure gradient across the valve with a higher pressure in the LV
than the aorta.Aortic valve stenosis causes a thickening and narrowing of the valve between the
heart's main pumping chamber (left ventricle) and the body's main artery (aorta). The
narrowing creates a smaller opening for blood to pass through. Blood flow from the heart to
the rest of the body is reduced or blocked
182. @4. What changes in hemodynamics occur with aortic valve insufficiency?
Aortic valve insufficiency is a heart valve disease where the aortic valve no longer functions
adequately to control the flow of blood from the left ventricle into the aorta. Commonly, aortic
insufficiency shows no symptoms for many years. Symptoms may then occur gradually or
suddenly.
• Aortic pulsation observed
• Pronounced pulsation of the carotid arteries is observed in patients.
• High & rapid pulse
• Increase in systolic pressure and a decrease in diastolic pressure
(general and heart area) with mitral stenosis?
Mitral valve stenosis may cause an irregular and chaotic heart rhythm called atrial
fibrillation.Mitral valve stenosis can make you tired and short of breath. Other symptoms may
include irregular heartbeats, dizziness, chest pain or coughing up blood. Some people don't
notice symptoms.Mitral valve stenosis can be caused by a complication of strep throat called
rheumatic fever.The auscultatory findings characteristic of mitral stenosis are a loud first heart
sound, an opening snap, and a diastolic rumble. The first heart sound is accentuated because of
a wide closing excursion of the mitral leaflets
(general and heart area) with mitral valve insufficiency?
Signs and symptoms of mitral valve insufficiency include: Sound of blood flow across the valve
(heart murmur) Irregular heartbeat (arrhythmia) Shortness of breath (dyspnea), especially
when lying down.
• Sound of blood flow across the valve (heart murmur)

• Irregular heartbeat (arrhythmia)
• Shortness of breath (dyspnea), especially when lying down
• Sensation of a rapid, pounding or fluttering heartbeat (palpitations)
• Swollen feet or ankles (edema)
(general and heart area) with aortic stenosis?
• An irregular heart sound (heart murmur) heard through a stethoscope.
• Chest pain (angina) or tightness with activity.
• Feeling faint or dizzy or fainting with activity.
• Shortness of breath, especially with activity.
• Fatigue, especially during times of increased activity.
The typical murmur of aortic stenosis is a high-pitched, midsystolic ejection murmur

heard best at the right upper sternal border radiating to the neck and carotid arteries.
(general and heart area) with aortic valve insufficiency?
• Shortness of breath with exercise or when you lie down.
• Fatigue and weakness, especially when you increase your activity level.
• Heart murmur.
• Irregular pulse (arrhythmia)
• Lightheadedness or fainting.
• increase in systolic blood pressure and decrease in diastolic blood pressure
• Diastolic murmur in the second intercostal space at the right edge of the sternum is heard.
187. @4. Palpatory and percussion pattern in mitral stenosis?

Palpation may reveal a palpable S1 over the apex. This finding is pathognomonic for mitral
stenosis. A diastolic thrill may rarely be appreciated at the apex with the patient in the left
lateral decubitus position.
The murmur of mitral stenosis is heard loudest at the 5th intercostal space on the
midclavicular line, approximately around the area of the left nipple. Also, it is heard best using
the bell of the stethoscope and with the patient in the left lateral decubitus position.
188 Ques . palpatory and percussion pattern in mitral valve insufficiency ?

Ans :
•A palpable thrill may be present in acute mitral regurgitation.
The apical impulse may be brisk and hyperdynamic and may be displaced leftwards secondary
to left ventricular enlargement.
•A thorough and systematic auscultation is needed to avoid missing any subtle signs of mitral
valve disease. The patient should be auscultated in three positions - supine, sitting, and left
lateral. Both the bell and the diaphragm of the stethoscope should be used. All of the five
classic areas are auscultated - mitral area (area over the apical impulse), tricuspid area (left
parasternal line, 5th intercostal space), pulmonary area (left parasternal line, 2nd intercostal
space), aortic area (right parasternal line, 2nd intercostal space), and accessory aortic area (left
parasternal line, 3rd intercostal space) [2].
•The stethoscope should be moved from one area to another by a small movement rather than
jumping from one to the other. Auscultation should also be extended to the relevant adjoining
areas to appreciate the radiation of the murmurs. Finally, dynamic auscultation is performed to
note the changes of sounds and murmurs with respiration, after ectopic beat and with some
specific manoeuvre
189 Ques . Palpatory and percussion pattern in aortic stenosis ?
Ans : • Boundary of relative cardiac dullness shift - to the left.
• Early development of the heart failure ( not characteristic).
• displacement of the right border of the relative dullness of the heart to outside is not
observed.
• systolic murmur in the second intercostal space at the right edge of the sternum is heard.
• relative cardiac stenosis is formed against the background of aortic valve insufficiency.
• systolic tremor in the 2nd intercostal bspace to the right of the sternum is observed.
• characteristic of 2 tones: weakened in aortic projection.
• pallor of the skin.
• 2 tone : weakened in aortic projection
190 Ques :. Palpatory and percussion pattern in aortic valve insufficiency
Ans : • Aortic pulsation observed
•BP = 180 - 40 mmHg observed
• Symptom of Musset is observed
• 2 tone : sharply weakened at the 2nd point
• 1 tone : weakened at 1st point
• There is a domed apical push
• relative aortic stenosis is formed against the background of aortic valve insufficiency.
• carotid dance is observed.
• Flint noise is heard
• pronounced pulsation of the carotid arteries is observed in patients.
• high 8 rapid pulse
• apical push shifts to the left and down.
• increase in systolic blood pressure and a decrease in diastolic blood pressure is

characteristic.
• Diastolic murmer in the second intercostal space at the right edge of the sternum is heard.
191 Ques : Auscultative pattern in mitral stenosis ?

Ans : • auscultation, mitral facies (plethoric cheeks with bluish patches), tapping apex and
apical diastolic thrill may suggest the presence of mitral stenosis.
• The jugular venous pulse may show prominent ‘a’ wave and there may be a right ventricular
(RV) heave in the presence of pulmonary hypertension.
•The first heart sound (S1) is typically loud due to the rapidity with which RV pressure rises
(dP/dt) at the time of mitral valve closure (because of high pressure in the left atrium, the left
ventricle [LV] needs to reach a higher pressure before it can close the mitral valve and hence LV
pressure has more time to accelerate) [5] and the wide closing excursion of the leaflets.
•The wide closing excursion of the leaflets happens because the transmitral gradient keeps the
valve wide open at the end of diastole rather than allowing the valve to go to a semi-closed
position as happens normally without mitral stenosis.
•The intensity of the first heart sound is reduced if the valve is thickened and calcified. The
presence of a loud S1 suggests that the patient may be a likely candidate for balloon mitral
valvuloplasty [2]. With the development of atrial fibrillation, the intensity of the S1 will vary
depending upon the RR intervals with a louder S1 audible in shorter cycles.
•The nature of the second heart sound (S2) depends upon the severity of pulmonary
hypertension. Initially, the intensity of P2 increases as pulmonary artery pressure increases. As
pulmonary artery pressure increases further, splitting of the S2 narrows as P2 becomes earlier
and then S2 becomes single and loud with further increase in pulmonary artery pressure.
•The opening snap (os )of the mitral stenosis is a high-pitched early diastolic sound due to
sudden tensing of the valve leaflets and subvalvular apparatus at the end of the opening
excursion. The OS occurs 40-120 milliseconds after A2. The A2-OS interval varies inversely with
the severity of mitral stenosis. An A2-OS interval of less than 70 milliseconds usually suggests
severe MS and an A2-OS interval of more than 100 milliseconds usually indicates mild MS [2]. In
the presence of AF, the A2-OS interval varies directly with the length of the previous RR
interval. Because of its higher pitch, the OS can be heard over a wider area over the precordium
than mid-diastolic rumble. It can be heard at the left sternal border and even at the base of the
heart. An OS is a much higher pitched sound than S3 which is also localised to the apex only. A
loud P2 may simulate the OS but normally P2 is not heard at the aortic area unless there is
severe pulmonary hypertension. A crisp OS suggests a pliable valve and hence is probably
suitable for balloon mitral valvuloplasty.
•The classic mid-diastolic low-pitched rumbling murmur of mitral stenosis with pre-systolic
accentuation is best audible at the apex, in the left lateral position with the bell of the
stethoscope. Pre-systolic accentuation usually means the presence of atrial contraction and
hence sinus rhythm, but it may persist in AF following short diastoles [6]. The duration of the
murmur is directly proportional to the severity of mitral stenosis, but the intensity of the
murmur is not. The murmur can be heard provided the atrioventricular gradient remains above
3 mmHg [3]. Because diastolic mean gradient is directly related to heart rate, the manoeuvres
that increase heart rate can help to detect an otherwise faint murmur.
192 Ques : Auscultative pattern in mitral valve insufficiency ?

Ans : • The fourth intercostal space in the lower left sternal border for the tricuspid valve. And
finally the fifth intercostal space at the midclavicular line for the mitral.
•The first heart sound results from the closing of the mitral and tricuspid valves. The sound
produced by the closure of the mitral valve is termed M1, and the sound produced by closure
of the tricuspid valve is termed T1.
• points are - Aortic – on the patients right side of the sternum.
• Pulmonary – on the left-hand side of the patients's sternum. •Tricuspid – in the fourth
intercostal space, along the lower-left border of the sternum.
•Mitral – in the fifth intercostal space, along the mid-clavicular line.
193 Ques : Auscultative picture in aortic valve insufficiency ?

Ans :. • Aortic – on the patients right side of the sternum. Pulmonary – on the left-hand side of
the patients's sternum.
•Tricuspid – in the fourth intercostal space, along the lower-left border of the sternum. Mitral
– in the fifth intercostal space, along the mid-clavicular line.
•Sound from the aortic valve is often transmitted to the carotid and can be heard by placing a
stethoscope over the carotid bifurcation.
•Pulmonary stenosis will produce a flow murmur that gets louder then softer (crescendo-
decrescendo) during systole.
•The 5 points of auscultation of the heart include the aortic, pulmonic, tricuspid, and mitral
valve as well as an area called Erb's point, where S2 is best heard.
•Listen over the aortic valve area with the diaphragm of the stethoscope. This is located in
the second right intercostal space, at the right sternal border
194. @4. Auscultative picture in aortic valve insufficiency?
195. @4. What are the properties of the pulse?

.normal pulse is regular in rhythm and force .
. normal pulse rate is between 60 and 80 beats per minute
.it is faster in children .
.pulse can be easily felt as a thumbing sensation in arteries that are located near the skins
surface .include radial ,carotid,brachial,femoral,popliteal.
.the pulse at the wrist is called the radial pulse
.rate,rhythm,volumeare the features of the pulse
196. @4. How and why can the pulse rhythm change in pathology?
.alcohol,tobacco,and recreational drugs can raise your risk medical conditions.
.high blood pressure,diabetes,low blood sugar,obesity,sleep apnea ,and auto immune disorders
are among the conditions that may cause heart rhythm problems
.an exaggerated upstroke ,or a bounding pulse,may be felt in patients with elevated stroke
output(ventricular septal defect,high fever)
197. @4. How and why can the pulse rate change in pathology?
alcohol,tobacco,and recreational drugs can raise your risk medical conditions.
.high blood pressure,diabetes,low blood sugar,obesity,sleep apnea ,and auto immune disorders
are among the conditions that may cause heart rhythm problems
.an exaggerated upstroke ,or a bounding pulse,may be felt in patients with elevated stroke
output(ventricular septal defect,high fever)
198. @4. What is anasarca and the mechanism of its occurrence?

.anasarca is a serious condition in which there is a generalized accumulation of fluid in the
interstitial space
.this accumulation of fluid occurs when capillary filtration exceeds the amount of fluid removed
via lymphatic drainage.
.it is usually a result of abnormalities in blood vessels,blockage in the lymphatic vessels,and

water retention in the whole body.
.when the liver does not work efficiently as it should,it can cause fluid to leak into the tissues.
.heart failure,cirrhosis,renalfailure,are the most common causes of this.
199. @4. What is pulse deficiency, when does it occur and how is it determined?
.it is the difference between the apical and peripheral pulse rates-can signal an arrhythmia.
.it occurs when the heart is contracting and the pulse is not reaching the periphery.
.pulse deficiency can be dangerous if not treated.
.the pulse deficiency is determined by listening to chest with a stethoscope and by noting the
heart beat ,but when they attempt to take your pulse,do not notice the same number of pulse
beat.

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1.Rules and questions of patient survey?

Be attentive. “Listen completely and attentively. ...

Ask open questions.

Involve friends and family.

Use the right tone.

Be aware of your patient's situation.

Get help from colleagues.

2. What condition must be observed for a general examination?

Assess patient's general condition

Detect manifestations of internal & systemic diseases

History taking - Clues are the symptoms

Physical exam - Clues are the signs

Investigations - Clues are test results

The Neurologic Examination:

3.Types of patient position and their characteristics.

• Forced position - the patient is taken to reduce the severity of symptoms...

Active position indicates on absence of severe functional disorders in case of trauma,

4.What is forced position of the patient? Give example of forced position of

Example of Forced position

• Disease - abdominal pain.

Example of Forced position.

• Disease - bronchial asthma. The main manifestation - dyspnea and asphyxia.

5.Tyoes of consciousness of a patient and its characteristics.

The inability to think rapidly and clearly. There is

impaired judgment and decision making.

Disoriented-This is the beginning of loss of consciousness. There is disorientation in place,

Different Categories of Comas

Persistent Vegetative State (PVS) -profound or deep state of unconsciousness. Persistent

7. Diagnostic value of face examination, give example of diagnostic faces and

Inspect the skull and face.

Palpate skull (especially if patient complains of tenderness or recent trauma).

Assess facial sensation and motor function

8.Types of constitution. Their characteristics.

basic physiological tendency that is believed to contribute to personality, temperament, and

Ways to Take a Temperature

Rectal. The thermometer is placed in the child's bottom. ...

Axillary. The thermometer is placed in the armpit.

Tympanic. The thermometer is placed in the ear.

Temporal artery. The thermometer scans the surface of the forehead...

10.Types of fever and their characteristics.

⚫ Temperature returns to normal at least once every 24 hours!

It is associated with viral upper respiratory tract, legionella, and

Temperature remains above normal with minimal variations;

It is seen in persons with drug fever;

It may be caused by a variety of infectious diseases, including tuberculosis, fungal infections,

11.Types of fever and their characteristics.

12. What type of fever is called permanent?

13.What type of fever is called laxative

14. What type of fever is called intermittent?

15.What type of fever is called debilitating or hectic?

16.What type of fever is called reverse?

17.What type of fever is called incorrect?

18.The main complaint of pulmonary patients with the explanation of their

a persistent chesty cough with phlegm that does not go away.

frequent chest infections.

Mechanism how pulmonary disease occur :

Appears as protective reaction at a congestion of mucus in respiratory ways or

2.Periodic cough - influenza,andar sharp catarrh, pneumonia, TB of lung, chronic bronchitis, is