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History Taking (Anamnesis) - Russian Medical University Format

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TITLE PAGE

• University & Department name
• Chief of Department / Assistant Professor names
• Patient's full name (Surname, First name, Patronymic)
• Principal diagnosis
• Complications
• Concomitant (concurrent) diseases
• Curator (student's year, faculty, group, and full name)
• Date of admission / discharge

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I. INQUIRY (INTERROGATION / РАССПРОС)

1. Patient's Identifying Data (Паспортная часть)

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2. Chief Complaints (Жалобы / Главные жалобы)

• Record the patient's own words exactly as stated (e.g., "My stomach hurts and I feel awful.")
• If no complaints: note the reason for admission (e.g., "admitted for routine check-up")
• After chief complaints, screen all other body systems to uncover secondary complaints
• Secondary complaints arise from a systems review and may be unrelated to the main illness

1. Location - where exactly
2. Quality - character (sharp, dull, burning, pressing)
3. Quantity/Severity - how intense (scale 1-10)
4. Timing - onset, duration, frequency, course
5. Setting - when/where does it occur (at rest, on exertion, at night)
6. Aggravating/Relieving factors - what makes it worse or better
7. Associated manifestations - accompanying symptoms

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3. History of Present Illness (Анамнез настоящего заболевания / История настоящего заболевания)

• Onset - when and how the illness began (sudden vs. gradual)
• Initial symptoms - first signs noticed
• Setting of development - circumstances at the time of onset
• Progression - how symptoms evolved over time
• Previous investigations and results - any labs, imaging, or tests done before
• Previous treatments and response - medications taken, procedures done, effect
• Hospitalizations - prior admissions for this condition
• Reason for current admission - what prompted this visit

Document the patient's response to symptoms and the effect the illness has had on their daily life and function.

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4. Past Medical History (Анамнез жизни / История жизни)

a) Biographical History

• Place and date of birth
• Development in childhood (physical and mental)
• Schooling and education

b) Past Illnesses & Surgical Procedures

• Diabetes mellitus
• Hepatitis (A, B, C)
• Tuberculosis
• Hypertension
• Myocardial infarction
• Stroke
• Asthma
• Blood transfusions (when, why, reactions)
• Any operations or injuries

c) Epidemiological History (Эпидемиологический анамнез)

• Contact with infectious patients
• Recent travel
• Animal contact
• Insect bites
• Food sources (water, raw meat)
• Vaccinations history

d) Allergological History (Аллергологический анамнез)

• Drug allergies (specify the drug and nature of reaction)
• Food allergies
• Environmental allergies
• Intolerance to any substances

e) Medications Currently Taken

• Drug name, dose, frequency, duration

f) Gynecological History (for female patients)

• Age of menarche
• Menstrual cycle regularity
• Number of pregnancies, deliveries, abortions
• Menopause (if applicable)

g) Occupational History (Профессиональный анамнез)

• All occupations held (chronologically)
• Occupational hazards - chemicals, dust, radiation, noise
• Duration of exposure

h) Social History (Социальный анамнез)

• Living conditions (housing quality, number of occupants)
• Nutrition and diet
• Physical activity
• Marital status and family situation

i) Bad Habits (Вредные привычки)

• Smoking: number of pack-years (packs per day × years smoked)
• Alcohol: frequency, amount, type
• Drug use: type, frequency, route

j) Family History (Семейный анамнез)

• Health of parents and siblings (if deceased - cause and age of death)
• Hereditary diseases in the family:
  • Cardiovascular disease
  • Diabetes mellitus
  • Malignancies (cancer)
  • Tuberculosis
  • Mental illness
  • Allergic diseases

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Logical Structure Summary

CASE HISTORY
│
├── I. INQUIRY (РАССПРОС)
│   ├── 1. Identifying Data (Паспортная часть)
│   ├── 2. Chief Complaints (Жалобы)
│   ├── 3. History of Present Illness (Анамнез morbi)
│   └── 4. Past Medical / Life History (Анамнез vitae)
│       ├── Biographical history
│       ├── Past illnesses & surgeries
│       ├── Epidemiological history
│       ├── Allergological history
│       ├── Medications
│       ├── Gynecological history (F)
│       ├── Occupational history
│       ├── Social history
│       ├── Bad habits
│       └── Family history
│
└── II. PHYSICAL EXAMINATION (Объективный статус)
    ├── General condition, temperature, posture, consciousness
    ├── Constitutional type, height, weight, BMI
    ├── Skin, mucous membranes, lymph nodes
    ├── Musculoskeletal system
    ├── Respiratory system
    ├── Cardiovascular system
    ├── Digestive system
    ├── Urinary system
    ├── Nervous system
    └── Endocrine system

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Key Differences from Western History Taking

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Tips for Russian University Examinations

1. The history is written in third person, past tense (e.g., "The patient complained of...")
2. Chief complaints must be listed in order of importance
3. Anamnez morbi and Anamnez vitae are always written as separate sections - never combine them
4. Every complaint in the chief section must be elaborated in the History of Present Illness
5. The document must be signed with the curator's details and dated
6. At Russian universities, students are expected to write the full case history (История болезни) which is typically 20-30 pages

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Percussion (Перкуссия) - Physical Examination

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Definition

• Size, shape, and borders of organs
• Consistency of underlying tissue (air, fluid, solid)
• Presence of pathological changes (fluid, consolidation, cavities)
• Position and displacement of organs

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Classification of Percussion

A. By Technique (Method of Performance)

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1. Direct Percussion (Непосредственная / Прямая перкуссия)

• Definition: Tapping directly on the patient's skin with one or two fingers, without a pleximeter
• How: Use the tip of the middle or index finger to tap directly on the body surface
• Used for: Assessing sinuses (frontal, maxillary), children's examination, areas where indirect percussion is difficult
• Advantage: Simple, quick
• Disadvantage: Produces a less distinct sound; not suitable for deep structures

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2. Indirect (Mediate) Percussion (Опосредованная / Медиатная перкуссия)

• Definition: Tapping is performed through a pleximeter (an intermediary)
• Two subtypes:
  • Finger-to-finger percussion (most common): The middle finger of the left hand acts as the pleximeter, placed firmly on the skin; the middle finger of the right hand (the plexor) strikes it
  • Hammer-and-pleximeter percussion: A percussion hammer strikes a pleximeter (rubber/ivory plate) - used historically, less common now
• How (finger-to-finger):
  1. Place the left middle finger (pleximeter) flat and firmly on the skin
  2. Only the middle phalanx should contact the skin
  3. Strike with the tip of the right middle finger (plexor) using a quick, wrist-flicking motion
  4. Two strikes per location, then move
  5. Strike perpendicular to the pleximeter finger
• Used for: Lungs, heart, liver, spleen, abdomen - most clinical percussion
• Advantage: Most precise, widely used, reproducible

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3. Blunt (Fist) Percussion (Перкуссия кулаком / Поколачивание)

• Definition: Using the ulnar edge of a fist (or the fist itself) to strike the body - this is actually a percussion-palpation technique
• Used for:
  • Kidney tenderness (Pasternatsky's sign / симптом Пастернацкого) - fist strikes over the costovertebral angle
  • Liver pain assessment
  • Spine tenderness
• Note: In Russian schools, this is classified as a separate form; in Western schools it may be called "blunt percussion" or "indirect fist percussion"

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B. By Purpose (Goal of Percussion)

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1. Comparative Percussion (Сравнительная перкуссия)

• Goal: Compare sounds over symmetrical areas of the body (left vs. right)
• Used for: Lungs - comparing right and left, upper vs. lower zones
• Technique: Strike with equal force over mirror-image locations
• Detects: Unilateral dullness (fluid, consolidation), unilateral hyperresonance (pneumothorax, emphysema)

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2. Topographic Percussion (Топографическая перкуссия)

• Goal: Determine the boundaries, size, and position of organs
• Technique: Percuss from resonant area toward dull area; the border is where the sound changes
• Rule: Always move from clear (resonant) → dull; mark the border on the dull side
• Used for:
  • Upper and lower borders of the lungs
  • Cardiac borders (right, left, upper border of cardiac dullness)
  • Liver size and borders
  • Spleen borders
  • Bladder (when distended)

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C. By Force of Strike

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1. Loud (Deep) Percussion (Громкая / Глубокая перкуссия)

• Strong blows; sound penetrates 7-8 cm deep
• Used for: Localizing deep structures, fluid in the pleural cavity, deep masses

2. Quiet (Threshold) Percussion (Тихая / Пороговая перкуссия)

• Light blows; sound penetrates 4-5 cm deep
• Used for: Determining organ borders more precisely (e.g., heart borders, liver)

3. Quietest Percussion (Тишайшая перкуссия)

• Very gentle taps; penetrates only 1-2 cm
• Used for: Superficial structures, determining absolute cardiac dullness (area directly in contact with chest wall without lung overlap)

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Percussion Sounds (Перкуторные звуки)

Pneumonic for Sounds (Loud → Quiet):

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Topographic Percussion of the Lungs (Clinical Example)

Lower Borders of the Right Lung:

Lung Mobility (Respiratory Excursion):

• Normally 6-8 cm along the midaxillary line

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Rules of Percussion Technique (Russian University Exam Standards)

1. The pleximeter finger must lie parallel to the expected border
2. Tap with the tip of the plexor finger, not the pad - use a wrist snap, not elbow motion
3. Two equal taps per site, then move
4. Always move from resonant → dull when determining borders
5. Mark the border on the dull side (the side from which you are approaching)
6. The patient must be in the correct position - standing or sitting for lung percussion
7. Room must be quiet
8. Apply equal force for comparative percussion

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Summary Table

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Topographic Percussion of the Lungs (Топографическая перкуссия лёгких)

1. Determination of the upper borders (apices)
2. Determination of the lower borders
3. Determination of the excursion (mobility) of the lower borders

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General Rules of Topographic Percussion

• Always move from resonant (clear) sound → dull sound
• Mark the border on the dull side (the side toward which you are moving)
• Use quiet (threshold) percussion - lighter force for more precise borders
• The pleximeter finger lies parallel to the expected border
• Perform on both right and left sides
• Patient position: standing or sitting (upright)

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I. Upper Borders of the Lungs (Apices / Верхушки лёгких)

Anterior (Front):

• Place pleximeter parallel to the clavicle
• Percuss from the middle of the clavicle upward and medially
• Move until dullness appears

Normal: Apex is 3-4 cm above the clavicle (both sides)

Posterior (Back):

• Place pleximeter parallel to the spine of the scapula
• Percuss from the middle of the scapular spine upward toward C7
• Move until dullness appears

Normal: Apex is at the level of the spinous process of C7 (7th cervical vertebra)

Width of Kronig's Fields (Поля Кренига):

• The band of resonance over the apex (on the trapezius muscle) measured in cm
• Percuss medially and laterally from the middle of the trapezius
• Normal: 4-8 cm on each side

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II. Lower Borders of the Lungs (Нижние границы)

Technique:

• Start above the expected border (in the area of clear resonance)
• Percuss downward along each topographic line, one intercostal space at a time
• Mark the border where the sound changes from resonant → dull

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Normal Lower Borders - Table (Normosthenic Person)

Note: The left lung borders are not determined along the parasternal and midclavicular lines because the heart occupies that area (cardiac dullness). Left lung borders are assessed from the anterior axillary line downward.

Memory Aid (Right Lung):

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III. Excursion (Mobility) of the Lower Lung Border

Technique:

1. Find the lower border at quiet (normal) breathing - mark it (Point A)
2. Ask the patient to take a deep breath and hold - percuss down again, mark new border (Point B)
3. Ask the patient to exhale fully and hold - percuss up from below until dullness, mark border (Point C)
4. Total excursion = distance from Point B to Point C

Normal Values of Respiratory Excursion:

The midaxillary line has the greatest excursion (6-8 cm) and is the most clinically important.

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IV. Changes in Borders - Clinical Significance

Bilateral Lowering of Lower Border:

• Asthenic body type (tall, thin)
• Acute pulmonary dilation - bronchial asthma attack
• Chronic pulmonary dilation - emphysema

Bilateral Elevation of Lower Border:

• Hypersthenic body type (stocky)
• Pleural effusion (bilateral)
• Ascites (pushes diaphragm up)
• Acute bloating/meteorism

Unilateral Lowering of Lower Border:

• Unilateral emphysema
• Compensatory emphysema (opposite lung after pneumonectomy)
• Unilateral pneumothorax

Unilateral Elevation of Lower Border:

• Pleural effusion (on affected side - dull sound, border rises)
• Pneumonia / consolidation (lobe involved)
• Atelectasis (lung collapse)
• Diaphragmatic paralysis

Decreased Excursion (Mobility):

• Inflammatory processes in the lung (pneumonia)
• Decreased elasticity - emphysema (most common cause)
• Pleural effusion or pleural adhesions
• Diaphragmatic fixation/obstruction

Increased Excursion:

• Compensatory (opposite lung after lobectomy)
• Athletic/deep breathing individuals

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V. Changes in Upper Borders

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Summary Diagram

TOPOGRAPHIC PERCUSSION OF LUNGS
│
├── UPPER BORDERS
│   ├── Anterior: 3-4 cm above clavicle
│   ├── Posterior: level of C7
│   └── Kronig's fields: 4-8 cm
│
├── LOWER BORDERS (Right)
│   Parasternal → 5th ICS
│   Midclavicular → 6th ICS
│   Ant. axillary → 7th ICS
│   Midaxillary → 8th ICS
│   Post. axillary → 9th ICS
│   Scapular → 10th ICS
│   Paravertebral → T11
│
└── EXCURSION
    Midaxillary: 6-8 cm (most important)
    Midclavicular / Scapular: 4-6 cm

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Question 16: Interviewing Patients with Respiratory Diseases

Расспрос при заболеваниях системы дыхания

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Structure of the Interview (Расспрос)

1. Chief complaints (главные жалобы) - what brought the patient in
2. Detailization of each complaint (детализация жалоб) - full characterization
3. History of present illness (анамнез болезни)
4. Past history (анамнез жизни) - with emphasis on respiratory risk factors

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Main Complaints in Respiratory Diseases

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1. COUGH (Кашель)

Definition:

1. Deep inspiration
2. Closure of the glottis + rise in intrathoracic pressure
3. Explosive opening of the glottis with forceful expiration

Mechanism:

The lung parenchyma itself has no cough receptors - cough from lung disease occurs via pleural or bronchial involvement.

Detailization (Детализация кашля):

Diagnostic Significance:

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2. SPUTUM (Мокрота)

Definition:

Detailization:

Diagnostic Significance:

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3. DYSPNEA (Одышка)

Definition:

Mechanism:

• Hypoxia (↓ PaO₂)
• Hypercapnia (↑ PaCO₂)
• Acidosis (↓ pH)

Detailization:

Types by Phase:

Diagnostic Significance by Disease:

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4. HEMOPTYSIS (Кровохарканье)

Definition:

Mechanism:

• Erosion of bronchial/pulmonary vessels (tumor, inflammation, abscess)
• Rupture of dilated vessels (bronchiectasis, tuberculosis)
• Increased pulmonary capillary pressure (mitral stenosis - "cardiac hemoptysis")
• Infarction of lung tissue (pulmonary embolism)

Detailization:

Distinguish from hematemesis (vomiting blood):

• Hemoptysis: bright red, frothy, alkaline pH, mixed with sputum, preceded by cough
• Hematemesis: dark brown, acid pH, mixed with food, preceded by nausea

Diagnostic Significance:

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5. CHEST PAIN (Боль в грудной клетке)

Mechanism:

The lung parenchyma has NO pain receptors. Chest pain in respiratory disease is caused by involvement of the parietal pleura (richly innervated), chest wall, or referred pain.

• Parietal pleura - most common in respiratory pain (intercostal nerves)
• Chest wall (ribs, muscles, costochondral junctions)
• Trachea and large bronchi (limited pain sensation)

Detailization (SOCRATES approach):

Diagnostic Significance:

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Summary: Complaints and Their Most Characteristic Diseases

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Anamnesis Features to Specifically Ask in Respiratory Diseases

• Smoking history - pack-years (главный фактор риска ХОБЛ и рака легкого)
• Occupational hazards - dust (silicosis, asbestosis, coal miners' pneumoconiosis), chemicals, fumes
• Contact with TB patients - epidemiological history
• Travel history - endemic mycoses, parasites
• Family history - lung cancer, asthma, cystic fibrosis, alpha-1-antitrypsin deficiency
• Prior lung diseases - pneumonia, TB, asthma, surgery
• Allergies - particularly inhaled allergens

Question 16 — Exam Answer

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Main Complaints (Главные жалобы)

1. Cough (кашель)
2. Sputum (мокрота)
3. Dyspnea (одышка)
4. Hemoptysis (кровохарканье)
5. Chest pain (боль в грудной клетке)

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1. COUGH (Кашель)

• Character: dry or wet (productive)
• Time: morning, night, constant, paroxysmal
• Sound: barking, hoarse, whooping, silent
• Duration: acute / chronic

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2. SPUTUM (Мокрота)

• Amount (ml/day)
• Color: white, yellow-green, rusty, pink, black
• Consistency: liquid, viscous, frothy
• Odor: odorless or fetid

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3. DYSPNEA (Одышка)

• Type: inspiratory / expiratory / mixed
• Onset: sudden or gradual
• Relation to exertion: at rest, on walking, on climbing
• Relieving factors: position, bronchodilators

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4. HEMOPTYSIS (Кровохарканье)

• Amount: streaks / tablespoons / massive (>100 ml)
• Color: bright red, dark, rusty
• Mixed with: pure blood / sputum / frothy

• Hemoptysis: bright red, frothy, alkaline, mixed with sputum, preceded by cough
• Hematemesis: dark brown, acid pH, mixed with food, preceded by nausea

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5. CHEST PAIN (Боль в грудной клетке)

• Site and radiation
• Character: sharp/stabbing vs. dull/aching
• Relation to breathing: worsened by deep inspiration and coughing = pleuritic
• Relation to movement/palpation

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Question 20 — Exam Answer

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Definitions

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Classification by Volume

The tracheobronchial tree holds only ~150 ml total - even "moderate" bleeding can be fatal.

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Distinguish Hemoptysis from Hematemesis (Important!)

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Mechanism of Bleeding

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Causes and Diagnostic Significance

By System:

• Coagulation disorders (anticoagulant therapy)
• Vasculitis (Goodpasture syndrome, Wegener's granulomatosis)
• Thoracic endometriosis (catamenial hemoptysis - linked to menstrual cycle)
• Trauma, post-procedural

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Diagnostic Significance Summary Table

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Pulmonary Hemorrhage - Clinical Danger Signs

• Volume >100 ml/day = emergency
• Asphyxiation is the main cause of death (not hypovolemia)
• Signs: rapid large volume fresh blood, respiratory distress, cyanosis, hemodynamic instability
• High-risk patients: active cancer, aspergillosis, alcoholism, pulmonary artery involvement, mechanical ventilation

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Exam Key Points

1. Hemoptysis = <100 ml/day; pulmonary hemorrhage = >100 ml/day
2. Blood originates below the vocal cords - distinguish from epistaxis and hematemesis
3. Most common cause worldwide = tuberculosis
4. In developed countries = cancer, bronchiectasis, pneumonia
5. Massive hemoptysis source = bronchial arteries (high pressure, direct aortic branches)
6. Death from hemorrhage = asphyxiation, not exsanguination
7. Frothy pink = cardiac (pulmonary edema); bright red frothy = bronchial/pulmonary vessel

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Blood Color in Hemoptysis — Diagnostic Significance

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Why Crimson = Tuberculosis?

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Key Rule for the Exam

Crimson (алая) blood = tuberculosis until proven otherwise

• Crimson blood + night sweats + weight loss + low-grade fever + upper lobe infiltrate = Tuberculosis
• Rusty sputum = Pneumonia
• Frothy pink = Pulmonary edema / cardiac cause
• Dark blood + sudden chest pain = Pulmonary embolism

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Question 21 — Exam Answer

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I. Normal Shape of the Thorax (Норма)

Normal Types by Body Build (Конституция):

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II. Pathological Forms of the Thorax (Патологические формы)

1. Emphysematous (Barrel) Chest — Бочкообразная грудная клетка

• Appearance: Barrel-shaped; AP diameter ≈ transverse (nearly circular cross-section)
• Features:
  • Ribs run horizontally (not obliquely)
  • Epigastric angle >90° (obtuse)
  • Intercostal spaces widened
  • Supraclavicular fossae bulging
  • Chest appears fixed in inspiration position
• Cause: Pulmonary emphysema (COPD) - air trapping causes chronic lung overinflation
• Respiratory excursion: Severely decreased

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2. Paralytic Chest — Паралитическая грудная клетка

• Appearance: Extreme asthenic type - flat, narrow, elongated
• Features:
  • AP diameter greatly reduced
  • Prominent clavicles, wide intercostal spaces
  • Asymmetric, scapulae "winged" (отстают)
  • Epigastric angle sharply acute (<60°)
• Cause: Pulmonary tuberculosis, cachexia, chronic debilitating diseases, connective tissue disorders
• Respiratory excursion: Decreased

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3. Rachitic (Keeled / Chicken) Chest — Килевидная (куриная) грудная клетка

• Appearance: Sternum protrudes anteriorly like a ship's keel (prow)
• Features:
  • AP diameter increased
  • Lateral (transverse) diameter decreased
  • Sternum pushed forward
  • Ribs curve sharply from sternum laterally ("rachitic beads" at costochondral junctions)
• Cause: Rickets (childhood vitamin D deficiency)
• Respiratory excursion: Reduced

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4. Funnel Chest — Воронкообразная грудная клетка (Pectus Excavatum)

• Appearance: Lower sternum and adjacent costal cartilages are sunken inward (funnel-shaped depression)
• Features:
  • Depression in lower third of sternum
  • Can compress heart and great vessels
• Cause: Congenital malformation (developmental), Marfan syndrome
• Diagnostic significance: Can cause cardiac displacement, murmurs, reduced lung capacity

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5. Scaphoid (Boat-shaped) Chest —Ладьевидная грудная клетка

• Appearance: Hollowing in the upper and middle parts of the sternum (boat-shaped)
• Cause: Syringomyelia (spinal cord disease)
• Note: Rare, specifically associated with syringomyelia in Russian propedeutics

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6. Asymmetric Chest — Асимметричная грудная клетка

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III. Determination of Respiratory Excursion of the Thorax

Method:

1. Axillary level — tape at the level of the 4th rib anteriorly / below the scapular angle posteriorly (most important)
2. Upper chest — level of the 2nd rib
3. Lower chest — level of the 10th rib

Technique:

1. Measure chest circumference at quiet (normal) breathing
2. Ask patient to take a maximum deep breath — measure again
3. Ask patient to do a maximum full expiration — measure again
4. Total excursion = inspiration measurement − expiration measurement

Normal Values:

Normal excursion at axillary level = 6-8 cm

Decreased Excursion — Causes:

• Emphysema (most common - chest fixed in inspiration)
• Pleural effusion or adhesions
• Pneumothorax
• Obesity
• Ankylosing spondylitis (rib joints fused)
• Severe pneumonia (pain limits breathing)

Increased Excursion:

• Compensatory on the healthy side after lobectomy/pneumonectomy

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IV. Other Parameters Assessed During Thorax Inspection

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Summary Table — Pathological Chest Forms

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Question 21 — Exam Answer

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I. Static Chest Inspection (Статический осмотр)

• Supraclavicular and infraclavicular fossae (pronounced, smooth, or bulging)
• Position of clavicles and ribs (oblique or horizontal)
• Intercostal spaces (width)
• Epigastric angle (angle of Louis)
• Position of scapulae
• Symmetry and ratio of anteroposterior (AP) to transverse dimensions (thoracic index)

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II. Normal Forms of the Chest (Норма)

Normal chest - regardless of form - is symmetrical, with both halves equal in size.

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III. Pathological Forms of the Chest

1. Emphysematous (Barrel-like) Chest

• Resembles hypersthenic but with wide intercostal spaces (unlike hypersthenic)
• AP diameter ≈ transverse; thoracic index may exceed 1.0
• Supra- and subclavian fossae smoothed or inflated (increased airiness of lung apex)
• Chest fixed in inspiration position
• Cause: Pulmonary emphysema (decreased lung elasticity, increased airiness)

2. Paralytic Chest

• Resembles a modified asthenic chest - flat, reduced AP diameter
• Can be asymmetric (one half smaller than the other)
• Lungs shrunken in size
• Cause: Severe malnutrition, long-term pulmonary tuberculosis

3. Rachitic (Pigeon / Keeled) Chest

• Sternum protrudes anteriorly (like a keel)
• AP diameter exceeds transverse diameter
• Cause: Rickets (vitamin D deficiency in childhood)

4. Funnel (Foveated) Chest — Pectus Excavatum

• Depression in the lower part of the sternum
• Also called "shoemaker's chest" (from prolonged pressure on the sternum)
• Cause: Congenital abnormality or chronic pressure

5. Scaphoid (Boat-shaped) Chest

• Depression in the upper and middle part of the sternum
• Cause: Syringomyelia (rare spinal cord disease)

6. Kyphoscoliotic Chest

• Develops from kyphoscoliosis (combined lateral + posterior curvature of the spine)
• Leads to impaired lung and heart function; predisposes to bronchitis, pneumonia, early respiratory and heart failure

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IV. Asymmetric Chest Changes

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V. Dynamic Chest Inspection (Динамический осмотр)

Types of Respiration:

Symmetry of Respiratory Movements:

• Normal: movements are symmetrical
• Unilateral lag (one side moves less) → pathology on that side:
  • Pleurisy, fluid or gas in pleural cavity, pleural adhesions, pneumofibrosis, obturator atelectasis, post-surgery

Respiratory Rate (RR):

• Normal: 16-20 per minute at rest
• Tachypnea (>20/min): bronchospasm, reduced respiratory surface (pneumonia, atelectasis, lung infarction), sharp chest pain (dry pleurisy, broken ribs)
• Bradypnea (<16/min): depression of the medullary respiratory center (cerebral hemorrhage, brain edema, brain tumor, toxic agents)

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VI. Chest Excursion (Дыхательная экскурсия грудной клетки)

Method:

• In men: under the inferior corners of the scapulae (posteriorly) and at the lower segment of the nipple (anteriorly)
• In women: at the level of attachment of IV rib to the sternum (anteriorly)

Measurement:

1. Measure circumference at maximum inspiration
2. Measure circumference at maximum expiration
3. Excursion = inspiration circumference − expiration circumference

Normal Values:

Decreased Excursion - Causes:

• Pulmonary emphysema (most common - reduced lung elasticity)
• Hydrothorax, pleurisy with effusion
• Pneumothorax
• Pleural adhesions
• Ossification of costal cartilages
• Rib fractures
• Severe obesity

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Summary Table

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Question 22 — Exam Answer

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Normal Breathing (Норма)

• Rate: 16-20 per minute
• Rhythm: regular
• Depth: moderate
• Both phases (inspiration + expiration) smooth and equal

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Abnormal Breathing Patterns — Overview

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1. Kussmaul's Respiration (Дыхание Куссмауля)

Character:

• Deep, noisy, frequent breathing
• Sometimes described as "breathing of a hunted animal"
• No pauses between cycles
• Very large tidal volume - audible from a distance
• Rhythm is regular but rate is fast

Mechanism:

Causes:

• Diabetic hyperglycemic-hyperketonemic coma (most classic cause - DKA)
• Uremic coma (renal failure - accumulation of acid metabolites)
• Severe metabolic acidosis of any origin

Key phrase for exam:

"Deep, noisy, frequent breathing in decompensated acidosis - diabetic or uremic coma"

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2. Cheyne-Stokes Respiration (Дыхание Чейна-Стокса)

Character:

1. Apnea (respiratory pause) lasting up to 1 minute
2. Then breathing resumes as very shallow breaths
3. Breaths gradually increase in depth (crescendo) - reaching maximum at 5th-7th breath
4. Then gradually decrease in depth (decrescendo)
5. Returns to apnea → cycle repeats

Apnea → shallow → deeper → DEEP → deeper → shallow → Apnea → ...
          ↑_____________crescendo-decrescendo____________↑

Mechanism:

Causes:

• Acute insufficiency of cerebral circulation (brain stroke) - classic cause per textbook
• Severe heart failure (cardiac Cheyne-Stokes)
• Brain edema, tumors
• Uremia, severe intoxication
• Can be physiological in newborns and elderly during sleep

Key phrase for exam:

"Crescendo-decrescendo breathing with prolonged apnea (up to 1 minute) - seen in acute cerebrovascular accident (stroke)"

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3. Biot's Respiration (Дыхание Биота)

Character:

• Series of rhythmic, deep respiratory movements of equal amplitude
• Interrupted by sudden respiratory pauses (apnea)
• Unlike Cheyne-Stokes: amplitude does NOT change between pauses - all breaths are equal depth
• Pauses appear and disappear abruptly (not gradually)

deep-deep-deep-deep → PAUSE → deep-deep-deep-deep → PAUSE → ...
(equal depth throughout)

Mechanism:

Causes:

• Inflammatory diseases of the brain and meninges:
  • Meningitis
  • Encephalitis
• Increased intracranial pressure
• Brain tumor pressing on medulla
• Severe brain injury

Key phrase for exam:

"Equal-depth breaths with sudden apnea - seen in meningitis and encephalitis"

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4. Grocco's (Undulant / Wavy) Respiration — Bonus

Character:

• Similar to Cheyne-Stokes but NO complete apnea
• Breathing only becomes very superficial at its minimum (never stops)
• Considered a prelude to Cheyne-Stokes respiration

Cause:

• Early stages of the same conditions causing Cheyne-Stokes
• Less severe depression of the respiratory center

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Comparison Table (Exam Summary)

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Memory Aid