8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 1/33
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 2/33
LEGENDAEu=normal
Dis=patologic Tahi= ↑ frecventei
Bradi = ↓ frecventei
Atelectazie=Emfizem pulmonar=Emfizem cutanat =Pleurezie=Pneumotorace=Empiem=
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 3/33
INSPECTIA(bolnavul in pozitie sezanda)
SCOP:
1. Conformatia2. Miscarile respiratorii
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 4/33
1. CONFORMATIA≈ Simetric Clavicule orizontale
Stern cu deprimare usoaraUnghiuri
Coaste+ spatii intercostale (i.c.)ScapuleApofize spinoase vertebraleØ AP /Ø transversal = 1:2→5:7
ElipticDiferente constitutionale:alungit (longilini)Ø transversal ≥ Ø vertical (picnici)
“torace patrat”
Louisepigastric (70-110°)
Coloana =45 ° (P)
Orizontale (A)
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 5/33
DEFORMARI ALE CUTIEI TORACICE
GLOBALE - simetrice- asimetrice
LOCALE
- asimetrice
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 6/33
A) DEFORMARI GLOBALE SIMETRICE:1.TORACE EMFIZEMATOS (in butoi/”in INSPIR”)
Emfizem pulmonar Cifoza rotunda Varstnici
Ø AP
-Orizontalizare coaste
-Umplere spatii i.c., fose supra/infraclaviculare MOBILITATE ↓
-Proeminentra unghiului Louis
EXPIR ↑ -Unghi epigastric>110° RIGIDITATE
-Umeri ridicati
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 7/33
2.TORACE PARALITIC (“in EXPIR”) constitutional
- turtire AP
- coaste vizibile, verticalizate
- unghi epigastric<70°
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 8/33
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 9/33
4.TORACE INFUNDIBULIFORM (pectus excavatum) congenital
dobandit (rahitism, “torace de pantofar”)
- depresiune in zona inf. stern+cartilaje costale
Repercursiuni asupra organelor intratoracic
CT
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 10/33
5.TORACE CONOID (“in clopot”) patologia intraabdominala, care → departarea rebordurilor costale
- Ø bazale ↑↑
- ↓miscarile respiratorii ale diafragmului
Hepatosplenomegalie
AscitaTumori
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 11/33
B) DEFORMARI GLOBALE A SIMETRICE:1.CIFOSCOLIOZA
Cifoza Scolioza
**
Modificari majore :
► dinamica respiratorie
► starea org. intratoracice (CPC)
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 12/33
Cifoza Scolioza
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 13/33
C) DEFORMARI UNILATERALE:
Bombarea bazei 1 hemitoraxLargire spatii i.c.Ascensiune umar+mamelonScolioza omolaterala
1. Colectii pleurale ↑ (lichidiene,aeriene): pleurezie, empiem,pneumotorax sub tensiune
2. Contralateral unei atelectazii
Retractia 1 hemitorax
Ingustare spatii i.c.
Coborare umar+mamelon
Scolioza omoconvexa
± Deplasare mediastin
1. Atelectazie
2. Fibrotorax
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 14/33
Tumefiere difuza torace ±gat, fata
Emfizem s.c.
Bombare circumscrisa
(pleurezia pulsatila)Empiem cu progresiune spre fistulizareext. (empiem de necesitate)
Stern deplasat??contra lateral
1. Pleurezii masive
2. Neo bronhopulmonare voluminoase
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 15/33
2. MISCARILE RESPIRATORII TORACICE
Ritmice
EgaleSincrone la ambele hemitorace Silentioase
ν= 16-20/min.
durata IN/durata EX= 1:3
Tip respirator
↑: Copii↓: Varstnici
Costodiafragmatic : Copii+♂
Toracic(Costal superior): ♀
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 16/33
A) MODIFICAREA FRECVENTEI RESPIRATORIITAHI PNEE ( ν >20/min)
BRADI PNEE ( ν <14/min)
HIPERVENTILATIE= hiperpnee generatoare de alcaloza metabolica
POLI PNEE (↑Amplitudine)
dispnee restrictiva necesitati ↑ (Febra, efort, anxietate, stari hipermetabolice, etc)
Resp. KÜSSMAUL(≈efort fizic)
Amplitudine Normala=VC 500ml vehiculat
↑ Amplitν = ↑/N/↓
Acidoza metabolica (cetoacidoza DZ, uremie, intox. medicamentoasa
Boli cerebrale (come, encefalopatie HTA, meningite) Intoxicatii Somn
exogene(alcool, opiacee, barbiturice)endogene (uremie, acidocetoza DZ)
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 17/33
B) DISRITMIE RESPIRATORIE = alterarea succesiunii regulate arespiratiilor
Respiratie CHEYNE-STOCKES (“marea respiratie periodica”):- hiperpnee fluctuanta+apnee (15-30sec.)
Respiratie BIOT- perioade scurte de apnee dupa 4-5 respiratii de amplitudine egala
APNEE – intreruperea respiratiei
sanatosi la altitudini ↑ varstnici : in somn
IVS BAV IR HTIC (edem cerebral, encefalopatie HTA)
meningite leziuni bulbare/ medulare
(angajare bulbopontina)
embolie pulmonara masiva obstructie completa cale respiratorie principala lez.cerebrale extinse
5 i /h
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 18/33
Apnee de somn: 1. obstructiva ( colaps faringe)2. centrala (lez.neuronale, pierderea stimularii reflexelor ventilatorii
de la Rec.nazali)
- treziri nocturne repetate
- somnolenta diurna
- cefalee matinala
- HTA, HTP
- deteriorare inteletuala
- modificarea personalitatii
- impotenta
>5 epis./h>30 epis./noapte
ATAXICA
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 19/33
Respiratie ATAXICA
- neregulata
Respiratie APNEUSTICA
- neregulata
- IN ↑+zgomotoasa→ retinerea aerului in torace→ EX ↓+ineficace
lez. grave+extinse bulbopontine
agonie
leziuni grave trunchi cerebral
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 20/33
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 21/33
3. ZGOMOTE RESPIRATORII
STRIDOR (Cornaj ):
- Intens- Tonalitate inalta- IN ± EX- ↑: tuse, hiperpnee (efort)- LARINGIAN (IN): edem, exudat, crup, spasm, corp strain- TRAHEAL ( IN+EX): Tu
WHEEZING
- Intensitate < stridor-Tonalitate inalta- timbru muzical (≈mienuat )- EX ± IN- ↑: infectii, expunere la praf, hiperpnee (efort)
obstructie partiala CRS (larinfe, trahee) +dispnee
obstructie partiala CRI +dispnee
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 22/33
3. ZGOMOTE RESPIRATORII
RONCHUS
RESP. STERTOROASA
-Tonalitate joasa- aspru- IN
- neregulat
barbotare aer in secretiile din CRS
vibrarea secretiilor aderente parietale
vibrarea luetei/val palpatin/pilieri post. in SOMN/COMA
Sanatosi 10% (obezi)
Patologic (apnee de somn)
4 SCA S A O A O A
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 23/33
4. MISCARI RESPIRATORII ANORMALE
MODIFICAREA TIP RESPIRATOR♂ cu tip costal sup.:
♀ cu tip diafragmatic:
ASIMETRIE/ASINCRONISM (resp. oblica) ! Hemitorax afectat ↓/0
durere ↑pres.intraabdominala (↑ F+Spl, ascita)
pleurezie.
SA ce inh. misc. plastron sternocostal
paralizie m.i.c.
restrictie ventilatorie 1 Plaman: pneumonie pleurezie pneumotorax TBC
neo corp strain in bronsie principala
ce inh. misc. resp. diafragm
4 MISCARI RESPIRATORII ANORMALE
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 24/33
4. MISCARI RESPIRATORII ANORMALE
IN fortata
- contractia m. SCM- narine dilatate- gura intredeschisa
EX fortata
- contractia m. abdominali- respiratie pufaita
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 25/33
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 26/33
PALPAREA
(bolnavul in pozitie sezanda)
SCOP:
1. confirmare/completare Inspectie2. semne noi
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 27/33
2 MISCARI RESPIRATORII
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 28/33
2. MISCARI RESPIRATORII
ν resp.:
Asimetrie+asincronism respir.:
Miscari resp. anormale
- Palma in epigastru
- Varful degetelor pe apendice xifoid
- Din fata/spatele bolnavului
- coaste sup.: maini pe umeri, varf degete pe clavicule
- coaste inf.: palme pe reborduri costale/fata lat.thorax
3 SENSIBILITATE PROVOCATA
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 29/33
3. SENSIBILITATE PROVOCATA
Durere de etiol. PARIETALA:
- Celulita
- ZZ
- Fracturi: coaste, clavicula, stern
- Polimiozita
- nevralgia i.c.: punctele VALLEIX toracice(spinal, axilar, parasternal)+tot sp.i.c.
+: flectarea coloanei ipsilaterala
- nevralgia n.frenic : punctele
o scalenic
o parasternal
o buton diafragmatic MUSSY
3 SENSIBILITATE PROVOCATA
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 30/33
3. SENSIBILITATE PROVOCATA
Durere de etiol. PLEUROPULMONARA:
- presiunea + junghiul
- flectare contralaterala coloana dorsala
4 FRECATURA PLEURALA: pleurita
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 31/33
4. FRECATURA PLEURALA: pleurita
Senzatie aspra (≈matase, talpa noua) IN+EX
↑: presiunea palmelor, hiperpnee ↓→Ø: faza exudativa ± reapare: resorbtia lichidului pleural
- respiratie profunda
- palme ant+post.+lat.
5 FREAMAT PECTORAL← fonatie tuse resp zgomotoasa
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 32/33
5. FREAMAT PECTORAL← fonatie, tuse, resp.zgomotoasa(VOCAL): “33”
Senzatie ≈ palma pe capacul pianului
↑: ♂, 1/3 sup.thorax sp.
- palme simetric+simultan in zone etajate toracice: 3ant, 3 post, 1 lat.
- intensitatea dep. de : intensit. vociitopografiegrosimea perete thorax
1. Condensari>10-12cm(pneumonie, infarct, TBC, Tu, atelectazie, fibro
2. Cavitate superficiala, >6-8cm, comunicare larga cu bronsia, tesutdens inconjurator ( caverna TBC, ch.hidatic, abces evacuat)
3. Bronsiectazie
! Bronsia de drenajPERMEABILA
I, II i.c.juxtasternalinterscapulovertebrale
5 FREAMAT PECTORAL← fonatie tuse resp zgomotoasa
8/13/2019 inspectia si palparea toracelui
http://slidepdf.com/reader/full/inspectia-si-palparea-toracelui 33/33
5. FREAMAT PECTORAL← fonatie, tuse, resp.zgomotoasa(VOCAL): “33”
↓:
Ø:
1. Boli cu afectarea vocii (debilitare fizica, pareza corzi vocale)2. ↓ Ø bronsii (stenoze, compresiuni ext., secretie ↑↑) 3. ↓ elasticitate plaman (emfizem)
4. Patologie pleurala cu ecranarea vibratiilor (colectii mici,pneumothorax partial, pahipleurita)
1. Afonie (paralizia de corzi vocale)
2. Obstructie completa bronsii (corp strain, Tu)→ atelectazie deresorbtie3. Bronsie plina cu exudat (pneumonia masiva Grancher)4. Patologie pleurala masiva (colectii mari, pneumothorax total)