Medical Semiology Guide of the Respiratory System 0128161132, 9780128161135

Table of contents :
Cover
MEDICAL SEMIOLOGY GUIDE OF THE RESPIRATORY SYSTEM
Copyright
About the Author
MANUELA STOICESCU
Motto
Thank you all my students!
Scientific Activity
ACCOMPLISHMENTS
Publications 51
BOOKS 7
PUBLICATIONS 56
CONFERENCES 2018
CONFERENCES 2019
Introduction
The History of the Patient
1 PERSONAL DATA
2 PLACE OF BIRTH AND HOME (ADDRESS)
3 ALLERGY?
4 THE REASON FOR HOSPITALIZATION
4 Example No. 1
4 Example No. 2
4 Example No. 3
4 Example No. 4
5 THE HISTORY OF THE CURRENT DISEASE
6 FAMILY HISTORY
7 PERSONAL PATHOLOGICAL HISTORY
8 PERSONAL PHYSIOLOGICAL ANTECEDENTS
9 LIFE CONDITIONS
A The housing conditions
B Eating
Toxic consumptions
C Alcohol consumption
C Smoking
C Coffee
C Drugs
10 WORKING CONDITIONS
11 GENERAL MANIFESTATIONS
1 - Questionnaire
2 - The Main Symptoms of the Respiratory Diseases
2.1 Pleural Pain—Stabbing Pain
2.2 Stabbing Pain in Pleural Diseases
2.3 Dyspnea
2.4 Cough
2.5 Sputum (Expectoration)
2.5.1 The Macroscopic Exam of the Sputum
2.5.2 The Quantity of Expectoration
2.6 Vomica
2.6.1 The Appearance and Color of Sputum
2.6.2 The Smell and Taste of Sputum
2.6.3 The Microscopic Examination of Sputum
2.6.4 The Bacteriological Examination of Sputum
2.7 Hemoptysis
Hemoptysis
Hemoptysis
The Chest X-Ray
3 - The Objective Examination
3.1 Typical Faces in the Respiratory Diseases
3.1.1 The Vultuous (Red) Face—In Pneumonia
3.1.1.1 Red Faces
RED FACES
3.1.1.2 Herpes on the Upper and Lower Lip Appears in Fever—Pneumonia
3.1.2 The Two Types of Face in Chronic Obstructive Pulmonary Disease
3.1.2.1 Faces in Pulmonary Emphysema—Type A
Pink Puffer
3.1.2.2 Faces in Chronic Bronchitis Blue Bloater–Type B
Blue Bloater
3.1.2.2.1 Blue Bloater Faces Left Lateral View
3.1.2.2.2 Cyanosis of the Lips and Tongue
3.1.2.2.3 Type B of COPD Bronchitis Blue Bloater
3.1.2.2.4 Type B of COPD Bronchitis Blue Bloater
3.1.2.2.5 Type B of COPD Bronchitis; Blue Bloater
3.1.2.2.6 Blue Bloater Faces Type B—Bronchitis of COPD
3.1.3 Doll Face
3.1.4 Faces in Claude Bernard–Horner Syndrome
4 - The Objective Examination of the Thorax
4.1 The Clinical Topography of the Anterior Chest
4.2 The Clinical Topography of the Lateral Chest
4.3 The Clinical Topography of the Posterior Chest
4.4 The Inspection of the Thorax
4.4.1 Normal Shape of Thorax—Anterior View
4.4.2 Normal Shape—Posterior View
4.4.3 Global Symmetric Deformations
4.4.3.1 Barrel Chest, Rounded or Bulging Chest—Anterior View
4.4.3.1.1 Barrel Chest, Rounded or Bulging Chest—Posterior View
4.4.3.1.2 Barrel Chest, Rounded or Bulging Chest—Left Lateral View
4.4.3.1.3 Barrel Chest or Emphysematous Chest—Anterior View
4.4.3.1.4 Barrel Chest—Left Lateral View
4.4.3.1.5 Barrel Chest—Left Lateral View
4.4.3.1.6 Barrel Chest—Left Lateral View With Left Arm Up
4.4.3.1.7 Barrel Chest—Left Lateral View
4.4.3.1.8 Barrel Chest, Rounded or Bulging Chest—Posterior View
4.4.3.1.9 Barrel Chest and Asymmetric Gynecomastia—Anterior View
4.4.3.1.10 Barrel Chest—Posterior View
4.4.3.1.11 Barrel Chest or Emphysematous Chest—Right Lateral View
4.4.3.1.12 Barrel Chest and Bilateral Gynecomastia
4.4.3.1.13 Barrel Chest and Bilateral Gynecomastia
4.4.3.1.14 Increased Volume of the Right Breast—Close-up Image
4.4.3.1.15 Gynecomastia—New Patient
4.4.3.2 Paralytic (Asthenic) Thorax—Anterior View
4.4.3.2.1 Paralytic (Asthenic) Thorax—Anterior View
4.4.3.2.2 Paralytic (Asthenic) Thorax—Posterior View
4.4.3.2.3 Paralytic (Asthenic) Thorax
4.4.3.2.4 Paralytic (Asthenic) Thorax
4.4.3.2.5 Paralytic (Asthenic) Thorax—Anterior View
4.4.3.2.6 Paralytic (Asthenic) Thorax—Anterior View—Close-up Image
4.4.3.3 Pigeon Chest or Pectus Carinatum—Anterior View
4.4.3.3.1 Pigeon Chest or Pectus Carinatum—Left Lateral View
4.4.3.3.2 Pigeon Chest or Pectus Carinatum—Right Lateral View
4.4.3.3.3 Pigeon Chest or Pectus Carinatum—Left Oblique View
4.4.3.4 Funnel Chest or Pectus Excavatum—Anterior View
4.4.3.4.1 Funnel Chest—Pectus Excavatum—Right Lateral View
4.4.3.4.2 Pectus Excavatum
4.4.3.4.3 Funnel Chest—Pectus Excavatum
4.4.3.4.4 Funnel Chest—Pectus Excavatum Anterior View
4.4.3.4.5 Funnel Chest—Pectus Excavatum Left Lateral View
4.4.3.4.6 Funnel Chest Pectus Excavatum—Top View
4.4.3.4.7 Funnel Chest Pectus Excavatum—Top View
4.4.3.4.8 Funnel Chest Or Pectus Excavatum—Top View
4.4.3.4.9 Funnel Chest or Pectus Excavatum—Top View—Closer View
4.4.3.4.10 Funnel Chest or Pectus Excavatum—Anterior View
4.4.3.4.11 Funnel Chest or Pectus Excavatum—Left Lateral View
4.4.3.4.12 Funnel Chest or Pectus Excavatum—Left Lateral View
4.4.3.4.13 Pectus Excavatum
4.4.3.4.14 Pectus Excavatum
4.4.3.4.15 Funnel Chest or Pectus Excavatum—Upper View
4.4.3.4.16 Posterior View of the Thorax
4.4.3.4.17 Posterior Left Lateral View of the Thorax
4.4.4 Asymmetric Global Deformations—Kyphoscoliosis
4.4.4.1 The Kyphoscoliosis—Posterior View Unilateral Deformations
4.4.4.1.1 The Kyphoscoliosis—Left Oblique Posterior View
4.4.4.1.2 The Kyphoscoliosis—Posterior View
4.4.4.1.3 The Previous Patient With Kyphoscoliosis—Anterior View
4.4.4.1.4 The Spine Kyphoscoliosis—Posterior View
4.4.4.1.5 Posterior View
4.4.4.1.6 Anterior View
4.4.4.2 Kyphosis—Left Lateral View
4.4.4.2.1 Kyphosis—Posterior View
4.4.4.2.2 Kyphosis—Left Lateral View
4.4.4.3 Scoliosis
4.4.4.4 Malformation of the Thorax After Dislocation of the Clavicle During Delivery
The Same Patient—Top View
4.4.4.5 Other Diverse Important Signs During the Inspection of the Thorax
4.4.4.5.1 Missing the Left Nipple—A Scar After Surgery—The Left Lateral View
4.4.4.5.2 Oblique Scar on the Left Lateral View of the Thorax After Surgery
4.4.4.5.3 Chest With Pacemaker—Anterior View
4.4.4.5.4 Chest With Pacemaker—Left Lateral Oblique View
4.4.4.5.5 Enlarged Right Breast—Anterior View
4.4.4.5.6 Enlarged Right Breast—Left Lateral View
4.4.4.5.7 Hypertrichosis
4.4.4.5.8 Hypertrichosis
4.4.4.5.9 Pityriasis Acromial
4.4.4.5.10 Pityriasis Acromial
4.4.4.5.11 Lipoma—Posterior Thorax
4.4.4.5.11.1 Lipoma—Posterior Thorax
4.4.4.5.11.2 Lipoma—Posterior Thorax
4.4.4.5.11.3 Lipoma—Posterior Thorax
4.4.4.5.11.4 Lipoma—Posterior Thorax
4.4.4.5.11.5 Lipoma—Posterior View
4.4.4.5.11.6 Lipoma—Lateral View
4.4.4.5.11.7 Lipoma—Anterior View
4.4.4.5.11.8 Lipoma—Lateral View
4.4.4.5.11.9 Lipoma
4.4.4.5.11.10 Palpation—Soft Consistency
4.4.4.5.11.11 Deep Palpation—Soft Consistency
4.4.4.5.11.12 Mobility Present
4.4.4.5.11.13 Lipoma—Posterior Thorax
4.4.4.5.11.14 The Palpation of Lipoma—Soft Consistency
4.4.4.5.11.15 Lipoma
4.4.4.5.11.16 Lipoma—Posterior View
4.4.4.5.11.17 Lipoma in the Posterior Region of the Thorax
4.4.4.5.11.18 Lipoma View Side View
4.4.4.5.11.19 Lipoma
4.4.4.5.11.20 Lipoma—On the Base of the Right Hemithorax
4.4.4.5.11.21 Giant Lipoma on the Posterior Thorax
4.4.4.5.11.22 Lipoma—Closer View
4.4.4.5.11.23 Giant Lipoma—Left Lateral View
4.4.4.5.11.24 Lipoma of the Left Shoulder
4.4.4.5.11.25 Lipoma—Top View
4.4.4.5.11.26 Lipoma—Top View
4.4.4.5.12 Purpura Eruption on the Anterior Chest and Arms
4.4.4.5.12.1 Purple Rash at the Rear of the Thorax
4.4.4.5.12.2 Purple Rash at the Level of Posterior Face at the Base of Right Hemithorax
4.4.4.5.13 Shingles on the Posterior Region of the Thorax
4.4.4.5.14 Pityriasis Acromial
4.4.4.5.15 Hemangioma
4.4.4.5.15.1 Hemangioma
4.4.4.5.15.2 Hemangioma—Close-up Images
4.4.4.5.16 Hives
4.4.4.5.17 Venectasia
4.4.4.5.18 Depigmented Area
4.4.4.5.19 Lentigines at the Level of the Anterior Chest
4.4.4.5.19.1 Lentigines—Close-up Images
4.4.4.5.19.2 Lentigo—Left Lateral Thorax
4.4.4.5.19.3 Lentigo—Change to Melanoma—Close-up Image
4.4.4.5.19.4 Lentigo—Posterior Thorax—Change to Melanoma
4.4.4.5.20 Collateral Circulation
4.4.4.5.21 Tattoos
4.4.5 Respiratory Movements of the Thorax
4.4.5.1 Changes in the Frequency of Respirations
4.4.5.1.1 Tachypnea
4.4.5.1.2 Polypnea
4.4.5.1.3 Hyperventilation
4.4.5.1.4 Kussmaul Breathing
4.4.5.1.5 Bradypnea
4.4.5.2 Cheyne–Stokes Breathing: Great Periodical Breathing
4.4.5.3 Biot Breathing
4.4.5.4 Ataxic Breathing
4.4.5.5 Apneustic Breathing
4.4.5.6 Apnea
4.4.5.7 Respiratory Sounds
4.5 Method of Palpation of the Thorax—The Apex of the Lungs—Posterior Incidence
4.5.1 Method of Palpation of the Thorax—The Middle Lobes of the Lungs—Posterior Incidence
4.5.2 Method of Palpation of the Thorax—The Inferior Lobes of the Lungs—Posterior Incidence
4.5.3 Method of Palpation of the Thorax—The Apex of the Lungs—Anterior Incidence
4.5.4 Method of Palpation of the Thorax—The Middle of the Lungs—Anterior Incidence
4.5.5 Method of Palpation of the Thorax—The Inferior Lobes of the Lungs—Anterior Incidence
4.5.6 Method of Palpation of the Thorax—Base Lateral Incidence
4.5.7 The Method of Palpation of the Thorax—Middle Lateral Incidence
4.6 Method of Percussion of the Thorax
4.6.1 Method of Percussion of the Posterior Thorax Right Apex
4.6.2 The Method of Percussion
4.6.3 Method of Percussion of the Anterior Thorax—Right Apex
4.6.4 Method of Percussion of the Anterior Thorax—Left Apex
4.6.5 Percussion of the Clavicles
4.6.6 Percussion at the Base of the Left Lateral Side of the Thorax
4.6.7 Percussion of the Base of Right Lateral Side of the Thorax
4.6.8 Percussion of the Middle Area of the Left Lateral Thorax
4.6.9 Percussion of the Middle Area of the Right Lateral Thorax
4.6.10 The Normal Resonant Sound of Thoracic Percussion
4.6.11 Pathological Sounds After Thoracic Percussion
4.6.11.1 Hyperresonance
4.6.11.2 Dullness
4.6.11.2.1 Pulmonary Consolidation Pneumonia
4.6.11.2.2 Acute Pulmonary Edema
4.6.11.2.3 Pus or Blood Inside The Pulmonary Alveoli
4.6.11.2.4 Atelectasis, Complete Resorption of Air From Pulmonary Alveoli
4.6.11.2.5 Pleural Effusion
4.6.11.2.6 Hard Dullness; Massive Pleural Effusion
4.6.11.2.7 Bilateral Pleural Effusion
4.6.11.2.8 Bilateral Pleural Effusion
4.6.11.3 Tympanic
4.6.11.3.1 Lung Abscess Before Evacuation—Dullness
4.6.11.3.2 Lung Abscess After Evacuation—Cavern Tympanic
4.6.11.3.3 Lung Tuberculoma Before and After Evacuation; Dullness—Tympanic
4.6.11.3.4 Hydatid Cyst in Lung Before and After Evacuation; Dullness—Tympanic
4.6.11.3.5 Lung Carcinoma Super infected
4.7 Modifications of the Lower Limit of the Lungs and Active Pulmonary Mobility
4.8 The Method of Auscultation of the Lung
4.8.1 Auscultation of the Anterior Chest
4.8.2 Auscultation of the Anterior Chest
4.8.3 Auscultation of the Posterior Thorax
4.8.4 Auscultation of the Left Lateral Chest
4.8.5 Basics of Lung Sounds
4.8.5.1 Vesicular Breath Sound
4.8.5.2 Bronchial Breath Sound
4.8.5.2.1 The Suprasternal Area and Posterior Area of the Neck
4.8.5.2.2 Bronchial Breath Sound
4.8.5.2.3 The Right and Left Lateral Cervical Area of the Neck
4.8.5.2.4 Bronchial Breath Sound
4.8.5.3 Bronchovesicular Sound
4.8.5.4 The Normal Auscultation of the Lung
4.8.6 Changes in Intensity of the Vesicular Sound
4.8.6.1 Vesicular Sound Accentuated
4.8.6.2 Vesicular Sound Diminished By Thickened Wall of the Thorax
4.8.6.2.1 Obesity
4.8.6.2.2 Edema of the Wall and Enlarged Breasts
4.8.6.3 Abolished Vesicular Sound—Respiratory Silence
4.8.6.3.1 Massive Left Pleural Effusion
4.8.6.4 Vesicular Sound With Prolonged Expiration
4.8.6.5 Pulmonary Emphysema
4.8.6.6 Crisis—Bronchial Asthma
4.8.6.7 Interrupted Vesicular Sound
4.8.7 Bronchial Pathology Breath Sound
4.8.7.1 Pneumonia in Phase of Consolidation
4.8.7.2 Pulmonary Infarction
Left Deep Vein Thrombosis
4.8.7.3 Infiltrative Tuberculosis
4.8.7.4 Lung Tumors
4.8.8 Pleuritic Murmur
4.8.8.1 Consolidation Area With Pleural Effusion
4.8.9 Pulmonary Cavity
4.8.9.1 Cavernous Murmur
4.8.9.2 Amphora Murmur
4.8.10 Blower Breathing Broncho Vesicular
4.8.11 Added Breath Sounds
4.8.11.1 Crackles—Fine (Rales)
4.8.11.2 Crackles—Coarse (Rales)
4.8.11.2.1 Pneumonia Congestive Phase—Crackles
4.8.11.2.2 Pneumonia Consolidation Phase—Pathologic Bronchial Sound
4.8.11.2.3 Pneumonia Resorption Phase—Crackles
4.8.11.2.4 Bronchopneumonia—Crackles and Wheeze
4.8.11.2.5 Acute Left Ventricular Failure
4.8.11.2.6 Acute Pulmonary Edema
4.8.11.2.7 Pulmonary Infarction
Deep Vein Thrombosis
4.8.11.2.8 Pulmonary Atelectasis
4.8.11.3 Rales of Decubitus
4.8.11.4 Bronchial Rales
4.8.11.4.1 Bullous Rales
4.8.11.4.2 Small Bullous Rales (Under Crackles)
4.8.11.4.3 Medium Bullous Rales
4.8.11.4.4 Big Bullous Rales
4.8.11.4.5 Dry Bronchitis Rales
4.8.11.4.5.1 Wheeze Rales
4.8.11.4.5.2 Rhonchus Rales
4.8.11.5 Pleural Rub
5 - The Complementary Investigations
5.1 The Radiologic Examination
5.1.1 The Pulmonary Vessels
5.1.2 Anomalous Pulmonary Parenchyma Transparency
5.1.2.1 Nodular Opacities
5.1.2.1.1 Pulmonary Tuberculosis
5.1.2.1.2 Acute Pulmonary Abscess
5.1.2.1.3 Pulmonary Abscess
5.1.2.1.4 Primary Tumors or Metastatsis
5.1.2.1.5 Lung Metastasis
5.1.2.1.6 Silicosis
5.1.2.1.7 Lobar Pneumonia in Phase of Condensation
5.1.2.1.8 Consolidation Syndrome
5.1.2.1.9 Lobar Pneumonia in Phase of Condensation
5.1.2.1.10 Pulmonary Atelectasis
5.1.2.1.11 Atelectasis
5.1.2.1.12 Apical Opacity—Atelectasis
5.1.3 Pleural Abnormalities
5.1.3.1 Pleural Effusion in Very Small Quantity
5.1.3.2 Pleural Effusion in a Small Quantity
5.1.3.3 Pleural Effusion in Medium Quantity
5.1.3.4 Massive Pleural Effusion
5.1.3.5 Encapsulation Pleural Effusion
5.1.3.6 The Pneumothorax
5.1.4 Mediastinal Abnormalities
5.1.4.1 Aneurysm of the Aortic Arch
5.1.4.2 Thymoma—Tumor of the Thymus
5.1.5 Hilar Lymphadenopathy
5.1.5.1 Asymmetrical Hilar Lymphadenopathy
5.1.5.2 Symmetrical Hilar Lymphadenopathy
5.1.5.3 Symmetrical Hilar Enlargement; Pulmonary Stasis
5.1.6 Pericarditis or Dilated Cardiomyopathy
5.1.7 Pulmonary Emphysema
5.1.8 Hydropneumothorax
5.1.9 Interstitial Pulmonary Fibrosis
5.1.10 Pneumonia in the Phase of Condensation
5.1.10.1 Pneumonia in the Phase of Condensation
5.1.10.2 Pneumonia the Phase of Condensation
5.1.10.3 Pneumonia in the Phase of Condensation
5.1.11 Nodular Formation
5.1.11.1 Nodular Formation
5.1.11.2 Nodular Formation
5.1.11.3 Nodular Formation
5.2 The Pleural Puncture
5.3 The Respiratory Functional Tests
5.3.1 Spirometry
5.3.2 Blood Gas Analysis
6 - Respiratory Clinical Cases
Pleural Effusion
Clinical Case No. 1
Pachypleuritis
Clinical Case No. 2
Pneumothorax
Clinical Case No. 3
Hydropneumothorax
Clinical Case No. 4
Hemothorax
Clinical Case No. 5
Lung Consolidation
Clinical Case No. 6
Atelectasis of the Lung
Complete Obstruction of the Bronchi
Atelectasis of the Lung
Clinical Case No. 7
Cavern of the Lung
Clinical Case No. 8
Abscess of the Lung Before Evacuation
Abscess After Evacuation
Clinical Case No. 9
Bronchial Asthma
Clinical Case No. 10
Acute Bronchitis
Clinical Case No. 11
Chronic Bronchitis
Clinical Case No. 12
Bronchiectasis
Clinical Case No. 13
Pulmonary Emphysema
Clinical Case No. 14
COPD
Clinical Case No. 15
COPD Type A—Pink Puffer
COPD Type B—Blue Bloater
The Chest X-Ray—COPD
Bronchopulmonary Neoplasm
Clinical Case No. 16
Clinical Case No. 17
Clinical Case No. 18
Pulmonary Emphysema
Clinical Case No. 19
Inspection of the Thorax
Palpation—Normal Tactile Fremitus
Percussion—Resonance
Auscultation—Tight Sound and Crackles at the Base of the Left Lung
Normal Alveoli and Alveolar Congestion
Clinical Case No. 20
Herpes Eruption on the Upper Lip
Auscultation of the Left Base of the Lung
Index
A
B
C
D
E
F
G
H
I
K
L
M
N
O
P
Q
R
S
T
V
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Back Cover

Citation preview

MEDICAL SEMIOLOGY GUIDE OF THE RESPIRATORY SYSTEM

Dr. Manuela Stoicescu Consultant Internal Medicine PhD, Assistant Professor University of Oradea Faculty of Medicine and Pharmacy Medical Disciplines Department Romania

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2020 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-0-12-816113-5 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

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About the Author MANUELA STOICESCU Consultant Internal Medicine doctor, PhD, Assistant Professor at University of Oradea, Faculty of Medicine and Pharmacy Medical Disciplines Department, Romania Education: Philology-History High School, Oradea, Chemistry e Biology e field High school diploma University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Faculty of Medicine and Pharmacy Romania - Physician University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca Romania - Residency Internal Medicine 5years - Certificate- Internal Medicine Specialist Feb 1996eOct 2001 Pe´dagogie training department, ClujeNapoca, Romania e Psychope´dagogie Certificate. Certificate of English language proficiency Residency e Internal Medicine Cluj Napoca e University of Medicine and Pharmacy ”Iuliu Hatieganu” Cluj-Napoca Romania, Department of Medical Semiology, Medical II Clinic e Cluj Napoca e City Internal Medicine Department, Medical II Clinic Cluj Napoca City. Assistant Professor at the University of Oradea e Medical Semiology Department e 2002epresent. Consultant Internal medicine doctor e 2006 Ph.D. thesis: "Hypertension in the young people - clinical features", -publication date Jul 28, 2010 publication description Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research Nr.4542 on 28. 07. 2010. publication description Ph.D. Thesis: "Hypertension in the young people - clinical features", original work, Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research, Youth and Sports Nr.4542 on 28. 07. 2010. PhD Consultant Internal Medicine doctor. PhD, Assistant Professor, University of Oradea, Faculty of Medicine and Pharmacy, Medical Disciplines Department Dates Employed: Jan 2001ePresent 2019; Employment Duration: 18 years 8 months; Location: Oradea - Romania She has been an invited speaker at 56 International Conferences in US and Europe, is Organizing Committee Member (OCM) in International Conferences in US and Europe, published 20 articles in prestigious journals in US and is Editorial Board Member in two prestigious ISSN journals in US: Journal of Developing Drugs and Surgery: Current Research.

ix

Motto

“Each patient is unique.We have to practice a personalized medicine”

“Semiology is a window that opens to the universe of internal medicine”

Thank you all my students!

I want to thank all my students because they exist; in this way I can continually perfect myself and remain young together with them through their enthusiasm.

Scientific Activity ACCOMPLISHMENTS Publications 51 Invited as speaker and Organizing Committing Member (OCM) at the 24th Annual Cardiologists Conference at Barcelona, Spain from June 11e13, 2018 - Manuela Stoicescu - “The cause of a young patient with third degree AV block”. Invited as speaker and Organizing Committing Member (OCM) at the 25th Annual Congress on Cardiology and Medical Interventions July 16e17, 2018 Atlanta, Georgia, USA - Manuela Stoicescu e“The hidden cardiovascular disease at a patient with pain in the left hypochondrium “ Invited as speaker Manuela Stoicescu at 17th Annual Conference on Nephrology” on December 04e05, 2017 Dallas, USA, publication dates 04 December, 2017 publication description:” Atypical urinary tract infection to a patient with unique kidney “. Invited as speaker Manuela Stoicescu at “International Conference on Biomarkers & Clinical Research” November 27e28, 2017 Atlanta, USA, publication date November 27, 2017, publication description: ”Noncorrelation between tumor biomarkers levels in peritoneal carcinomatosis”-volume 2, Issue 4. Invited as speaker Manuela Stoicescu and Committing Organizing Memberat “21st International Conference on Clinical & Experimental Cardiology” November 06e07, 2017 Las Vegas, USA, publication date November 06, 2017 publication description: “The risk of antidepressants drugs in patients with prolonged congenital QT syndrome “, volume 8, Issue 11, ISSN 2155e9880. Invited as speaker Manuela Stoicescu and Committing Organizing Member at “19th Annual Cardiology Conference” August 31 - September 01, 2017 Philadelphia, USA publication date August 31, 2017 publication description:“Silent ischemic heart disease - an ignored problem?!” Invited as speaker Manuela Stoicescu “15th International Conference on Nephrology” 28e30 August 2017 Philadelphia USA. Publication date August 30, 2017 publication description: “A simple renal cyst is really an innocent issue?”Volume 3, Issue 3: ISSN: 2472-1220. • Edit publication The risk of nitroglycerin drug administration in chronic diabetic patients Invited as speaker Manuela Stoicescu “4th Annual Congress on Drug Discovery & Designing” July 03e05, Bangkok, Thailand 2017 Publication title: “The risk of nitroglycerin drug administration in chronic diabetic patients” publication date July 3, 2017, Volume 6, Issue 3, ISSN: 2169-0138. • Edit publication The Liver - A victim at the Middle - due to Association of oral Antidiabetics Drugs with Statin Publication title - article “The Liver - A victim at the Middle - due to Association of oral Antidiabetics Drugs with Statin” Manuela Stoicescu Publication date May 11, 2017 publication description Journal of Developing Drugs ISSN 2329-6631 USA IF ¼ 0,97 • Edit publication “Surgical treatment of atrial fibrillation between benefit and risk” - Manuela Stoicescu - invited as speaker -“15th World Cardiac Surgery & Angiology Conference ” December 08e09, 2016 in Philadelphia, USA. Invited as speaker Manuela Stoicescu “15th World Cardiac Surgery & Angiology Conference ” December 08e09, 2016 in Philadelphia, USA. Publication title “Surgical treatment of atrial fibrillation between benefit and risk” Publication date Dec 8, 2016 publication description December 2016, Volume 7 Issue 10, ISSN: 2155-9880. • Edit publication “The surprise of diagnosis of a fluid collection around the spleen” - Manuela Stoicescu - Invited as speaker - 5th International Conference and Exhibition on Surgery - November 7e8, 2016 Alicante, Spain

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Invited as speaker Manuela Stoicescu“5th International Conference and Exhibition on Surgery” - November 7-8, 2016 Alicante, Spain Publication title “The surprise of diagnosis of a fluid collection around the spleen”Publication date November 7, 2016, Alicante Spain. • Edit publication “Early Predictive Markers Of Atherosclerosis In The Young” Manuela Stoicescu Publication title - article -“Early Predictive Markers Of Atherosclerosis In The Young” Manuela Stoicescu publication date September 30, 2016 publication description International Journal of Development Research Thomson Reuters - Impact factor 4,25 publication description Volume 06 Issue 09, September 2016, ISSN: 2230-9926 • Edit publication “The Risk of Sudden Decrease of Severe Arterial Hypertension” Manuela Stoicescu Publication title e article - “The Risk of Sudden Decrease of Severe Arterial Hypertension” Manuela Stoicescu Publication date July 31, 2016 publication description Journal of Clinical & Experimental Cardiology. USA, ISSN: 2155-9880 Journal Impact Factor 1.219*; 1.97* (5 Year Impact Factor) • Edit publication “Acanthosis Nigricans - early marker in cancer ” Manuela Stoicescu Publication title e article-“ Acanthosis Nigricans - early marker in cancer” Manuela Stoicescu Publication date July 15, 2016 publication description Asian Academic Research Journal of Multidisciplinary ISSN: 2319-2801 Thomson Reuters - IF ¼ 2,015 publication description Volume 3, Issue 7, July 2016 • Edit publication “Controversial in Menopausal Hormone Replacement Therapy” Manuela Stoicescu Publication title e article - “Controversial in Menopausal Hormone Replacement Therapy” Manuela Stoicescu publication date July 11, 2016 publication description Journal of Developing Drugs - USA. ISSN 2329-6631, IF ¼ 1,32 • Edit publication “The Unusual Cause of Dangerous Arrhythmias at the Young” Manuela Stoicescu Publication title - article-“The Unusual Cause of Dangerous Arrhythmias at the Young” Manuela Stoicescu publication date April 30, 2016 publication description Journal of Clinical & Experimental Cardiology USA, ISSN: 2155-9880 Journal Impact Factor 1.219*; 1.97* (5 Year Impact Factor) • Edit publication “Acute Pancreatitis after therapy with GABARAN” Manuela Stoicescu Publication title - article-“Acute Pancreatitis after therapy with GABARAN” Manuela Stoicescu publication date December 24, 2015 publication description Journal of Developing Drugs - USA. ISSN 2329-6631, IF ¼ 1,32 • Edit publication LAUNCH BOOK: “ Sudden cardiac in the young” - Manuela Stoicescu Invited as speaker Manuela Stoicescu “8th Global Cardiologists and Echocardiography Annual Meeting”- July 18-20, 2016 Berlin, Germany -LAUNCH BOOK: “Sudden cardiac in the young” - Manuela Stoicescu:publication date December 15, 2015 publication description book“ Sudden cardiac in the young”LAMBERT ACADEMIC PUBLISHING -LAP- GERMANY ISBN:978-3-659-81,073-2 Berlin, Germany July 2016 Volume 7, Issue 6, ISSN: 21559880. Invited as speaker Manuela Stoicescu and Committing Organizing Member at “ 6th International Conference on Clinical&Experimental Cardiology” November 30- December 02,2015 San Antonio, USA, - “ The Chest Pain with Normal EKG”, publication date November 30, 2015, San Antonio, USA. • Edit publication The Chest Pain with Normal EKG Invited as speaker Manuela Stoicescu and Organizing Committee Member at ”4th International Conference and Exhibition on Surgery”-October 05e07, 2015 Dubai, UAE • Publication title “Nodular Formations From The Hair Skin Of The Head”, publication date October 3, 2015 Dubai, UAE. https://www.linkedin.com/in/manuela-stoicescu-07974841/edit/publication/1478911795/ Invited as speaker Manuela Stoicescu - Workshop - Organizing Committee Member at ”4th International Conference on Nephrology & Therapeutics”- September 14e16, 2015 Baltimore, USA, Publication Workshop title: ”How We Can Protect The Kidney About The Side Effects Of Drugs?- publication date September 14, 2015, • Edit publication An Unusual Risk Factor in the Breast Cancer

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Invited as speaker Manuela Stoicescu and Organizing Committee Member-“World Congress on Cancer and Prevention Methods”- August 27e29, 2015, Dubai, UAE, Publication title “An Unusual Risk Factor in the Breast Cancer”, publication date August 27, 2015, Dubai, UAE. • Edit publication The Cause Of The Left Bundle Branch Block at a Young Patient Invited as speaker Manuela Stoicescu at the “5th International Conference on Clinical & Experimental Cardiology “- April 27e29, 2015 Philadelphia, USA, Publication title “The Cause Of The Left Bundle Branch Block at a Young Patient:publication date April 29,2015 Philadelphia, USA Invited as speaker Manuela Stoicescu and Organizing Committee Member-“Global Conference on Vaccines” April 13e15, 2015, Dubai, UAE, Publication title: “The Vital Importance of BCG Vaccination at the Newborns”: publication date April 13, 2015, Dubai, UAE. • Edit publication Beta- Human Chorionic Gonadotrophin (B-HCG total) as a tumor marker in pregnancy Invited as speaker Manuela Stoicescu “5th World Congress on Cell & Stem Cell Research” - March 23e25, 2015 Double Tree by Hilton ChicagoeNorth Shore, USA, Publication title: “Beta- Human Chorionic Gonadotrophin (B-HCG total) as a tumor marker in pregnancy”, publication date March 23, 2015 ChicagoeNorth Shore, USA. • Edit publication “The real cause of a patient with abdominal pain” Invited as speaker Manuela Stoicescu and Organizing Committee Member of the“3rd International Conference on Surgery and Anesthesia” from November 17e19 2014 at ChicagoeNorth Shore USA, Publication title: “The real cause of a patient with abdominal pain”, publication date November 17, 2014 at ChicagoeNorth Shore USA Invited as speaker Manuela Stoicescu at “4th World Congress on Cell Science & Stem Cell Research “e June 24e16, 2014 Valencia Conference Centre, Valencia, Spain. s” -Invited as speaker InPublication title:“Diagnosis traps in a rare hematologic disease”-publication date June 24, 2014 Valencia, Spain. • Edit publication -“The risk of coarctation of the aorta in pregnancy”Invited as speaker Manuela Stoicescu at “4th International Conference on Clinical & Experimental Cardiology” - April 14e16, 2014 Hilton San Antonio Airport, TX, USA. Publication title -“The risk of coarctation of the aorta in pregnancy”-, publication date April 14, 2014 San Antonio,TX, USA. Publication title - article - “Osteogenesis Imperfecta”- Manuela Stoicescu - Journal of Molecular and Genetic Medicine, USA., Published Date: February 26, 2014, ISSN: 1747-0862 Invited as speaker Manuela Stoicescu at “3rd World Congress on Cancer Science & Therapy” October 21-23, 2013 Double Tree by Hilton Hotel San Francisco Airport, CA, USA Publication title:“The risk of excessive vaccination in medullar thyroid carcinoma”, publication date October 21, 2013, San Francisco USA. • Edit publication “Onset of acute pancreatitis with transitory type II IN diabetes mellitus” Invited as speaker Manuela Stoicescu at “2nd International Conference on Surgery and Anesthesia, September 16-18, 2013, Hampton Inn Tropicana, Las Vegas, NV, USA. Publication title “Onset of acute pancreatitis with transitory type II IN diabetes mellitus”, publication date September 16, 2013, Las Vegas, Nevada, USA, • Edit publication “The Risk of administration plasma” Publication title-article - “The Risk of administration plasma”- Manuela Stoicescu, publication date July 23, 2013 publication description JOURNAL OF DEVELOPING DRUGS - ISSN 2329e6631, 2:106. https://doi.org/10.4172/ 2329-6631.1000106 Published July 23, 2013 USA. • Edit publication “Diagnosis Traps in Polyarteritis Nodosa” Publication title - article -“Diagnosis Traps in Polyarteritis Nodosa”- Manuela Stoicescu, publication date July 2013, publication description JOURNAL OF LIFE SCIENCES”- David Publishing Company e July 2013, Vol. 7, No. 7, pp. 749e753 ISSN 1934-7391, USA

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• Edit publication “The Risk of Breast Carcinoma with Interferon Plus Ribavarin Therapy during Treatment of Chronic Hepatitis C Virus Infection” Publication title - article -“The Risk of Breast Carcinoma after therapy with Interferon Plus Ribavarin during Treatment of Chronic Hepatitis C Virus Infection”-Manuela Stoicescu Published May 27, 2013.U S A. JOURNAL OF DEVELOPING DRUGS - ISSN: 2329e6631, Volume 2, Issue 1, 2:102. https://doi.org/10.4172/2329-6631.1000102. • Edit publication “Uncommon cardiac malformation in a rare genetic disease” Publication title - article - “Uncommon Cardiac Malformation in a Rare Genetic Disease”- Manuela Stoicescu publication date Apr 15, 2013: publication description JOURNAL OF CLINICAL & EXPERIMENTAL CARDIOLOGY SCOPUS U.S.A. J Clin Exp Cardiolog 2013, 4:51,000,244, ISSN: 2155e9880 JCEC,. 4:5 https://doi. org/10.4172/2155-9880.1000244, Volume 4, Issue 5, 1000244, ISSN: 2155e9880 JCEC. Publication title e article - “Kidney Tumor in Pregnancy” - Manuela Stoicescu publication date: July 29, 2013 publication description JOURNAL OF NEPHROLOGY & THERAPEUTICS 3: 138, https://doi.org/10.4172/2161-0959.1000138 2013 U S A. ISSN: 2161-0959. • Edit publication “Leyden V Syndrome and Hashimoto Thyroiditis”-original case report Invited as speaker Manuela Stoicescu at “Asian Clinical Congress”-Bangkok, Thailand, January 28e2013, Publication title: “Leyden V Syndrome and Hashimoto Thyroiditis”- publication date: January 28, 2013 Invited as speaker online Conference - Manuela Stoicescu. at” Target meeting, Draft Conference Program, TM’S 2 s world online Conference, January 8-11 2013, Innsbruck st, Bellaire, Texas, USA.-Publication title:”The real cause of a severely anemia syndrome”, Publication date January 8, 2013 Publication title - article -“The real intraoperative diagnosis of a patient with lipothymia and arterial hypotension”- Manuela Stoicescu, publication date November 26, 2012 publication description JOURNAL OF TRANSPLANTATION TECHNOLOGIES & RESEARCH- ISSN 2161-0991.U S A • Edit publication -“Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urographic Lack of Kidney Function” Publication title-article- “Avoiding Nephrectomy in an Unexpected Diagnosis in Case of Urographic Lack of Kidney Function”- Manuela Stoicescu - publication date November 22, 2012, USA. • Edit publication “High blood pressure in the young e a ignored problem?! ” Publication title“High blood pressure in the young e a ignored problem?! “Manuela Stoicescu publication date October 29, 2012 publication description University of Oradea Publishing House publication description Monography published: “High blood pressure in the young e a ignored problem?! ”. ISBN: 978-606-10-0755-4. • Edit publication “Carcinogenic risk of anabolic steroids in young athletes” Invited as speaker - Manuela Stoicescu - “Montreal 2012 International Anticancer Forum” eAugust 27e30, 2012., Publication title:“Carcinogenic risk of anabolic steroids in young athletes”, Publication date: August 27e30, 2012, Montreal, Canada Invited as speaker - Manuela Stoicescu - “8th International Stroke Summit (ISS8) World Stroke Organization (WSO)”, July 6-8 2012 Nanjing, China, Publication title “Neurological manifestations in systemic vasculitis” Publication date July 6, 2012 Nanjing, China. Publication title: “Clinical manifestations in primary erythrocytosis“-Manuela Stoicescu Publication date June 9, 2012 Xuzhou 2012 International Forum on Modern Medicine e June 9e10 2012, Xuzhou China. Invited as speaker - Manuela Stoicescu at “Montreal International Endoscopy Forum - International Forum on Biotechnology and Medicine” - May 24e25,2012 Montreal, Quebec, Canada, Publication titlee“The role of endoscopy in the diagnosis of Von Recklinghausen dissease” publication date May 24, 2012. • Edit publication -“Transiet ischaemic stroke attack at young age”-original case reportPublication title-“Transient ischemic stroke attack at young age” publication date March 15, 2012, publication description International Neuroscience Conference March 15e16, 2012, Toho University Omori Medical Center Tokyo, Japan. Publication description Invited as speaker Manuela Stoicescu -“Transient ischemic stroke attack at

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young age”-original case report-International Neuroscience Conference March 15e16, 2012, Toho University Omori Medical Center Tokyo, Japan. • Edit publication -“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- original case reportPublication title-“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- Manuela Stoicescu, Publication date January 13, 2012 publication description Hong Kong 2012 International Medical Summit, January 13e14, Hong Kong Community Healthcare and Healthcare Management Forum Hong Kong, China, January 13e14,2012. Publication description Invited as speaker Manuela Stoicescu -“The Abusive Utilization of Paraclinical Investigations at Limits between Methods of Depistations and Iatrogenic Risk Factors for Cancer”- original case report- Hong Kong 2012 International Medical Summit, January 13e14, Hong Kong Community Healthcare and Healthcare Management Forum Hong Kong, China, January 13e14,2012. • Edit publication “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”- original research Publication title “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”- original research Publication date January 12, 2012 publication description Target meeting, Draft Conference Program, TM’S 1st world online Conference, January 12e14, 2012, Innsbruck st, Bellaire, Texas, USA. publication description Invited as speaker online Conference - Manuela Stoicescu - “The dosage of plasma renin level-early marker in diagnosis of kidney carcinoma and pheochromocytoma in the young”original research eTarget meeting, Draft Conference Program, TM’S 1st world online Conference, January 12e14, 2012, Innsbruck st, Bellaire, Texas, USA. • Edit publication ”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- original research Publication title”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- Original research Publication date October 28, 2011 publication description EPS Global International Forum of Regional & Targeted Cancer Therapies Shanghai, China. Publication description Manuela Stoicescu - ”Determination of renin e early marker in the diagnosis of cancer at hypertensive young patients is important to become a screening test.”- original research - 3rd EPS Global International Forum of Regional & Targeted Cancer Therapies Shanghai, China. October 28e30, 2011 • Edit publication -“The role of increased plasmatic renin level in the pathogenesis of arterial hypertension in young adults.”- original research Publication title“The role of increased level of plasma renin in etiopathogenic arterial hypertension in the young “publication date 2011 publication description Volume 52 Number 1 ISSN 1220-0522. publication description Manuela Stoicescu, S. Bungau, C, Csepento, M. Gabriela: “The role of increased level of plasma renin in etiopathogenic arterial hypertension in the young” ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY Volume 52 Number 1 e Supplement (new series) - 2011, ISSN 1220e0522 PhD. thesis: “Hypertension in the young people - clinical features”, Publication date July 28, 2010 publication description obtained the title of doctor of medicine according to the Order of the Minister of Education, Research Nr.4542 on 28.07.2010. Publication description PhD thesis: “Hypertension in the young people - clinical features”, original work, Obtained the title of doctor of medicine according to the Order of the Minister of Education, Research, Youth and Sports Nr.4542 on 28.07.2010. PhD.

BOOKS 7 “Clinical Cases for Students of the Faculty of Medicine”Publication date 2010 publication description University of Oradea University assistant Publishing House. Publication description “Clinical Cases for Students of the Faculty of Medicine”-author: Dr Manuela Stoicescu Internal Medicine MD, PhD, University of Oradea University assistant Publishing House, 2010 - ISBN 978-606-100198-9/publication in English languages- and Romanian. Language ISBN:978-606-10-0132-3.

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Book published: Manuela Stoicescu: “Sudden Cardiac Death in the Young” International Editure LAMBERT Academic Publishing e Germany e ISSN:978-3-659-81,073-2 -2015. Manuela Stoicescu e “Side effects of antiviral hepatitis treatment” International Editure LAMBERT Academic Publishing e Germany ISSN 978-3-659-47,428-6 - 2013. Book published: Manuela Stoicescu: “Tumor Markers in Hypertensive Young Patients” e OMICS PUBLISHING HOUSE, USA ISBN:978-1-63,278-041-6 e March 2015. Cardiovascular diseases: Causes, Risks, Management CVD 1 e Causes of Cardiovascular Diseases Manuela Stoicescu MD, PhD 1.5, 1.6- on Amazon, USA. High blood pressure in the young - an ignored problem?! e Manuela Stoicescu - monograph published Publishing House Oradea, Romania 2012 ISBN:978-606-10-0755-4. “Acute renal failure after therapy with Interferon” Publication description speaker and Co-chair Manuela Stoicescu - Member in Committing Organizing of the 3rd International Conference on Nephrology & Therapeutics (Nephro-2014) June 26e27, 2014 Valencia Conference Centre, Valencia, Spain. Publication description Invited as speaker and Co-chair Manuela Stoicescu - Member in Committing Organizing of the Conference e“Acute renal failure after therapy with Interferon”- 3rd International Conference on Nephrology & Therapeutics (Nephro-2014) June 26e27, 2014 Valencia Conference Centre, Valencia, Spain. Member in manes Committing Organizing International Conferences USA Member in Committing Organizing International Conference DUBAI Member in Committing Organizing International Conference SPAIN Editorial Board Member International Conference Cardiology

PUBLICATIONS 56 CONFERENCES 2018 Invited as speaker at the 27th World Oncologist Annual Conference on December 07-08, 2018, Chicago, USA, Theme: “Believe there is hope for a cure”dManuela Stoicescud“The pesticidesdcarcinogenic risk factor!“ Invited as speaker at the 12th International Conference on Hematology and Hematological Oncology on October 29-30, 2018, San Francisco, USAdManuela Stoicescud“The quantification of irradiant investigations important role in prophylaxis of hematologic diseases” Invited as speaker at the 4th "International Conference on Gastrointestinal Cancer and Therapeutics“d"Termination of GI Cancer by Novel and Innovative Technologies" on October 29-30, 2018, San Francisco, USAdManuela Stoicescud“The patients with hyperuricemia needs screening colonoscopy” Invited as speaker and Organizing Committing Member (OCM) at the American Heart CongressdCVD 27th International Conference on Clinical & Experimental, Cardiology Research on October 05-06, 2018, Los Angeles, California, USAdManuela Stoicescud“Hormone replacement therapy really protects a woman against myocardial infarction?” Invited as speaker at Euro Pharmaceutics 2018d17th Annual Congress on Pharmaceutics & Drug Delivery SystemsdSeptember 20-22, 2018, Prague, Czech RepublicdManuela Stoicescud“Drug abusedan uncontrollable phenomenon !?”

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CONFERENCES 2019 Invited as speaker and Organizing Committing Member (OCM) at the 31st Annual Cardiologists Conference on June 17-19, 2019, Rome, ITALY, Theme:“ Insights of Cardiology & Healthcared Manuela Stoicescud”The combination between digoxin, beta blocker and cordarone is dangerous” Invited as speaker at the 27th Annual Congress on Cardiology and Medical Interventions on July 31-August 01, 2019 Chicago, USA, Theme: “Prediction and Preventions” dManuela Stoicescud” Very severe bradycardia 10 bates/min after combination of drugs “

YOU ARE READY? I AM YOUR LADY TEACHER

WE WILL DISCUSS THE PATIENT’S HISTORY

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Introduction The History of the Patient The history of the patient represents the first contact and discussion of the physician with the patient and is very important. Taking a superficial history because of a lack of time is not excusable because it can generate mistakes. A serious and careful history of the patient will aid in a successful diagnosis. We must always ask a few typical questions, which are presented next.

Look at me how carefully I am talking to the patient and take notes!

In the first instance I will ask about personal information: name, age, gender.

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1. PERSONAL DATA What is your name? How old are you? I observe if the patient is a man or a woman, because I know that some diseases are more common in women and other diseases appear more often in men.

2. PLACE OF BIRTH AND HOME (ADDRESS) Where were you born? Where do you live? What is your address? What is your phone number?

3. ALLERGY? I will ask my patient if he or she is allergic to any drugs. If the answer is yes, I will ask what drugs have caused allergy in the past and I will mark it with red color in the personal papers of the patient. Very important! The administration of these drugs must to be avoided to prevent anaphylactic shock, Quincke edema, or sudden death. For example, I noticed: allergy to aspirin allergy to penicillin

So, I will never give this patient aspirin or penicillin!

4. THE REASON FOR HOSPITALIZATION The reason for hospitalization represents the main symptoms about which the patient came for consultation. There is always a major symptom; this is the leading symptom. The patient may also present with other symptoms. These must be put in order per anatomy and system.

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Example No. 1 -

Syncope is the leading symptom Dyspnea Chest pain Palpitations

Example No. 2 -

Hematuria is the leading symptom Pollakiuria Dysuria Chills Fever

Example No. 3 -

Hemoptysis is the leading symptom Dyspnea Chills Fever

Example No. 4 - Abdominal pain - Nausea - Vomiting

5. THE HISTORY OF THE CURRENT DISEASE In this section we need to describe in detail the history of the current disease of the patient. First, we need to specify: How did the disease start? Was it sudden or insidious? How long ago did it begin? What are the symptoms? What was the patient’s attitude toward the disease? Has the patient presented him- or herself to a doctor or stayed at home? Did the patient begin medical treatment on the advice of a physician or did he or she begin treatment alone? Or did the patient not follow any treatment? Did he or she start a drug treatment that had an influence on the disease? Was there improvement, aggravation, or any influence? Is this the first episode or have there been other similar episodes in the past? In this section it is necessary to describe in detail the actual history of the patient as regards what he or she is being hospitalized for, as complete as possible. If the patient currently has more than one disease, we have to take a history of each one, following the same elements presented before.

6. FAMILY HISTORY In this section we need to describe what diseases are in the patient’s family. What diseases have the mother, father, brothers, sisters had? This is because there exists a risk for genetic transmission, for example, arterial hypertension, diabetes mellitus, cancers at various locations, and genetic diseases with dominant or recessive transmission. These diseases are important because the patent has a genetic risk for developing these diseases at any point in time.

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7. PERSONAL PATHOLOGICAL HISTORY In this section we need to describe all the diseases that the patient had in the past and also surgical procedures, in chronological order, except for the current illness.

8. PERSONAL PHYSIOLOGICAL ANTECEDENTS In this section we need to describe all the physiological antecedents in women regarding menstrual cycles and pregnancies. At what age did the first cycle (menarche) occur? Normal age is between 12 and 14 years. Have menstrual cycles been regular? Once per month? Normal cycle is 28 days. How many days does the flow take? Normal is between 3 and 5 days. How do you estimate the amount of blood lost during the menstrual cycle? Normal is between 300 and 500 mL of blood. Have you ever had cycles longer than 10 days? This is called menorrhagia. This is specific for uterine fibroids. Have you ever had bleeding between menstrual cycles? This is called metrorrhagia. This is specific for uterine fibroids Have you had abnormal menstrual cycles with a quantity more than 500 mL? This is called hypermenorrhea. This is specific for uterine fibroids Have you had abnormal menstrual cycles with increased quantity and with blood clots and prolonged duration of more than 5 days? This is specific for uterine fibroids. How do you describe the color of the blood? Normal is fresh red. Have you ever had a dark bleeding that looks like coffee or coffee grounds? This is specific for uterine carcinoma. Have you ever had bleeding like juice in which meat was washed? This is specific for uterine carcinoma. Are you in menopause? At what age did menopause begin? Normal age for menopause is between 45 and 50 years. Are you in early menopause or artificial menopause after ovariectomy, radiotherapy, or chemotherapy? This is a risk factor for ischemic heart disease, because the woman has lost the protection of estrogen hormones against atherosclerosis. Have you had bleeding in menopause? This is specific for uterine carcinoma. Have you been pregnant, and how many times? Was the delivery at normal time, 9 months, or early or late? Have you had any abortions, and how many? Were the abortions spontaneous or induced? What did your babies weigh after delivery? Normal weight is between 3 and 4 kg. A baby bigger than 4 kg is a “big baby” or has macrosomia and represents a risk factor for diabetes mellitus of the mother in the future. A baby less than 3 kg is premature.

9. LIFE CONDITIONS The life conditions of the patient are very important. Especially important are the housing conditions, eating, and toxic consumptions.

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A. The housing conditions The housing conditions are very important because people spend most of their time at home. It is important to know how many persons live in a room and how many rooms are in the house. The infectious contagious diseases such as viruses, pneumonia, and tuberculosis are transmitted when the people cohabit. Another important condition is the cleanliness of the house. Is it a clean house or not? Is it an overcrowded house or not? Are people living together with cats, dogs, a parrot? Because animals can transmit diseases to the persons who live with the animals. Room air conditioning is a risk factor for respiratory tract infections and allergies as well.

B. Eating A person’s diet is very important. It must be nutritionally balanced in accordance with the physical effort. A normal diet should be varied and balanced in the content of proteins, carbohydrates, lipids, and vitamins. A unilateral diet excessive in glucoses and carbohydrates represents a risk factor for diabetes mellitus. A unilateral diet increased in animal lipids represents a risk factor for dyslipidemia, atherosclerosis, ischemic heart diseases, angina pectoris, and heart attack. Also, excess calories together with sedentary habits are a risk factor for obesity, high blood pressure, and diabetes mellitus. Deficiency in diet leads to weight loss. Failure to eat regular meals is a risk factor for the occurrence of gastritis and gastric or duodenal ulcers.

C. Toxic consumptions In this section, the patient should be asked about the toxic consumption of alcohol, smoking, coffee, and drugs. Alcohol consumption In terms of alcohol consumption the patient should be asked how often he or she consumes alcohol: every day or occasionally? The truth is that alcohol is often not recognized by the person concerned; usually the family is the one who informs the doctor about alcohol consumption. It is important to know the amount consumed and what kind of alcoholic beverages are consumed, hard alcohol or light alcohol, like beer or wine? Persons with chronic alcohol consumption have risks for many diseases, such as chronic alcoholic hepatitis, liver cirrhosis, gastric or duodenal ulcers, mental illnesses such as alcoholic dementia, and others. Smoking Smoking is another risk factor for many diseases. It is really important to ask the patient at what age he or she began smoking (how long?). What type of cigarette, with filter or without filter? How often? Daily? How many cigarettes per day? Pipe smokers are at risk for lip cancer. Smoking is an important risk factor for cardiovascular diseases such as ischemic heart disease, angina pectoris, acute myocardial infarction, cardiac arrhythmias, and sudden death; respiratory diseases such as chronic tobacco bronchitis, COPD, and bronchusepulmonary cancer; and digestive diseases such as gastric ulcer or duodenal ulcer. We must consider the state of the passive smoker. This is represented by peopledinnocent victimsdwho passively inhale cigarette smoke because they are around a person who smokes. The most innocent victims are children. Passive smokers are at risk for the aforementioned diseases in a percentage almost as great as active smokers! The younger the age at which smoking started, and the higher the number of cigarettes a day, the higher is the risk for the diseases mentioned. Coffee Coffee consumption has been known from the earliest times. This small daily vice is practiced around the world. Abuse of coffee consumption can cause palpitations, tachycardia, irritability, nervousness, and insomnia. It is also a risk factor for the occurrence of high blood pressure and dangerous arrhythmias. Drugs Drug consumption represents a risk factor for dangerous arrhythmias, myocardial infarction at a young age, and sudden death. Bacterial endocarditis represents another risk after drug consumption. Drug consumption must to be stopped, especially because many victims are young people.

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10. WORKING CONDITIONS Working conditions represent another important part of the history of the patient. Many risk factors are present at the workplace. For this reason it is very important to ask and to know the profession of the patient. How many hours are worked per day? Risk factors from work include dust, humidity, and noise. Does the patient work during the night? Work supplementary hours? How are his or her relationships with colleagues? Relationship with the boss? Everything is important!

11. GENERAL MANIFESTATIONS The history of the patient finishes with a few important questions regarding general manifestations such as: Appetite The weight curve - increasing? - decreasing? - stationary? The stool The urine Frequency of urination in 24 h? Diuresis? Sleep Do you sleep during the night? Do you have insomnia? The history of the patient is finished with these general manifestation questions.

I'm really happy! We're done with patient history!

ARE YOU READY? NOW WE TALK ABOUT

MEDICAL SEMIOLOGY GUIDE OF THE RESPIRATORY SYSTEM

C H A P T E R

1 Questionnaire If you want to know if a patient suffers from a respiratory disease, you must ask about the main symptoms of the respiratory disease. These are stabbing pain, dyspnea, cough, expectoration, and hemoptysis. In addition to these major symptoms, there could also be present a few minor symptoms such as chills (shivering), fever, and sweating. 1. Do you have stabbing pain (a sudden chest pain like a cut starting in your anterior chest wall with posterior irradiation accented in deep inspiration)? 2. Do you have difficulty breathing (dyspnea)? 3. Which is more difficult: to inhale or to exhale? Expiratory dyspnea is typically present in respiratory diseases. 4. Do you hear any sounds in your expiration, such as the caterwaul of a cat? This noise is called wheezing and signifies significant obstruction of the small bronchi and is typically present in the case of bronchial asthma. 5. Do you cough? 6. For how long have you been coughing? 7. Is it a dry cough or a productive cough? 8. If it is a productive cough, what color is your expectoration (sputum)? 9. Is your expectoration white? This is mucous expectoration. 10. Is your expectoration yellow? This is purulent expectoration. 11. Is your expectoration a combination of white and yellow? This is mucousepurulent expectoration. 12. Is your expectoration a combination of serous consistency (like water) with white (mucous) and yellow colors (purulent)? This is serousemucousepurulent expectoration. 13. Is your expectoration of greenish color? 14. When coughing, do you expectorate sputum in high quantities, more than 300 mL/24 h, which is stratified in three or four layers: serous, mucous, and purulent? This is a typical sign of bronchiectasis. 15. Do you expectorate (sometimes) a high quantity of pus after an episode of excessive cough? This is vomicadelimination of the pus contained in a pulmonary abscess! 16. Do you sometimes expectorate with streaks of blood? 17. How often? 18. Were the streaks of blood combined with sputum? 19. Were the streaks of blood combined with white or yellow sputum? 20. Do you expectorate only fresh blood? This is hemoptysis, specific for lung carcinoma or lung tuberculosis (TB). 21. In what quantity? 22. How many times? 23. Was the color of the blood fresh red? 24. Was the color of the blood dark? 25. Was the color of the blood black? Medical Semiology Guide of the Respiratory System https://doi.org/10.1016/B978-0-12-816113-5.00001-6

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3 26. Was the color of the expectoration like that of currant jelly? This is specific for lung carcinoma. 27. Do you have rust-like (rubiginosa) expectoration? This is specific for pneumonia. 28. Do you expectorate very viscous dark blood? This is specific for pulmonary embolism. 29. Did you have chills (shivering), fever, sweating, and stabbing pain? This is the sudden onset of pneumonia. 30. Do you smoke? 31. How many cigarettes per day? 32. For how long have you smoked? 33. What type of cigarettes you smoke, with filter or without filter? This is a risk factor for chronic bronchitis, chronic obstructive pulmonary disease (COPD), and lung carcinoma. 34. Do you smoke a pipe? This is a risk factor for carcinoma of the lips. 35. Do you work in a medium with dust? This is a risk factor for bronchitis and bronchial asthma. 36. Do you work now or have you worked in the past in a mine? This is a risk factor for silicosis. The patients with silicosis have a higher risk for TB and this is silicotuberculosis. 37. Do you work in a medium with asbestos? This is a risk factor for pleural mesothelioma. 38. Do you work under cold-temperature conditions? This is a risk factor for pneumonia. 39. Do you come in contact with parrots and canaries? This is a risk factor for psittacosis. 40. Have you had pulmonary TB for a short period? 41. Do you have any family members with active pulmonary TB? 42. Do you have any friends or persons with active pulmonary TB who have come in contact with you? 43. Do you have in your family history any members with lung cancer? 44. Do you have in your family history any members with bronchial asthma? 45. Have you ever had oraletracheal intubation during general anesthesia? This is a risk factor for aspiration pneumonia and abscess of the lung. 46. Have you had thoracic trauma with any fracture or fractures of the ribs? This is a risk factor for pneumothorax and hemothorax because a fractured rib can break the pleural cavity and let air pass into the pleural cavity (pneumothorax) or it can cause blood to appear inside the pleural cavity (hemothorax). 47. Do you live in a cold and overcrowded home? This is a risk factor for respiratory tract infections and pulmonary TB. 48. Do you live with a person who smokes? You are a passive smoker and you have a risk factor for juvenile chronic bronchitis.

C H A P T E R

2 The Main Symptoms of the Respiratory Diseases O U T L I N E 2.1 Pleural PaindStabbing Pain 2.2 Stabbing Pain in Pleural Diseases 2.3 Dyspnea

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2.6.1 The Appearance and Color of Sputum

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2.6.2 The Smell and Taste of Sputum

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2.6.3 The Microscopic Examination of Sputum

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2.6.4 The Bacteriological Examination of Sputum

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2.4 Cough

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2.5 Sputum (Expectoration) 2.5.1 The Macroscopic Exam of the Sputum 2.5.2 The Quantity of Expectoration

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2.6 Vomica

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2.7 Hemoptysis

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Hemoptysis

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Hemoptysis

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The Chest X-Ray

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The main symptoms of the respiratory diseases are: • • • • • • •

Pleural pain, stabbing pain in pleural diseases Stabbing pain pleuraepulmonary in origin Parietal thoracic pain Dyspnea Cough Expectoration (sputum) Hemoptysis

2.1 Pleural PaindStabbing Pain Stabbing pain is a unilateral thoracic pain, with sudden onset, like a stab, that starts from the anterior chest wall and irradiates to the posterior chest. The most important characteristic of this pain is that it is accentuated in a deep inspiration and after cough, sneeze, or laugh.

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2. The Main Symptoms of the Respiratory Diseases

All these situations increase the intrathoracic pressure and indicate that the mobilization of the pleural foils has been damaged and they are inflamed. For this reason, in deep inspiration or during the procedures mentioned that increase the intrathoracic pressure, the inflamed pleural follicles with fibrin rub together and develop this characteristic pain. So the presence of stabbing pain suggests: • Pleuritis • Pleural empyema • Spontaneous pneumothorax • Pleuritis represents the inflammation of the visceral and parietal pleura, which are rubbing together because of the presence of fibrin at this level, and at the auscultation of the lung in this situation we are listening to specific pleural rub. • Pleural empyema represents the accumulation of pus between the visceral and the parietal pleura. • Spontaneous pneumothorax represents the accumulation of air inside the pleural cavity. This is one of the most dangerous emergencies in medical practice, which appears frequently after fractures of the ribs that pass inside the pleural cavity.

2.2 Stabbing Pain in Pleural Diseases

Stabbing pain starts in the anterior chest, irradiates to the posterior chest Stabbing pain irradiates to the posterior chest

2.2 Stabbing Pain in Pleural Diseases

Stabbing pain starts in the anterior chest and irradiates to the posterior chest Pleuritisdpleural inflammation

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2. The Main Symptoms of the Respiratory Diseases

Inflammation of the pleural foils; pleural empyemadpus inside the pleural cavity

Pus inside the pleural cavity Spontaneous pneumothorax

2.3 Dyspnea

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Air inside the pleural cavity Stabbing pain of pleuraepulmonary origin

2.3 Dyspnea Dyspnea represents shortness of breath and difficulty in breathing. This symptom is not specific only for respiratory diseases. It is also present in cardiovascular diseases; in a normal person, under conditions of excessive physical effort; in severe anemia; or in psychiatric disorders.

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2. The Main Symptoms of the Respiratory Diseases

If a patient declares feeling shortness of breath (dyspnea), we must analyze a few important features: 1. Does the patient feel it is harder to inhale air? This is inspiratory dyspneadsuggesting a cardiovascular disease. 2. Does the patient feel it is harder to exhale air? This is expiratory dyspneadsuggesting a respiratory disease. 3. Is dyspnea accompanied by an increased rate of breathing (tachypnea)? This suggests a cardiovascular disease. 4. Is dyspnea accompanied by a decreased rate of breathing (bradypnea)? This suggests a respiratory disease. 5. Was the onset of dyspnea gradual or sudden? Gradual onset is typical of a chronic disease. Sudden onset is typical of an acute disease. 6. Is the occurrence of dyspnea progressive or paroxysmal? Progressive dyspnea is typical of a chronic disease. Paroxysmal dyspnea is typical of an acute disease. 7. The intensity of dyspnea is also important. The intensity could be light, medium, or severe. 8. What factors induce dyspnea? The body position in bed? Dyspnea in a flat position suggests acute left ventricular failure and bronchial asthma. Physical effort? It is typical in chronic ventricular failure. Different types of substances? It is typical in bronchial asthma. Contact with different environmental allergens? It is typical in bronchial asthma. After administration of drugs such as beta blockers, aspirin, or NSAIDs? It is typical in bronchial asthma. 9. Has the patient tried an antidyspnea position such as with orthopnea? This is a position with the head up, because in this position the patient feels that it is easier to breath. It is typical in acute left ventricular failure and bronchial asthma. 10. Do you hear any noise in inspiration? Stridor is a noise that appears during inspiration, which means large airway obstruction. 11. Do you hear any noise in expiration? Wheezing (like the caterwaul of a cat) is a noise on expiration, which means small airway obstruction. It is typical in bronchial or cardiac asthma. In bronchial asthma the dyspnea is typically paroxysmal, expiratory with bradypnea, and with the patient staying in the orthopnea position.

2.4 Cough Cough is one of the most common symptoms of the respiratory diseases. Cough may be a symptom in diseases of the cardiovascular system: in pulmonary stasis, in acute left ventricular failure, and in heart failure. Cough represents a defense mechanism of the body against foreign substances. When a patient comes for consultation with cough, we must ask our patient about the most semiologic features: 1. When did the cough start? A few days ago? weeks or months? So is it a recent episode or a chronic event? 2. Is it a dry cough or a productive cough? Dry cough is without expectoration and productive cough is with expectoration. 3. If it is a productive cough, how does the expectoration (sputum) look? Is the color of sputum white? Yellow? Is the sputum a combination of white and yellowish colors? Does the sputum contain blood streaks?

2.5 Sputum (Expectoration)

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4. After excessive attacks of cough, does the patient feel any nausea or start vomiting? This is coughing that causes vomiting. 5. After an exaggerated episode of cough, does the development of syncope sometimes occur? This is possible and represents coughing syncope. 6. Do you have dyspnea at the same time with cough? 7. When do you cough, during the day or during the night? 8. During the day, do you cough in the morning or in the afternoon? 9. Do you observe what induces your cough? Inhaling cold air? During meals? During physical effort? A specific position of the body? Changing your position? 10. Some patients are used to their cough, and they do not declare that they cough, but if you observe this symptom you must take it into account. The most important diseases that produce cough are: Acute laryngitisdproduces hoarse or barking cough. Pertussisdproduces explosive coughing in excess so strong that can develop vomiting. Paresis of vocal cordagesdproduces bitonal cough and appears in laryngeal diseases. Acute tracheitisdsignificant inflammation of the trachea, starts with dry cough and then becomes productive Tumors of the tracheadthese produce a cough because the tumor is like a foreign body and the cough is an attempt to eliminate it. Acute bronchitisdtypically the cough in this case is with a sudden onset, at first it is a dry cough and after that it becomes a productive cough with sputum. Chronic bronchitisdtypically the cough in chronic bronchitis is in the morning and is productive, and the patient coughs every morning and to clean the bronchi. Also the cough occurs predominantly in cold seasons. The patient coughs at least 3 months of the year and 2 years in a row. If the patient has chronic bronchitis and pulmonary emphysema, this is COPD. Bronchial asthma crisisdtypically in asthma crisis the cough has a character of whistling and the intensity of wheezing and dyspnea increases. At first it is a dry cough, after that it becomes productive. Bronchiectasisdtypically occurs when the patient changes position in bed, and it is a productive cough, with increased quantity of expectoration per 24 h, because it drains the secretions accumulated in the bronchiectasis bags. Pneumoniadat first the cough is dry and after that becomes productive with specific expectorationdrubiginosa expectoration. Pneumothoraxdit has a metallic cough. Pleural effusiondcough accented when the patient changes position. Pulmonary embolismdthe patient feels a sudden dyspnea and dry cough at first and then later with a specific expectoration that is very viscous, with dark blood. Acute left ventricular failuredbecause of pulmonary stasis nocturnal dry cough appears. In people with psychoemotional instabilitydthe tic of coughddry cough is very common in children after the parents go through a divorce.

2.5 Sputum (Expectoration) Sputum or expectoration represents the product eliminated after productive cough. The analysis of sputum is very important in the respiratory system diseases.

2.5.1 The Macroscopic Exam of the Sputum The macroscopic examination of sputum represents one of the most important and simple investigations because it shows evidence and important features regarding the quantity of expectoration, appearance, color, smell, and expectoration taste.

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2. The Main Symptoms of the Respiratory Diseases

2.5.2 The Quantity of Expectoration The quantity of expectoration is very variable in 24 h. The highest quantity of sputum, 500 mL/24 h, appears in bronchiectasis because an increased amount of sputum is deposited in the bronchiectatic bags. Lung abscess and pulmonary gangrene represent two other diseases in which a large amount of sputum is eliminated. In acute pulmonary edema the patient eliminates a large amount of expectoration of whiteepink color like beaten egg whites. This appears typically in cardiovascular diseases such as mitral stenosis or other situations that can develop acute left ventricular failure, pulmonary stasis, and increased hydrostatic pressure, and a transudate appears inside of the pulmonary alveoli, and this leads to pulmonary edema.

2.6 Vomica Vomica is the situation in which, after an excessive amount of coughing, the patient eliminates an increased amount of expectoration, like pus from, for example, a pulmonary abscess, or can eliminate the contents of a tuberculoma, TB collection, or a hydatid cyst. After this incident, a cavity remains inside the lungda hole.

2.6.1 The Appearance and Color of Sputum 1. Serous Sputum is sputum that looks like water. It appears in chronic bronchitis. 2. Mucoid or Mucous Sputum If the sputum is like mucusdthis suggests acute or chronic bronchitis. 3. Purulent Sputum If the sputum is yellow in colordthis suggests a bacterial superinfection. It may be present in acute bronchitis, chronic bronchitis, and pneumonia. 4. Mucopurulent Sputumdacute and chronic bronchitis. 5. Seromucopurulent Sputumdthis type of sputum is present in bronchiectasis. 6. Bloody Sputumdstreaks of blood in yellow sputum. This appears in pulmonary carcinoma and chronic bronchitis. 7. Blood Expectoration appears in the following diseases: pulmonary carcinoma, pulmonary TB, pulmonary embolism, and mitral stenosis.

2.6.2 The Smell and Taste of Sputum The smell of sputum is sensed during the first contact with the patient, because when the patient talks a bad smell is exhaled, such as: Rotten eggsdbronchiectasis Putrid smelldpulmonary gangrene A bad taste is present in: - Chronic bronchitis - Bronchiectasis

2.6.3 The Microscopic Examination of Sputum CharcoteLeyden crystals appear in the sputum of patients with bronchial asthma. Neoplastic cells: - Lung neoplasm Polynuclear eosinophils: - Pulmonary hydatid cyst - Bronchial asthma

2.7 Hemoptysis

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2.6.4 The Bacteriological Examination of Sputum The bacteriologic examination of sputum can reveal evidence of germs and inform about etiologic agents. For example, in pneumonia, etiologic agents such as Staphylococcus, Streptococcus, Haemophilus influenzae, pneumococcus, etc., can be found. ZiehleNeelsen coloration is typically used for Koch bacillus. The periodic acideSchiff method is typically used for fungus infections.

2.7 Hemoptysis Hemoptysis is defined as expectoration of blood after cough. The source of the blood is the respiratory tract. The most important differential diagnosis in medical practice is hematemesis, which includes significant vomiting of blood, and the source of blood is the digestive system. Another important differential diagnosis is swallowed epistaxis. If a patient has a massive epistaxis and swallows the blood of epistaxis, then the patient can expectorate the blood and induce an error, that is, hemoptysis. In the image of a receptacle below, you can see the appearance of blood and how it looks after being coughed up by a patient:

Hemoptysis

Hemoptysis

This expectoration with blood (hemoptysis) was from a smoker patient with carcinoma of the lung. The female patient in the following image, after an episode of cough, expectorated fresh blood into the receptacle below:

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2. The Main Symptoms of the Respiratory Diseases

Hemoptysis

The 68-year-old female patient expectorated fresh blood after cough. She had pulmonary carcinoma (neoplasm of the lung).

Fresh blood in receptacle after coughdhemoptysis

A 72-year-old female patient was hospitalized for hemoptysis. During the physician visit, she had an episode of a massive hemoptysis and expectorated fresh blood into many napkins and collected all in a plastic bag as shown in the following images:

2.7 Hemoptysis

Hemoptysis

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2. The Main Symptoms of the Respiratory Diseases

The chest X-ray of this patient with massive hemoptysis is shown in the image below:

The Chest X-Ray

The chest X-ray put in evidence an enlarged opacity at the apex of the right lung and attraction of the mediastinum to the right sideda sign of atelectasisdsuggesting cancer of the lung. During bronchoscopy, a bronchial tumor was put in evidence inside the right main bronchi and a biopsy was performed, which later confirmed bronchial carcinoma with small cells at histopathology examination. The patient needed irradiation at first to stop the hemoptysis, as the bleeding did not stop after anticoagulant and intravenous therapy, and later was transferred into the oncology department.

C H A P T E R

3 The Objective Examination O U T L I N E 3.1 Typical Faces in the Respiratory Diseases 3.1.1 The Vultuous (Red) FacedIn Pneumonia 3.1.2 The Two Types of Face in Chronic Obstructive Pulmonary Disease

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3.1.3 Doll Face

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3.1.4 Faces in Claude BernardeHorner Syndrome

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3.1 Typical Faces in the Respiratory Diseases 3.1.1 The Vultuous (Red) FacedIn Pneumonia 1. In frank lobar pneumonia the face appears red. Redness on the cheekbones is observed, which occurs due to vasodilatation caused by fever as shown in the image below:

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3. The Objective Examination

3.1.1.1 Red Faces

Redness on cheekbones due to vasodilatation caused by fever

RED FACES

The red face in pneumoniadredness on cheekbones; and observe the herpes sore at the level of the lower lip that occurred because of fever

3.1 Typical Faces in the Respiratory Diseases

Herpesdphase of vesicles containing pus at the lower lip, appears in feverdpneumonia

3.1.1.2 Herpes on the Upper and Lower Lip Appears in FeverdPneumonia

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3. The Objective Examination

Herpes on the upper lips; appears in feverdpneumonia

3.1 Typical Faces in the Respiratory Diseases

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3.1.2 The Two Types of Face in Chronic Obstructive Pulmonary Disease 3.1.2.1 Faces in Pulmonary EmphysemadType A 1. In emphysema, the type A face, panting pink or pink puffer or fighter against obstruction, presents with hyperpnea and polypnea and maintains the level of blood gases in normal range. In pulmonary emphysema the face of the patient shows exophthalmia and injected conjunctiva because of hypercapnia and increased cerebrospinal fluid pressure, which gives it the appearance of a batrachian face with “frog eye.” Pink Puffer

Pink puffer faces and the upper area of a barrel chest with full supraclavicular and subclavicular fossae

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3. The Objective Examination

3.1.2.2 Faces in Chronic Bronchitis Blue BloatereType B 2. In type B COPD, the face is cyanoticdblue bloaterdthe patient coughs, with expectoration but not fighting, and the external ventilation is low. The patient suffers from hypoxemia and consequently hypercapnia, because there is disturbance throughout the alveolidcapillaries that exchange gases at the lung level. In conclusion there exist two major types of COPD: 1. Type A, emphysemadpink puffer 2. Type B, bronchitisdblue bloater Blue Bloater

Facesdtype B, bronchitisdblue bloater

The main semiology features of the blue bloater face are cyanosis of the cheeks, nose, and lips, and the whole face looks cyanotic and bloated. This patient was a previous smoker, one packet of cigarettes/day for 20 years, and now he has developed chronic obstructive bronchitis type Bdblue bloater, with the typical face as shown in the image above.

3.1 Typical Faces in the Respiratory Diseases

Blue bloater face

Blue bloater

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3. The Objective Examination

3.1.2.2.1 Blue Bloater Faces Left Lateral View

Cyanosis of the lips

3.1 Typical Faces in the Respiratory Diseases

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3.1.2.2.2 Cyanosis of the Lips and Tongue

Cyanosis of the lips and tongue

In the preceding image, we can see the signs very clearly, because the patient has an open mouth, of cyanosis of the upper and lower lips, and the tongue is cyanotic as well. This appears in COPD type B, bronchitis, because the patient coughs and expectorates but does not force it, and for this reason the exchange of the gases at the alveoli capillary level is not good. So this results in decreased levels of oxygenated hemoglobin and increased levels of reduced hemoglobin, and this is the “pigment” of cyanosis, responsible for the blue color of the face, lips, tongue, ears, and nails as well. We can recognize the blue bloater face in this category of patients from the first look, very easily, if we know the information beforehand, and this is typical of an old smoker patient with chronic tobacco bronchitis.

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3. The Objective Examination

3.1.2.2.3 Type B of COPD Bronchitis Blue Bloater

Blue bloater facedcyanotic and bloater

Cyanosis of the lips

3.1 Typical Faces in the Respiratory Diseases

3.1.2.2.4 Type B of COPD Bronchitis Blue Bloater

Blue bloater facedcyanotic and bloater

Cyanosis of the lips

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3. The Objective Examination

3.1.2.2.5 Type B of COPD Bronchitis; Blue Bloater

Blue bloater facedcyanotic and bloater

Cyanosis of the lips

3.1 Typical Faces in the Respiratory Diseases

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3.1.2.2.6 Blue Bloater Faces Type BdBronchitis of COPD

Blue bloater facedcyanotic and bloater

Cyanosis of the lips

In pulmonary TB patients have been described as having a so-called “doll face” on a background of pale skin and red cheekbones.

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3. The Objective Examination

3.1.3 Doll Face

“Doll face” in tuberculosis

Pale face color with earthy hue and dark circles around the eyes is seen in chronic forms of tuberculosis and lung abscesses

3.1 Typical Faces in the Respiratory Diseases

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3.1.4 Faces in Claude BernardeHorner Syndrome

Right ptosis of superior eyelid and enophthalmia

Claude BernardeHorner syndrome appears after invasion of the thoracic sympathetic nerve and cervical nerves as well. The patient with this syndrome presents with: - Miosis - Palpebral ptosis - Enophthalmia This suggests a pulmonary apical neoplasm because it compresses the sympathetic cervical plexus. This patient was a heavy smoker of two packets of cigarettes/day for 15 years with right apical pulmonary neoplasm. Right ptosis of superior eyelid and enophthalmia

Miosis

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3. The Objective Examination

C H A P T E R

4 The Objective Examination of the Thorax O U T L I N E 4.1 The Clinical Topography of the Anterior Chest 34 4.2 The Clinical Topography of the Lateral Chest

4.6.2 The Method of Percussion 4.6.3 Method of Percussion of the Anterior ThoraxdRight Apex 4.6.4 Method of Percussion of the Anterior ThoraxdLeft Apex 4.6.5 Percussion of the Clavicles 4.6.6 Percussion at the Base of the Left Lateral Side of the Thorax 4.6.7 Percussion of the Base of Right Lateral Side of the Thorax 4.6.8 Percussion of the Middle Area of the Left Lateral Thorax 4.6.9 Percussion of the Middle Area of the Right Lateral Thorax 4.6.10 The Normal Resonant Sound of Thoracic Percussion 4.6.11 Pathological Sounds After Thoracic Percussion

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4.3 The Clinical Topography of the Posterior Chest 35 4.4 The Inspection of the Thorax 4.4.1 Normal Shape of ThoraxdAnterior View 4.4.2 Normal ShapedPosterior View 4.4.3 Global Symmetric Deformations 4.4.4 Asymmetric Global DeformationsdKyphoscoliosis 4.4.5 Respiratory Movements of the Thorax

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4.5 Method of Palpation of the ThoraxdThe Apex of the LungsdPosterior Incidence 132 4.5.1 Method of Palpation of the ThoraxdThe Middle Lobes of the LungsdPosterior Incidence 132 4.5.2 Method of Palpation of the ThoraxdThe Inferior Lobes of the LungsdPosterior Incidence 133 4.5.3 Method of Palpation of the ThoraxdThe Apex of the LungsdAnterior Incidence 133 4.5.4 Method of Palpation of the ThoraxdThe Middle of the LungsdAnterior Incidence 134 4.5.5 Method of Palpation of the ThoraxdThe Inferior Lobes of the LungsdAnterior Incidence 134 4.5.6 Method of Palpation of the ThoraxdBase Lateral Incidence 135 4.5.7 The Method of Palpation of the ThoraxdMiddle Lateral Incidence 135 4.6 Method of Percussion of the Thorax 4.6.1 Method of Percussion of the Posterior Thorax Right Apex

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4.7 Modifications of the Lower Limit of the Lungs and Active Pulmonary Mobility 162 4.8 The Method of Auscultation of the Lung 4.8.1 Auscultation of the Anterior Chest 4.8.2 Auscultation of the Anterior Chest 4.8.3 Auscultation of the Posterior Thorax 4.8.4 Auscultation of the Left Lateral Chest 4.8.5 Basics of Lung Sounds 4.8.6 Changes in Intensity of the Vesicular Sound 4.8.7 Bronchial Pathology Breath Sound 4.8.8 Pleuritic Murmur 4.8.9 Pulmonary Cavity 4.8.10 Blower Breathing Broncho Vesicular 4.8.11 Added Breath Sounds

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4. The Objective Examination of the Thorax

4.1 The Clinical Topography of the Anterior Chest

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2

4

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The topographic lines on the front of the chest

1. 2. 3. 4.

The anterior midline The sternal vertical linedthe vertical line corresponding to the edge of the sternum The midcollarbone linedperpendicular to the middle of the collarbone The parasternal linedthe vertical line midway between the two previous lines

4.3 The Clinical Topography of the Posterior Chest

4.2 The Clinical Topography of the Lateral Chest

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1

The topographic lines on the right lateral side of the thorax

1. The anterior axillary linedtangent to the anterior border of the axillary fossa 2. The middle axillary linedperpendicular line lowered from the apex of the axilla 3. The posterior axillary linedtangent to the posterior border of the axillary fossa

4.3 The Clinical Topography of the Posterior Chest 1

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The topographic lines on the posterior thorax

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4. The Objective Examination of the Thorax

1. 2. 3. 4. 1.

The posterior midline The scapula linedthe vertical line tangent to the internal edge of the scapula The thorny linedthe horizontal line that passes the spine of the scapulas The lower horizontal linedpasses at the peaks of the scapulas. The projections of the lungs on the thorax are: The apex of the lungs: - anterior: 3e4 cm above the clavicle beyond - posterior: to the spinous process of vertebra C7 2. The hills of the lungs: - anterior: III intercostal space - posterior: interscapular space between vertebrae D4 and D6 3. The base of the lungs: - anterior: VI cartilage rib on the midclavicle line - posterior: vertebra D10

4.4 The Inspection of the Thorax The inspection puts in evidence the conformation (shape) of the thorax and respiratory movements.

4.4.1 Normal Shape of ThoraxdAnterior View

On the anterior thorax the collarbones are slightly protruding and horizontal. Supra- and subclavicular pits are visible. Louis’s angle (where the second rib articulates with the sternum) is prominent; the sternum is depressed between the two hemithoraxes. The epigastric angle is between 70 and 110 degreesdmarked with a black line on the picture. The ribs and intercostal spaces are seen and the angle between the ribs and the backbone is 45 degrees; both hemithoraxes must be symmetric. The ratio between anterioreposterior diameter and the transverse of the normal thorax is 1:2.

4.4 The Inspection of the Thorax

4.4.2 Normal ShapedPosterior View

The normal shape of the posterior thorax on the back appears as two prominently symmetric scapula. There is a depression between their internal edges and the string spinous. The spine must have normal curvatures. Both shoulders must be at the same level. The hemithoraxes must be symmetric. The ratio of the diameter between anterioreposterior and transverse must be 1:2. This ratio must not be equal. The thorax must be elliptical on section. This patient looks like a person who plays sports because we can see hypertrophy of the muscles.

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4. The Objective Examination of the Thorax

4.4.3 Global Symmetric Deformations 4.4.3.1 Barrel Chest, Rounded or Bulging ChestdAnterior View

Normal shape of the thoraxdanterior view The main features of the barrel chest are: 1. 2. 3. 4. 5.

Increased anterioreposterior diameter that tries to become equal with the transverse diameter. The supra- and subclavicular areas become full. The ribs become horizontal. The intercostal spaces are full, we cannot see the intercostal spaces. The epigastric angle becomes enlarged, obtuse, and increased more than 110 degreesdmarked with a black line in the image above.

4.4 The Inspection of the Thorax

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4.4.3.1.1 Barrel Chest, Rounded or Bulging ChestdPosterior View

The main features of the barrel chest on posterior view are: 1. 2. 3. 4. 5. 6. 7.

The ribs become horizontal. The intercostal space is full. We cannot see the intercostal space. The angle between the ribs and the vertebral column is increased to more than 45 degreeso . The thorax looks like a barrel. This type of thorax is typical in pulmonary emphysema. It is important to recognize clinically the important features of barrel chest, because this shape of thorax suggests to us the diagnosis of pulmonary emphysema. 8. Chronic bronchitis and pulmonary emphysema represent COPD.

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4. The Objective Examination of the Thorax

4.4.3.1.2 Barrel Chest, Rounded or Bulging ChestdLeft Lateral View

The examination of this shape of thorax from the lateral view is the best, because from this we can observe better that the lateral (transverse) diameter of the thorax becomes equal with the anterioreposterior diameter, and this is the most important feature of the barrel chest. On transverse section this type of thorax looks round, not elliptical.

4.4 The Inspection of the Thorax

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4.4.3.1.3 Barrel Chest or Emphysematous ChestdAnterior View

The main important features are: 1. 2. 3. 4. 5. 6.

Increased anterioreposterior diameter tries to become equal with transverse diameter. The supra- and subclavicular areas are full. The ribs become horizontal. The intercostal spaces are full and are not visible. The neck is short. Everything gives the sensation of a deep inspiration and the patient looks like a person in deep inspiration with the neck short and with the lungs full of air. 7. The epigastric angle becomes obtuse, increased to more than 110 degrees.

4.4.3.1.4 Barrel ChestdLeft Lateral View

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4. The Objective Examination of the Thorax

The lateral (transverse) diameter of the thorax becomes equal with the anterioreposterior diameterdindicated with two red arrows. This image from the lateral view shows characteristics typical of barrel chest. When we see this type of thorax, it suggests to us the diagnosis of pulmonary emphysema; this is the reason that barrel chest is also called emphysematous chest. The whole aspect of the patient gives the impression of forced inspiration. 4.4.3.1.5 Barrel ChestdLeft Lateral View

The image of the barrel chest or emphysematous chest in the same left lateral view is shown. We can see once again, the most important sign, that the increase in dimensions of the anterioreposterior diameter tries to become equal with that of the transverse diameter. This patient was a 68-year-old smoker, one pack of cigarettes/day for 15 years, with chronic tobacco bronchitis, because he had coughed and expectorated mucusdpurulent sputumdevery morning for more than 3 months/year and 2 years continuously. Because at the objective examination he presented a barrel chest or emphysematous chest, the association between chronic bronchitis and pulmonary emphysema suggests COPD.

4.4 The Inspection of the Thorax

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4.4.3.1.6 Barrel ChestdLeft Lateral View With Left Arm Up

This is an image of barrel chest from the left lateral view with the left arm up. We can see very well the increased anterioreposterior diameter of the thorax indicated with two red arrows. Also we can see the ribs and the intercostal spaces because this patient had Intercostal retractions in inspire occur when the muscles between the ribs retracted inside (TIRAJ)drepresents the retraction of the intercostal spaces on inspirationdat deep inspiration (inspiratory depression), and this is a very important semiological sign that occurs in respiratory obstruction in large airways. The most common cause of obstruction of large airways is increased quantity of mucus in patients with chronic bronchitis or bronchiectasis. 4.4.3.1.7 Barrel ChestdLeft Lateral View

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4. The Objective Examination of the Thorax

This is a typical image of another patient with barrel chest from the left lateral view, where we can see once again the increase in the anterioreposterior diameter of the thorax. This patient was a 58-year-old man who played the saxophone for 8 years. Because he played a wind instrument, he had risk for pulmonary emphysema, because people who blow an instrument and push air every day with forced counterpressure will develop breakage of the interalveolar septa; the pulmonary alveoli will connect and develop an enlarged cavity, and this is pulmonary emphysema. For this reason the shape of the thorax becomes the typical barrel chest or emphysematous chest as shown in the preceding image. 4.4.3.1.8 Barrel Chest, Rounded or Bulging ChestdPosterior View

This is the same patient, 58-year-old man, who played the saxophone for 8 years. He developed a typical barrel chest. This is the image of the emphysematous thorax from the posterior view. We can observe the neck is short. The shape suggests a deep inspiration. People who play wind instruments, because they blow against pressure all the time while playing the wind instrument, have a risk of developing pulmonary emphysema. So, this patient, who plays the saxophone, developed typical barrel chest.

4.4 The Inspection of the Thorax

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4.4.3.1.9 Barrel Chest and Asymmetric GynecomastiadAnterior View

This is a typical image of barrel chest in anterior view.

In addition to this, we can see asymmetric gynecomastia. Gynecomastia represents an increase in volume of the breasts in men. In the image above we can see the increase in dimensions of the breasts, but it is clear that the left breast is more enlarged compared with the right breast. This is an asymmetric gynecomastia. This patient used therapy with spironolactone, and this developed side effects of gynecomastia; at the same time he had a tumor in the left breast. 4.4.3.1.10 Barrel ChestdPosterior View

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4. The Objective Examination of the Thorax

This is the image of the same patient in the posterior view. This patient had a specific workplace, he was a glassblower. Under the conditions of this profession he had a risk factor at the workplace for developing barrel chest and pulmonary emphysema, because daily he blows against pressure, when he makes glass. It is very well known that this professiondglassblowerdpredisposes to developing pulmonary emphysema, because these people blow against pressure every day to make the glass; and during this procedure the interalveolar septum breaks and develops an enlarged cavity with pulmonary alveolidpulmonary emphysema. 4.4.3.1.11 Barrel Chest or Emphysematous ChestdRight Lateral View

The image of the barrel chestdright lateral view is shown.

We observe the increased anterioreposterior diameter, indicated with two red arrows, which tries to become equal to the lateral diameter of the thorax. This is the most important characteristic of the barrel chest, which suggests pulmonary emphysema. So, in conclusion, two important professions represent the most important risk factors for pulmonary emphysema. These are playing an instrument such as saxophone, tarogato, trumpet, and others, and glassblowing.

4.4 The Inspection of the Thorax

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4.4.3.1.12 Barrel Chest and Bilateral Gynecomastia

In the image above, we can see very easily, indicated with the red arrows, an increase in dimensions of both breasts of this man. So, sometimes during the inspection of the thorax we can see the enlarged dimensions of the breasts of a man, and this situation represents gynecomastia. This situation is rare in men, but possible, and suggests a hyperestrogenismdan increased level of estrogensd and for this reason there appear signs of feminization such as increased volume of the breasts. Other causes of bilateral gynecomastia are are side effects from spironolactone drug use. Spironolactone is a diuretic antialdosteronic, very often used in therapeutic schemes in medical practice, especially in patients with cardiac failure, together with loop diuretics (for example, furosemide), and in therapy of cirrhosis of the liver with vascular decompensation. After a long period of spironolactone therapy side effects appeardgynecomastia. 4.4.3.1.13 Barrel Chest and Bilateral Gynecomastia

This is another image of the previous patient but the view is from the bottom, and from this position, we can observe the increased volume of the breasts of this man better.

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4. The Objective Examination of the Thorax

If you look carefully, you can see now that the right breast is larger than the left breast. So there exists an asymmetry regarding the dimensions of both breasts. The most important observation is that in gynecomastia the increased volume of the breasts is symmetrical. So, this situation suggests that there also exists a local problem at the level of the right breast, like a nodule inside or really a possible carcinoma of the right breast, rare in medical practice in men, but possible. In the next image, we will see a close-up of the right breast of this man. 4.4.3.1.14 Increased Volume of the Right BreastdClose-up Image

In this close-up image, we see clearly the increased volume of the right breast, indicated with the red arrow. At palpation this patient had a firm nodule inside the right breast, with dimensions of 1/2 cm, regular borders and surface, and firm consistency; mobile compared with the tissue around; and without pain. The patient underwent mammography, and this common investigation confirmed the presence of the nodule mentioned inside the right breast. The patient underwent a surgical removal of this nodule and the histopathologic examination from the tissue nodule confirmed the diagnosis of adenoma of the breast. So, it was a benign formation, but this type can also degenerate in time into adenocarcinoma if it is not removed.

4.4 The Inspection of the Thorax

4.4.3.1.15 GynecomastiadNew Patient

Gynecomastiadanterior view

Gynecomastiadlateral view

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4. The Objective Examination of the Thorax

4.4.3.2 Paralytic (Asthenic) ThoraxdAnterior View

Supraclavicular areas visibledexcavated With highly visible clavicles Visible ribs Intercostal spaces visible The epigastric angle becomes sharp This is the typical image of the thorax of a person with weight loss. The patient in the preceding image confirmed that he had lost 12 kilos in the past 8 months and for this reason the shape of the thorax was changed as shown in the image, with all the features mentioned before. 4.4.3.2.1 Paralytic (Asthenic) ThoraxdAnterior View

4.4 The Inspection of the Thorax

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Supraclavicular areas visibledexcavated With highly visible clavicles Visible ribs Intercostal spaces visible The epigastric angle becomes sharp This is the typical image of the thorax of a person with weight loss. The patient in the preceding image confirmed that she had lost 10 kilos in the past 6 months, and for this reason the shape of the thorax changed as shown in the image, with all the features mentioned before. 4.4.3.2.2 Paralytic (Asthenic) ThoraxdPosterior View

This is the same patient from the previous image, who lost 10 kilos in the past 6 months, but now we can observe the features of the thorax from the posterior view. Both scapulas are very prominent, indicated with red arrows. We can observe the internal prominence of the scapulas and also many skin folds, indicated with the lower red arrowdwhich suggest that the patient lost weight. So, this is the typical appearance of the paralytic or asthenic thorax from the posterior view.

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4. The Objective Examination of the Thorax

4.4.3.2.3 Paralytic (Asthenic) Thorax

Paralytic thoraxdanterior view

Paralytic thoraxdright lateral view

4.4 The Inspection of the Thorax

4.4.3.2.4 Paralytic (Asthenic) Thorax

Paralytic thoraxdanterior view

Paralytic thoraxdanterior viewdclose-up image

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4. The Objective Examination of the Thorax

4.4.3.2.5 Paralytic (Asthenic) ThoraxdAnterior View

Paralytic thoraxdanterior view

Supraclavicular areas visibledexcavated With highly visible clavicles Visible ribs Intercostal spaces visible The epigastric angle becomes sharp. This is the typical image of the thorax for a person who lost weight. The patient in the preceding image confirmed that he had lost 8 kilos in the past 5 months, and for this reason the shape of the thorax changed as shown in the image, with all the features mentioned before. 4.4.3.2.6 Paralytic (Asthenic) ThoraxdAnterior ViewdClose-up Image

4.4 The Inspection of the Thorax

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Supraclavicular areas visibledexcavated Highly visible clavicles The ribs are visible The intercostal spaces are visible Also on the chest we can see two pigmentary nevi. In this imagedbecause it is a close-up imagedwe can see better how prominent the clavicles are, and the supraclavicular areas are evident and subclavicular areas are excavated, indicated with red arrows, because the patient lost a lot of weight in a short period of time. 4.4.3.3 Pigeon Chest or Pectus CarinatumdAnterior View Pigeon chest or pectus carinatum is a typical anomaly of shape of the thoraxda malformation of the chest with the sternum very prominent as shown in the image below: the red arrow indicates the prominence at the sternum.

Pigeon chestdpectus carinatumdanterior view

Pectus carinatum is also called “pigeon chest” because the chest can look like a bird’s breast or chicken. It is very easy to recognize this type of chest because at the first look the doctor can observe a prominence of the sternum in the middle area. This is visible better from the lateral view. This suggests a sequela of rickets from the newborn period, because there existed a deficit of vitamin D in this period of life and this is the cause of rickets. This abnormality of the sternum remains as a sequela for the whole life.

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4. The Objective Examination of the Thorax

4.4.3.3.1 Pigeon Chest or Pectus CarinatumdLeft Lateral View

4.4 The Inspection of the Thorax

4.4.3.3.2 Pigeon Chest or Pectus CarinatumdRight Lateral View

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4. The Objective Examination of the Thorax

4.4.3.3.3 Pigeon Chest or Pectus CarinatumdLeft Oblique View

4.4 The Inspection of the Thorax

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4.4.3.4 Funnel Chest or Pectus ExcavatumdAnterior View Pectus excavatum or funnel chest is a deformity of the anterior chest wall, such as a hole in the inferior area of the sternum, which looks as shown in the following image, indicated with a red arrow.

Pectus excavatumdfunnel chest

This is a congenital deformity and the name means “hollowed chest.” It is a genetic condition; sometimes many family members have the same abnormality. Another possibility is the sequela of rickets due to the same cause, deficit of vitamin D in the newborn period stage. It remains a sequela for the whole life. If the malformation is congenital, the patient is born with this abnormality and first-degree relatives have the same modification. In this case, this 19-year-old patient had a deficit of vitamin D in the newborn period and childhood and developed rickets, and now the funnel chest represents a sequela of rickets. 4.4.3.4.1 Funnel ChestdPectus ExcavatumdRight Lateral View

Pectus excavatumdfunnel chest

In the lateral view we can see better the hole located in the lower area of the sternum, indicated with the red arrow. Almost everyone considers this change of shape of the thorax as only a cosmetic issue, but sometimes if the hole is very deep, it can produce disturbances in the respiratory movements of the lung and perturb the normal dynamic of the lung.

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4. The Objective Examination of the Thorax

Some patients want to have a surgical intervention of the thorax to correct this malformation, but other patients refuse and understand that they can live well, without important issues, with this shape of thorax. This patient does not agree to a surgical procedure. 4.4.3.4.2 Pectus Excavatum

Pectus excavatumdfunnel chestdright oblique view

Pectus excavatumdfunnel chestdanterior view

4.4 The Inspection of the Thorax

4.4.3.4.3 Funnel ChestdPectus Excavatum

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4. The Objective Examination of the Thorax

4.4.3.4.4 Funnel ChestdPectus Excavatum Anterior View

Infundibuliform thorax, also called “funnel chest” or pectus excavatum, presents as a depression in the lower part of the sternum and rib cartilages around. It can be congenital or acquired during life, due to rickets or profession factors, e.g., the “shoemaker chest.” The deformation has consequences on intrathoracic organs and may be due to misinterpretation of respiratory signs or cardiac murmurs. In this patient’s case, it was a sequela of rickets, because in the newborn period, there was a deficit of vitamin D. 4.4.3.4.5 Funnel ChestdPectus Excavatum Left Lateral View

4.4 The Inspection of the Thorax

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The funnel chest or pectus excavatum has a depression in the lower part of the sternum and rib cartilages around. It can be congenital or acquired during life, due to rickets or profession. From the left lateral view, we can see better, indicated with the red arrow, the depression in the lower part of the sternum, enlarged, and very deep as well. For this young patient, 19 years of age, this change in the shape of the thorax appears in the context of the sequelae of rickets, because in the newborn period stage, he had a deficit of vitamin D; he did not take in enough vitamin D. This change of shape of the thorax will remain as a sequela for his whole life. 4.4.3.4.6 Funnel Chest Pectus ExcavatumdTop View

In this image, because it is a top-view image, we can see very clearly, indicated with the red arrow, a deep hole, a depression in the lower area of the sternum at the level of the xiphoid process of the sternum. Because it is a top-view image, with the patient in a flat position, we can observe how deep the depression of the sternum is. In this case, there was disturbance of the respiratory movements of the lung and also the normal cardiac cycle of the heart inside the thorax cavity.

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4. The Objective Examination of the Thorax

4.4.3.4.7 Funnel Chest Pectus ExcavatumdTop View

This is another top-view image of the same patient seen previously. We can observe, indicated with two red arrows, up and down, the depression in the lower part of the sternum. We see that the hole is very deep. Because of this cosmetic problem, this young patient had an inferiority complex. The young patient has sequelae of rickets, due to deficit of vitamin D in the newborn period of life and childhood as well. 4.4.3.4.8 Funnel Chest Or Pectus ExcavatumdTop View

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In this image we observe well the area excavated in the lower third of the sternum, indicated by two red arrows. Maybe this is the best top-view image where we can see better how deep the hole in the lower part of the sternum is. This young patient, 19 years of age, was not born with this shape of the thorax, so it was not a congenital change in the thorax, but it was acquired in the newborn period of life because of a deficit of vitamin Ddricketsdand remained as a sequela for his whole life. Sometimes, rarely, in the context of a patient with a genetic diseasedMarfan syndromedit is possible to present with this shape of thoraxdfunnel chest or pectus excavatum. 4.4.3.4.9 Funnel Chest or Pectus ExcavatumdTop ViewdCloser View

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4.4.3.4.10 Funnel Chest or Pectus ExcavatumdAnterior View

Pectus excavatumdthe depressed sternum at the xiphoid process level

This is another example of a patient with funnel chestdpectus excavatum. We can see a holeda depressed area in the lower area of the sternum at the level of the xiphoid process, indicated with the red arrow. This patient is a shoemaker and in this case the change in shape of the thorax was acquired because every day, this person at his workplace puts the shoe on his chest and hits with pressure on his chest with a metal object, which changed the shape of the thorax into funnel chest or pectus excavatum. For this reason, sometimes, this type of chest is called also the shoemaker chest. 4.4.3.4.11 Funnel Chest or Pectus ExcavatumdLeft Lateral View

Pectus excavatumdthe depressed sternum at the xiphoid process level

From the oblique left lateral view, we can see the hole better in the lower area of the sternum at the level of the xiphoid process, indicated with the red arrow.

4.4 The Inspection of the Thorax

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We can observe also many pigmented nevi on the whole area of the chest with different shapes and shades; the patient must avoid sun exposure because it is possible to degenerate into melanoma. 4.4.3.4.12 Funnel Chest or Pectus ExcavatumdLeft Lateral View

Pectus excavatumdthe depressed sternum

In the preceding image we can see very well the enlarged hole at the inferior area of sternum at the level of the xiphoid process, and we can observe that the hole is deep, indicated with the red arrow. We observe also, during inspection, many pigmented nevi on the anterior chest of the patient. These do not have any connection with the funnel chest or pectus excavatum. 4.4.3.4.13 Pectus Excavatum

Pectus excavatumdfunnel chestda hole in the lower sternum

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4. The Objective Examination of the Thorax

Pectus excavatumdfunnel chestda hole in the lower sternum

4.4.3.4.14 Pectus Excavatum

Pectus excavatumdfunnel chestdthe depressed sternum

4.4 The Inspection of the Thorax

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A hole in the lower sternum at the level of the xiphoid process

4.4.3.4.15 Funnel Chest or Pectus ExcavatumdUpper View

Pectus excavatumdfunnel chestdthe depressed sternum

From the upper view of the thorax we can observe the change in the thorax better. When this patient heard that his malformation of the thorax had a connection with his jobdshoemakerdhe wanted to change his workplace, but was informed that it was too late, because this anomaly of shape of the thorax will remain as a sequela for his whole life. He was informed also that this is not dangerous and is only a cosmetic problem and not to worry regarding this issue.

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4. The Objective Examination of the Thorax

4.4.3.4.16 Posterior View of the Thorax

Many pigmented nevi on the skin

4.4 The Inspection of the Thorax

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4.4.3.4.17 Posterior Left Lateral View of the Thorax

Kyphosisdaccented curvature of the dorsal column and many pigmented nevi on the skin with different shapes and shades

We can observe that this patient with funnel chestdpectus excavatumdalso has kyphosis and this also has a connection with his workplace because he works daily in a vicious position with the body bent forward. So, in conclusion, this patient has funnel chestdpectus excavatumdand kyphosis in the context of his workplace as a shoemaker. Also he has many pigmented nevi on the skin with different shapes and shades with risk of degeneration into melanoma after excessive sun exposure.

4.4.4 Asymmetric Global DeformationsdKyphoscoliosis

Kyphoscoliosisdposterior view

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4. The Objective Examination of the Thorax

We can observe in the preceding image an asymmetry of the thorax. The right shoulder is more prominent and elevated compared with the left shoulder, indicated with red arrows, and this sign is suggestive of kyphosis. At the same time we can observe the lateral curvature of the vertebral column, like an S, this accentuation of the lateral curvature is scoliosis. The combination of kyphosis and scoliosis represents kyphoscoliosis, an asymmetric global deformation of the thorax. 4.4.4.1 The KyphoscoliosisdPosterior View Unilateral Deformations

The kyphoscoliosis shape of the thorax

We can observe clearly the asymmetry of the thorax in the preceding image. The left shoulder is elevated compared with the right shoulder, indicated with a red arrow. The left shoulder is more prominently evident compared with the right shoulder, indicated with red arrows. The curvature of the vertebral column is accented in the lateral view like an S, indicated with red arrows. These are typical signs of scoliosis. Because the patient also presents with an accented curvature of the thoracic column, which is typical of kyphosis, this patient has kyphoscoliosis.

4.4 The Inspection of the Thorax

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4.4.4.1.1 The KyphoscoliosisdLeft Oblique Posterior View

The kyphoscoliosis shape of the thorax

In this left oblique posterior view, we can see better all the signs of the scoliosis and kyphosis. Evident are the preeminence of the left shoulder and upper and accented curvature in the lateral side of the vertebral column like an S, suggesting scoliosis. Accented curvature of thoracic column suggests kyphosis. The combination of both changes suggests the diagnosis of kyphoscoliosis. 4.4.4.1.2 The KyphoscoliosisdPosterior View

The kyphoscoliosis shape of the thorax

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4. The Objective Examination of the Thorax

The left shoulder is elevated compared with the right shoulder, indicated with a red arrow. The left shoulder is evidently more prominent compared with the right shoulder, indicated with a red arrow. The curvature of the vertebral column is accented in the lateral view, like an S, indicated with the red arrows. These are typical signs of scoliosis. Because the patient also presents with the accented curvature of the thoracic column, which is typical of kyphosis, this patient has kyphoscoliosis. 4.4.4.1.3 The Previous Patient With KyphoscoliosisdAnterior View

The patient with kyphoscoliosis, anterior view: the left shoulder is more elevated than the right shoulder; gynecomastiadenlarged breasts in a man

This is the same patient with kyphoscoliosis, but now we can see how the patient looks from the anterior view. If you look carefully, you can observe the left shoulder elevated compared with the right shoulderda sign of scoliosis. Surprisingly, we can observe another signdgynecomastiadenlarged breasts in a mandindicated with the red arrows. This does not have any connection with the anomalous shape of the thorax.

4.4 The Inspection of the Thorax

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4.4.4.1.4 The Spine KyphoscoliosisdPosterior View

Spinal kyphoscoliosisdposterior view

This young patient, 16 years of age, has an impressive asymmetric deformity of the thorax, accentuated spinal kyphoscoliosis. We can observe an important asymmetry of the thorax. The right hemithorax is very prominent compared with the left hemithorax. The curvature of the spine is very accentuated in the lateral side like an S, and the right shoulder is elevated compared with the left shoulder because of scoliosis. The accentuation of the curvature of the right hemithorax is like a hump (kyphosis). This malformation of the thorax disrupts the normal movement of the lungs in the chest cavity and the activity of the heart. This patient had TB of the spinedPott disease. Sometimes Pott disease can appear secondary to extrapulmonary TB. This deformation of the spine needs a surgical procedure for correction of the spine malformation in the department of orthopedic surgery. 4.4.4.1.5 Posterior View

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4. The Objective Examination of the Thorax

4.4.4.1.6 Anterior View

4.4.4.2 KyphosisdLeft Lateral View

Kyphoscoliotic thoraxdleft lateral view

4.4 The Inspection of the Thorax

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This is the same patient with kyphoscoliosis, from the left lateral view. In this view we can see only the much accentuated curvature of the thorax, kyphosis, indicated with the red arrow. This deformation of the thorax is more common in older patients. It is possible to develop back pain. With this anomaly of the curvature of vertebral column, the patient can sometimes feel back pain, and also it is possible to disturb the normal ventilation of the lung. This patient is has kyphoscoliosis, but from the left lateral view we can observe only the kyphosis. 4.4.4.2.1 KyphosisdPosterior View

Kyphosis of the thoraxdposterior view

We can observe in this patient the accentuation of the curvature of the vertebral columndindicated with the red arrowdand this is a typical change and sign of kyphosis. Persons with this shape of thorax develop an inferiority complex because the people around them say they are hunchback. This patient feels back pain in the context of kyphosis. This type of thoracic shape disturbs the normal respiratory movements of the lung inside the thoracic cavity. Surgical procedures can correct this malformation of the thorax.

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4. The Objective Examination of the Thorax

4.4.4.2.2 KyphosisdLeft Lateral View

Kyphosis of the thoraxdleft lateral view

We can observe very well in this patient the accentuation of the curvature of the vertebral columndindicated with the red arrowdand this is a typical change and sign of kyphosis. This patient feels back pain in the context of kyphosis. This patient cannot stay in a vertical position. It is possible that breathing difficulties will develop due to pressure put on the lungs. In the preceding image we can see an old patient 72 years of age with kyphosis, but changes in the shape of the thorax just like that can affect people of any age. When it appears in children, this is Scheuermann disease and the cause is unknown.

4.4 The Inspection of the Thorax

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4.4.4.3 Scoliosis

Scoliosis

Scoliosis represents the lateral changes of the vertebral column into an S shape. In the preceding image we can see these changes indicated with red arrows. The first red arrow in the preceding image indicates the first lateral deviation of the curvature of the thoracic vertebral column into the right side. The second red arrow below it indicates the deviation of the lumbar vertebral column into the left side. These two deviations of the vertebral column in these two opposite directions develop the appearance of the vertebral colon like an S. Consecutive to this deviation there appear also a few changes: the right scapula is preeminent and the right shoulder is elevated compared with the left shoulder, indicated with two other arrows.

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4. The Objective Examination of the Thorax

4.4.4.4 Malformation of the Thorax After Dislocation of the Clavicle During Delivery

Malformation of the thorax after dislocation of the clavicle after delivery

This young patient, 21 years of age, has a very asymmetric thorax. First we can observe that the breasts are asymmetric: The right breast is elevated and retracted compared with the left breast. A deep hole is also present in the lower area of the sternum, like in funnel chest or pectus excavatum, but in reality this is not the shape of the thorax. The history of the patient is an interesting situation. During the patient’s delivery, he had a dislocation of the right clavicle. The mother of this boy refused the surgical correction of the problem during the newborn stage of life and the deviation of the right clavicle consolidated naturally in evolution and the patient remained with this anomalyd malformation of the thorax as a sequela.

Malformation of the thorax after dislocation of the clavicle after delivery

4.4 The Inspection of the Thorax

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Do you think that this malformation is only a cosmetic problem or can this also lead to other consequences? At first this was considered a cosmetic problem. Because the patient suffers from the malformation of his thorax, he developed an inferiority complex, especially during the summer season when everybody gets a lot of sun exposure and he looked different. But with psychological support he can pass these moments and realize that other qualities are more important. In addition to the cosmetic problem, this unusual and rare malformation of the thorax can disturb the normal ventilation of the lungs and can affect the normal respiratory movements of the lungs inside the thorax cavity.

Malformation of the thorax after dislocation of the clavicle after deliverydright lateral view

Malformation of the thorax after dislocation of the clavicle after deliverydleft lateral view

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4. The Objective Examination of the Thorax

The Same PatientdTop View

The same patientdtop view

4.4 The Inspection of the Thorax

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4.4.4.5 Other Diverse Important Signs During the Inspection of the Thorax

Missing the left nipple after middle lung lobectomy

In this image, we can observe, during the inspection of the thorax, the left nipple is missing and this is indicated with a red arrow. This suggests that it is possible to be surgically removed for some reasons. The patient went through a surgical intervention in the past for a malignant tumor of the left lung, more exactly at the level of the left middle lobe, and the patient suffered a resection of the middle left lobe of the lung with a malignant tumor formation. After the surgical procedure the left nipple was removed. 4.4.4.5.1 Missing the Left NippledA Scar After SurgerydThe Left Lateral View

Missing the left nippledscar after resection of the middle left lung lobe for malignant tumor of the lung

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4. The Objective Examination of the Thorax

This image is the same patient as presented before. But the image of the patient is from the left lateral view. From this view we can see an oblique scar after surgery, indicated with the red arrow, and the lack of the left nipple as well. Now we can understand better why the left nipple is missing from the previous image of the patient from the anterior view. This scar is after the resection of the middle left lung lobe for a malignant tumor of the lung located in this area. 4.4.4.5.2 Oblique Scar on the Left Lateral View of the Thorax After Surgery

Scar on the left lateral thorax after resection of the middle lung lobe because of malignant tumor of the left lung

These images are of the same patient who suffered resection of the left middle lobe of the lung for a malignant tumor that presented at this level, and this scar is after the surgery. We can observe the oblique surgery scar indicated with the red arrows in the image.

4.4 The Inspection of the Thorax

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4.4.4.5.3 Chest With PacemakerdAnterior View

Chest with pacemakerdanterior view

During the inspection of the thorax of this patient, we could observe a round foreign body at the level of the left hemithorax, preeminent on the skin, indicated with the red arrows. This is a pacemaker. Sometimes, but rarely, we can observe it in a simple inspection of the thorax, a round device on the left hemithorax, prominent in the skin; and in this moment we know that the patient has an implanted pacemaker. This patient had in his past history repeated AdamseStokes syncope, and on the EKG the patient presented with a complete atrioventricular (AV) block, grade 3, with complete AV dissociation and needed implantation of a permanent pacemaker.

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4. The Objective Examination of the Thorax

4.4.4.5.4 Chest With PacemakerdLeft Lateral Oblique View

Chest with pacemakerdleft lateral view

From the oblique left lateral incidence we can observe better the disposition of a permanent pacemaker, indicated with red arrows. The shape of the pacemaker is perfectly round with a dimension of 3/3 cm and very preeminent in the skin. This patient needs this pacemaker throughout his life because he had a complete third degree AV block. This pacemaker emits impulses in place of the heart and maintains the patient’s life. 4.4.4.5.5 Enlarged Right BreastdAnterior View

4.4 The Inspection of the Thorax

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During the inspection of the thorax of this patient, we could observe enlargement of the right breast compared with the left breast, indicated with the red arrow. This patient had a nodular formation inside the right breast. This is a rare case, but can occur. This was also confirmed at the palpation of the breast: the presence of a nodular formation 1/2 cm with irregular borders, with hard consistency, and fixed in the surrounding tissue. These elements suggest malignancy. The palpation of the right axilla did not put in evidence the presence of enlarged lymph nodes. The nodular formation was removed surgically and the histopathology examination confirmed the diagnosis of breast carcinoma. 4.4.4.5.6 Enlarged Right BreastdLeft Lateral View

From the left lateral view of this patient we can see well the enlargement of the right breast. This patient had a malignant tumor formation inside the right breast and after surgical removal the histopathology examination confirmed the diagnosis of carcinoma of the breast. Carcinoma of the breast is very rare in men. The risk factors are exposure to radiation, family history, or an inherited faulty gene. After its surgical removal the patient followed complete protocol management with radiotherapy and chemotherapy as well, with a good evolution.

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4. The Objective Examination of the Thorax

4.4.4.5.7 Hypertrichosis

Hypertrichosis is excessive hair growth, over the normal quantity, but the hair distribution is in normal areas of the body. This is a man 42 years of age, with an excessive quantity of hair on his back, indicated with the red arrows. Because the increased quantity of hair is on a normal area of hair distribution in men, this situation is hypertrichosis. This patient had an increased level of androgen hormonesdhyperandrogenism. This hormonal disturbance was the cause of hypertrichosis. Hirsutism represents the presence of hair in abnormal areas of the body, where it is not present under normal conditions. This is the difference between hypertrichosis and hirsutism.

4.4 The Inspection of the Thorax

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4. The Objective Examination of the Thorax

4.4.4.5.8 Hypertrichosis

Anterior view

4.4 The Inspection of the Thorax

Posterior view

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4. The Objective Examination of the Thorax

Hypertrichosisdposterior thorax

Hypertrichosisdanterior thorax

4.4 The Inspection of the Thorax

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4.4.4.5.9 Pityriasis Acromial

Pityriasis acromial

Another important element during the inspection of the thorax is the possibility of skin changes or infections of the skin. In the preceding image, we can observe many white spots, with different dimensions, with irregular borders like a map, on the posterior chest, indicated with the red arrows. This can be confused with vitiligo because it appears like small depigmented areas on the skin, like in vitiligo, but in reality it was a fungus infection of the skindpityriasis acromial. This is a fungus infection of the skin, looks typically as shown in the preceding image. This patient went frequently to the beach and the swimming pool at the beach area. From these places he came into contact with the fungus that led to the skin infection. After correct dermatological therapy with a specific cream (Vitix) and avoiding the contact sources, the white spots may disappear. 4.4.4.5.10 Pityriasis Acromial

Pityriasis acromial

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4. The Objective Examination of the Thorax

4.4.4.5.11 LipomadPosterior Thorax

Sometimes, lipoma can be present at the inspection of the thorax. Lipoma represents a benign formation of fatty tissue. It is a round formation, with different dimensions, soft consistency, and round borders and is mobile relative to the surrounding tissue. In the preceding image we can observe a round formationda lipomadindicated with a red arrow, located at the posterior thorax at the level of the upper area of the right scapula. If we look carefully, we can observe another

4.4 The Inspection of the Thorax

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lipoma located at the right lumbar area, indicated with the second red arrow. If the patient agrees, the solution is very simple because they can be removed with an easy surgery. The presence of lipoma can also suggest dyslipidemia; the patient must undergo a lipid profile because dyslipidemia is a risk factor for atherosclerosis, ischemic heart disease, and heart attack. 4.4.4.5.11.1 LipomadPosterior Thorax

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4. The Objective Examination of the Thorax

4.4.4.5.11.2 LipomadPosterior Thorax

We can observe in the preceding image the presence of a round formation, indicated with two red arrows, with a good delimitation, regular borders, and dimensions of 3/2 cm; elevated; located in the posterior area of the neck; with soft consistency and no pain. This is a typical image of a lipoma. The patient sustains the formation and it increases in dimension with time. The patient agreed to undergo the surgical removal of this formation. After the surgical resection of the formation, the macroscopic view was yellow and the contents were fat, so it was confirmed as lipoma. The lipid profile of the patient was cholesterol ¼ 270 mg/dL, HDL cholesterol ¼ 60 mg/dL, LDL cholesterol ¼ 42 mg/dL, triglycerides ¼ 280 mg/dL. The presence of lipoma represents a risk factor for dyslipidemia. 4.4.4.5.11.3 LipomadPosterior Thorax

4.4 The Inspection of the Thorax

4.4.4.5.11.4 LipomadPosterior Thorax

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4.4.4.5.11.5 LipomadPosterior View

4. The Objective Examination of the Thorax

4.4 The Inspection of the Thorax

4.4.4.5.11.6 LipomadLateral View

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4.4.4.5.11.7 LipomadAnterior View

4. The Objective Examination of the Thorax

4.4 The Inspection of the Thorax

4.4.4.5.11.8 LipomadLateral View

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4.4.4.5.11.9 Lipoma

4. The Objective Examination of the Thorax

4.4 The Inspection of the Thorax

4.4.4.5.11.10 PalpationdSoft Consistency

4.4.4.5.11.11 Deep PalpationdSoft Consistency

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4. The Objective Examination of the Thorax

4.4.4.5.11.12 Mobility Present

Superficial mobility

4.4 The Inspection of the Thorax

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Deep mobility

4.4.4.5.11.13 LipomadPosterior Thorax

This patient had an enlarged lipoma, indicated with the red arrow, located at the right posterior hemithorax at the level of the right scapula. The dimensions were very big, 8/7 cm, with regular borders and soft consistency, and it was mobile relative to the surrounding tissue. This is a benign formation of fat tissue. This patient had values of cholesterol ¼ 350 mg/dL, HDL cholesterol ¼ 88 mg/dL, LDL cholesterol ¼ 58 mg/dL, triglycerides ¼ 512 mg/dL, so it was a severe dyslipidemia, with risk factors for atherosclerosis, ischemic heart disease, and heart attack. When we see a patient with a lipoma in medical practice, we must check the lipid profile because the presence of lipoma suggests dyslipidemia.

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4. The Objective Examination of the Thorax

4.4.4.5.11.14 The Palpation of LipomadSoft Consistency

Palpation of lipomadsoft consistency

In the image above we observe a medical student performing palpation of the lipoma. When the student pushed with two fingers in the middle of the lipoma, it had a soft consistency. This sign is very suggestive of benign formations because the lipoma consists of fat and soft tissue. This patient also had other family members with lipoma, so it was a familial hereditary risk of lipoma. 4.4.4.5.11.15 Lipoma

4.4 The Inspection of the Thorax

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4.4.4.5.11.16 LipomadPosterior View

4.4.4.5.11.17 Lipoma in the Posterior Region of the Thorax

In the preceding image we can see in the middle of the posterior thorax a round formation, with regular border, elevated from the plane of the skin, and perfectly round with dimensions of 4/4cm, indicated with the red arrow. At palpation, this formation is very soft and mobile on the superficial and deep planes of the surrounding tissues. The round formation is soft, well delimitated, and mobile; these are good signs for a benign formation. This formation is a lipomada benign formation of fatty tissue. This suggests also dyslipidemia and risk factors for atherosclerosis and ischemic heart disease.

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4. The Objective Examination of the Thorax

The lipid profile of this patient was: -

Cholesterol ¼ 340 mg/dL Triglycerides ¼ 280 mg/dL HDL cholesterol ¼ 60 mg/dL LDL cholesterol ¼ 40 mg/dL Important dyslipidemia is present in this patient with lipoma.

4.4.4.5.11.18 Lipoma View Side View

4.4.4.5.11.19 Lipoma

4.4 The Inspection of the Thorax

4.4.4.5.11.20 LipomadOn the Base of the Right Hemithorax

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4. The Objective Examination of the Thorax

4.4.4.5.11.21 Giant Lipoma on the Posterior Thorax

4.4.4.5.11.22 LipomadCloser View

4.4 The Inspection of the Thorax

4.4.4.5.11.23 Giant LipomadLeft Lateral View

This formation reached this size in 5 years. The patient refused surgery. The formation is highly vascularized.

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4. The Objective Examination of the Thorax

4.4.4.5.11.24 Lipoma of the Left Shoulder

4.4 The Inspection of the Thorax

4.4.4.5.11.25 LipomadTop View

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114 4.4.4.5.11.26 LipomadTop View

4. The Objective Examination of the Thorax

4.4 The Inspection of the Thorax

4.4.4.5.12 Purpura Eruption on the Anterior Chest and Arms

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4. The Objective Examination of the Thorax

4.4.4.5.12.1 Purple Rash at the Rear of the Thorax

4.4 The Inspection of the Thorax

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4.4.4.5.12.2 Purple Rash at the Level of Posterior Face at the Base of Right Hemithorax

This purpura eruption, which is nonpalpable, at the level of the anterior and posterior thorax appeared in a patient with alcoholic liver cirrhosis in the context of thrombocytopenia