Vі. Tasks for verification of eventual level of knowledges.

Situation tasks for verification of eventual level of knowledges

1. The doctor of first-aid was caused in the evening to the 7-years-old boy in connection with worsening of his state. Approximately 1,5 days back a child with complaints about head pain was released from lessons home. On to the house he was examined by a district paediatrician and concerning a "acute respiratory viral infection" appointed anti-inflammatory and antibacterial preparations.

At examination the state of child is heavy, put on the brakes. Temperature of body 40 °C. According to a mother, before arrival of "first-aid" there were hallucinations. A face is pale, аcrоcyanosis. A pulse is 128 shots in a minute. Breathing — 28 in a minute, superficial. In the lower departments of lights hearkened to the dissipated dry and moist wheezes. A stomach is soft, painless. Liver, spleen not increased. Marked sickliness at palpation in lower third of right thigh, edema of him.

About what disease is it necessary to think? As far as will roentgenologic research be informing?

1. For a child it is necessary to suspect acute hematogenous osteomyelitis of right thigh. Roentgenologic research in these terms will be uninforming, as roentgenologic signs of acute hematogenous osteomyelitis appear in 10-15 days from the moment of disease.

2. In the admission department of hospital a boy is delivered 9 years with complaints on pain in a right foot. It is ill during 2 weeks. Treated oneself on to the house. The state was worsened, therefore directed on stationary treatment.

Temperature of body each evening to 40 °C. In lights hearkened to the single dissipated dry and moist wheezes. A liver and spleen is not increased. An edema and hyperemia of skin is determined in lower third of right thigh, acute sickliness. A knee-joint is increased in a volume, a leg in him is half-bent, motions are sickly. It is additionally set that 3 a week ago struck a right thigh at a school desk.

Your diagnosis? What researches must be executed in an admission department?

2. Judging to on clinical information, for a child it is necessary to suppose acute hematogenous osteomyelitis of right thigh, complicated a subperiosteum abscess or intermuscular phlegmon.

In the admission department of hospital it is necessary to execute the global analysis of blood, wet, roentgenoscopy of thorax and sciagram of right thigh in two projections.

3. A mother brought around to a reception to the surgeon of boy 13 years, which during the last year periodically aching pains disturb in overhead third of left shin. As a rule, pains appear at the change of weather and at nights.

Outwardly shin without features. The limited promoted sensitiveness is marked at pressing on on a tibia in the overhead third it. Motions in a knee-joint are carried out in full.

On sciagrams in spongy part of metaphysis of tibia the rounded cavity is determined by a diameter about 1 sm, surrounded well the visible area of sclerosis like a narrow border and tender periostitis impositions on a bone surface.

Your diagnosis?

3. A child has an initially-chronic form of hematogenous osteomyelitis: interosteal abscess Brodie.

4. Surgical infection department the sick entered with complaints on pain in a right shin, periodic increase of temperature of body to 38-39 °C. Moves by crutches. 12 months back carried the opened break. Treatment was conducted skeletal extraction and gipseous bandage. However from pains can not move independently.

On the front surface of right shin there is fistula with scanty purulent separated. A shin is an edema, round fistula there is moderate hyperemia of tissues. On sciagrams shins are marked false joint, end osteolisis of debris of tibia, endostal sclerosis, bulge and fringing of periost.

What diagnosis did the sick act with? What must be conducted additional methods of research?

4. A patient suffers chronic posttraumatic osteomyelitis of right tibia (fistulas form). From additional researches it is necessary to execute fistulography in two projections for determination of purulents pockets or computer tomography.

5. On a reception to the surgeon the sick came A., 63 years, with complaints on pain in a left thigh, which appeared about a week ago. Suffers chronic osteomyelitis of left thigh about 40 years after a splinter wound.

According to patient, periodically on a thigh fistulas was opened with purulent separated and pull out of "stone".

Left thigh considerably thicker right. Motions in a left knee-joint are absent. On the outward surface of thigh there is a great number of crateriform of the pulled in and linear scars as a result before opened fistulas and carried operative interferences. The area of hyperemia of skin, slight swelling, sickliness, is here determined, in the center of palpate infiltrate is softening influence. Temperature of body 37,8 °C.

What diagnosis will you put a patient? Your diagnostic tactic?

5. At patient intensifying of chronic gun osteomyelitis of left thigh, complicated a hypodermic phlegmon. It follows him to execute the global analyses of blood and urine and roentgenologic pictures of left thigh in two projections.

6. Surgical infection department the sick entered with "infiltrate" of posterior and lateral wall of stomach on the right. To the patients counts itself about 8 days, when each evening began to mark the increase of temperature of body to 38-39 °C.

Three years back treated oneself concerning gun osteomyelitis of front surface of comb of ilium. A process deleted under act of conservative measures. Since considered itself absolutely healthy.

What complication is it necessary to suspect at patient?

6. More credible than all, at patient intensifying of chronic gun osteomyelitis of front surface of comb of right ilium, that in real case dangerously by possibility of development of retroperitoneal phlegmon.

It should be remembered that can be complicated the phlegmon of retroperitoneal space also osteomyelitis of the XII rib and osteomyelitis of transversal sprouts of lumbar vertebrae.

7. A hospital of 23-years-old man, suffering chronic hematogenous osteomyelitis of right thigh chart comes into a question at medical conference. What changes in a bone will be observed on a sciagram for this patient?

7. On the sciagrams of patient in a thigh-bone a cavity will be determined with a freely lying sequestrum.

8. The doctor of first-aid was caused in the evening to the 7-years-old boy in connection with worsening of his state. Approximately 1,5 days back a child with complaints about head pain was released from lessons home. On to the house he was examined by a district paediatrician and concerning a "acute respiratory viral infection" appointed anti-inflammatory and antibacterial preparations.

At examination the state of child is heavy, put on the brakes. Temperature of body 40 °C. According to a mother, before arrival of "first-aid" there were hallucinations. A face is pale, аcrоcyanosis. A pulse is 128 shots in a minute. Breathing — 28 in a minute, superficial. In the lower departments of lights hearkened to the dissipated dry and moist wheezes. A stomach is soft, painless. Liver, spleen not increased. Marked sickliness at palpation in lower third of right thigh, edema of him.

Your medical tactic?

8. A patient must immobilise right lower extremity and quickly to transport in a hospital.

9. In the induction centre of hospital a boy is delivered 9 years with complaints on pain in a right foot. It is ill during 2 weeks. Treated oneself on to the house. The state was worsened, therefore directed on stationary treatment.

Temperature of body each evening to 40 °C. In lights hearkened to the single dissipated dry and moist wheezes. A liver and spleen is not increased. An edema and hyperemia of skin is determined in lower third of right thigh, acute sickliness. A knee-joint is increased in a volume, a leg in him is half-bent, motions are sickly. It is additionally set that 3 a week ago struck a right thigh at a school desk.

Your medical tactic?

9. A patient is hospitalized in a surgical separation, where an urgent operation is shown him: dissection of intermuscular phlegmon, subperiosteum abscess or trepanation of bone for emptying of abscess. General treatment is conducted on principles of treatment of acute purulent-septic diseases.

10. A mother brought around to a reception to the surgeon of boy 13 years, which during the last year periodically aching pains disturb in overhead third of left shin. As a rule, pains appear at the change of weather and at nights.

Outwardly shin without features. The limited promoted sensitiveness is marked at pressing on on a tibia in the overhead third it. Motions in a knee-joint are carried out in full.

On sciagrams in spongy part of metaphysis of tibia the rounded cavity is determined by a diameter about 1 sm, surrounded well the visible area of sclerosis like a narrow border and tender periostitis impositions on a bone surface.

Your medical tactic?

10. It is necessary to send a patient in a surgical department for operative treatment. As a rule, here made trepanation of bone, scraping of internal wall of abscess with taking in of wound tight with muscular the plastic arts of bone cavity or without it.

11. The sick entered into the surgical infection department with complaints on pain in a right shin, periodic increase of temperature of body to 38-39 °C. Moves by crutches. 12 months back carried the opened break. Treatment was conducted skeletal extraction and gipseous bandage. However from pains can not move independently.

On the front surface of right shin there is fistula with scanty purulent separated. A shin is an edema, round fistula there is moderate hyperemia of tissues. On sciagrams shins are marked false joint, end osteolisis of debris of tibia, endostal sclerosis, bulge and fringing of periost.

Your medical tactic?

11. Operative treatment is shown a patient. Excision of fistula and necrotic tissues is made. At end osteomyelitis with formation of false joint the ends of bones of resection and bone debris are fixed the vehicle of Ilizarov.

12. On a reception to the surgeon the sick came A., 63 years, with complaints on pain in a left thigh, which appeared about a week ago. Suffers chronic osteomyelitis of left thigh about 40 years after a splinter wound.

According to patient, periodically on a thigh fistulas was opened with purulent separated and pull out of "stone".

Left thigh considerably thicker right. Motions in a left knee-joint are absent. On the outward surface of thigh there is a great number of crateriform of the pulled in and linear scars as a result before opened fistulas and carried operative interferences. The area of hyperemia of skin, slight swelling, sickliness, is here determined, in the center of palpate infiltrate is softening influence. Temperature of body 37,8 °C.

Your medical tactic?

12. A patient is necessary to be hospitalized in the surgical infection department for operative treatment: dissections and drainage of phlegmon. It is the first stage of treatment, the second stage is sanation of hearth of infection in a bone it is necessary to conduct in the department of bone-purulent surgery after clearing of wound and completion of necrolisis.

13. On the sciagrams of sick S. in distal metaphisis of thigh-bone a cavity is determined with a freely lying sequestrum to 1,5 sm in a diameter. Operative treatment is shown a patient.

What did you offer for filling (seal integrity) of sequestral cavity after sequestrectomy and sanation of " sequestral coffin"?

13. Most effectively for the plastic substitution of bone defect filling his bloody clot, by autogenous bone or cartilaginous pieces with adding to them of antibiotics in hard forms, and also by a muscular shred on a proximal or distal feeding leg. Stoppings are used also from a periosteum, skin, canned bone, round petiolate shreds, deprived skins.