Semantic module 4. Traumatism and damage Practical employment # 33

Theme: methods of examination of surgical patients: abdomen and locomotor apparatus.

I. Actuality of theme.

The diseases of gastroenteric tract remain an important problem. It contingently their considerable prevalence, high enough indexes of invaliding and death rate, and also substantial economic charges, conditioned these diseases. A study of clinical displays of diseases of joints is the important and relevant problem of medicine, because these diseases even at timely and adequate treatment in most cases result in the proof loss of capacity (to disability), especially at the persons of young age.

II. Aims of employment:

1. To know basic and additional complaints of patient with the disease of gastrointestinal tract.

2. To know anatomical zones and topographic lines of front abdomen wall.

3. To know main causes of ascites and main methods of examination of patients with ascites.

4. To do general examination of patient, its clinical interpretation.

5. To do examination of abdomen, palpation of abdomen.

6. To know symptoms of irritation of peritoneum.

7. Can finding symtoms of abdominal hernias (umbilical, hernias of white line).

8. To know complaints of patients with deseases of joints, anamneses.

9. To do testing of active and passive movements of joints.

III. Providing of initial level of knowledges-abilities

Literature:

1.Butursky A. “General surgery”. (Simferopol 2004)

2.S. I. Shevchenko; A. A. Tolkoglas and etc. “Surgery” (Kharkov 2004)

3.Methodological Instruction.

Tests and tasks for verification of initial level of knowledges

1.Decline of appetite is:

A аnоrехіа

B hурогехіа+

C сіtоfоbіа

D eruсtаtіоn

E геguгgіtаtіоn

2. The symptom of fluctuation is characteristic for:

A flatulence

B ascites +

C obesities

D edema of front wall of stomach

E pyloristenosis

3. Heartburn is:

A аnогехіа

B сіtоfobіа

C eruсtаtіоn

D ругоsіs

E nаusеа +

4. Belch air is:

A аnогехіа

B hурогехіа

C сіtоfobіа

D eruсtаtіоn +

E геguгgіtаtіоn

5. Pain in an epigastrium, which has girdle character and irradiats to the back, testifies to:

A gastritis or ulcerous illness of stomach

B duodenitis or ulcerous illness of duodenum

C pancreatitis

D cholecystitis

D irritations of abdominal interlacement as a result of disease of stomach, duodenum, gall-bladder, pancreas +

6. Tarry color of excrement the masses testifies to:

A gastric bleeding +

B pulmonary bleeding

C enterorrhagia

D bleeding from haemorrhoidal veins

7. The symptom of muscle defence is characteristic for:

A inflammation of organs of abdominal region

B inflammation of peritoneum +

C ulcerous illness of stomach

D ulcerous illness of duodenum

E pyloristenosis

8. Absence of appetite

A аnогехіа +

B hурогехіа

C сіtоfobіа

D eruсtаtіоn

E геguгgіtаtіоn

IV. Table of contents of teaching

Basic complaints at the diseases of gullet: odynophagia, pains, vomiting, regurgitation, belch, hiccup, heartburn, salivation, bleeding.

An odynophagia is the laboured passing of meal on a gullet, a permanent and temporal. Dysphagia form meets at the organic damages of gullet (new formations, scars). Paroxysmal an odynophagia more frequent meets at functional changes, quite often provoked agitation, hasty use of meal. Thus it can be paradoxical - passing mostly of soft and liquid meal stays too long. Pains - permanent, aching or boutе, localized after a breastbone, irradiation to a shoulder, neck, counter-clockwise half of thorax. Oesophageal vomiting: meets at a substantial esophagostenosis, unlike gastric vomit provoked the delay of meal in a gullet, arises up quite often without previous vomit, carried out without participation of muscles of front abdominal wall, contains tailings of the undigested littlechanged meal, does not contain muriatic acid and pepsin, there are admixtures of saliva. Regurgitation is returning insignificant part of the used food in an oral cavity, more frequent than all meets at presence of barrier for passing of food. Nightly regurgitation («symptom of wet pillow») - at the achalasia of cardium. Heartburn is conditioned the irritation of mucous membrane of distal department of gullet by sour content, that gets from a stomach at reflux-esophagittis, to hernia of oesophageal department of diaphragm, insufficiency of cardium. Bleeding reasons: ulcer, tumour, damage of wall of gullet, break of the varicose-extended veins of gullet, linear tears of mucous membrane. The arterial oesophageal bleeding is characterized appearance vomit the masses of the unchanged blood. At bleeding from veins blood of darkly-cherry color is selected.

Basic complaints at the diseases of stomach: pains, vomiting, nausea, belch, heartburn, violation of appetite, gastric bleeding. Attention on working out in detail of pain applies: localization, irradiation, character of pain, periodicity, seasonality, intensity, connection with the reception of meal. Localization is a epygastral area, an irradiation is various: at pathology of cardial department - in the counter-clockwise half of thorax, pectoral department of spine at the damage of antral and pyloric department - in the area of right subcostal. Characteristic clear connection with the use of meal: early pains appear through 30-60 mins after-meal and proceed during 1-1,5 hours. Late pains - through 1,5-3 hours after the reception of meal, increase as far as the receipt of sour gastric content in duodenum, characteristic for duodenitis and ulcer of bulb to duodenum. Hungry pains appear in 6-7 hours after-meal and disappear after its reception. Nightly pains - at ulcerous illness, they arise up in a period between 23 - 3 hours. Vomiting can be central origin and internal. Working out in detail: time of origin (morning, right after the reception of meal, in 1,5-2 .), the volume of vomit the masses, their smell, color, consistency, reaction, character of tailings of meal, presence of admixtures, brings the patient of facilitation. The features of the gastric bleeding is vomiting by coffee-grounds and melena, which appears in 8-12 hours after bleeding.

Pay a regard to changes original appearance of patient at different pathology of gastroenteric highway (skin covers), examination of cavity of mouth, sequence of examination of stomach (form, sizes, symmetry, participating in the act of breathing, state of skin and belly-button, fatness, state of hypodermic vessels, character of hair cover). Students remember topographical areas and topographical lines on-the-spot stomach.

A teacher explains the method of leadthrough of superficial palpation of abdomen (palpation on the arc of large and small radius), verification of symptoms of irritation of peritoneum, exposures of divergence of direct muscles of stomach, presence of umbilical hernia and hernia of white line of abdomen. During the leadthrough of superficial palpation of abdomen estimate a local sickliness, tension. Concept of hydroperitoneum, differential diagnostics with flatulence and obesity. The methods of exposure of hydroperitoneum are demonstrated: survey percussion, by the method of fluctuation.

Artralgiya is a term, that will characterize the concept of the sickly feelings in a joint without the objective signs of his inflammation, ossalgy are the sickly feelings in bones (spontaneous and at percussion on bones), arthritis is the state, that will characterize inflammation of joint at which 5 signs of inflammation take a place is pain, feeling of «heat» in a joint, was swollen, hyperemia, parafunction; артроз is a noninflammatory disease of joint (with deformation or without its). The concept of arthral syndrome takes a place in that case when the defeat of joints is observed as one of displays of general disease of internalss (for example, at rheumatism, psoriasis, dysentery, collagenosess).

At examination attention on gait of patients, character of motion, applies during undressing, lying and upright in comfortable for a patient position. At palpation the oedematousness of periarthicular fabrics is determined, localization and character of pain is specified the degree of deformation appears, the size of circumference of joints is measured. At auscultation it is possible to define a crunch or crepitus. The feature of clinical objective inspection of patients with an arthral syndrome is measuring of degree of mobility of joint purpose of which - to define whether there is pain or restrictive defect by reason of diminishing of mobility. Active mobility (motions are made a patient independently) and passive mobility is thus probed (motions are made a doctor). The degree of limitation of mobility is determined in percents from the proper as compared to an of the same name healthy joint.

At laboratory research of sick with diseases joints have to adhere to the following algorithm of diagnostics: the analysis of blood, biochemical blood test, is probed on activity of inflammatory process (CRB, seromucoid, haptoglobin, albuminous spectrum), level general Fibrinogenum and faction In, level of ALT and AST, KFK, global analysis of urine (at infectious arthritises of type of syndrome of Reytera), level of urinary acid at suspicion on a gout.

For verification of diagnosis research of synovia, morphological research of joints (oligobiopsy of synovium or synosteotomy). Obligatory research is sciagraphy of joints, a thermography and arthroscopy of joints is used on occasion. Obligatory in the plan of inspection of patients with an arthral syndrome there is EKG and ultrasound of heart for the exposure of system defeats of muscles and valves of heart. Diagnostic symptoms of rheumatic polyarthrittis are autoimmune defeats with development of reactive polyarthrittis on a streptococcus infection: descending character has arthritis, large and symmetric joints are struck, as a rule,, pains are brief, an inflammatory process proceeds 3-5 days and quickly regresses on a background antibacterial therapy. 5 signs of inflammation are characteristic at a sharp rheumatic attack, never results in deformation of joints. At Ekg-research it is possible to expose the signs of myocarditis or heart-disease.