V. Reference basis of action

Method of measuring of absolute and relative lengths of extremity

Length of lower extremity is determined from the overhead fore-axle of huckle-bone to medial malleolus (relative length), from a trochinter to medial malleolus (absolute length) length of thigh - from a trochinter to the arthral crack of knee, length of shin - from a knee-joint to the ectocondyle. For overhead extremity, measurings conduct: length of overhead extremity - from the fcromial end of collar-bone to the tag of the III finger; for a shoulder - from the acromial end of collar-bone to the olecranon and for a forearm - from an olecranon to the subulate sprout of raduis.

Method of palpation of peripheral arteries of lower extremities

A. tibialis posterior palpaits between the back-lower edge of entocondyle and Achilles tendon. A. dorsalis pedis palpaits between the first and second metatarsus bones. Popliteal artery: during deep palpation of poples at an arcuated under the corner of 120 degrees knee-joint in position of patient by a stomach downward. Femoral artery palpaits on 1,2-2 see of мmedial from the middle of inguinal ligament.

Method of determination of symptoms irritation of peritoneum

Symptom of Schetkin-Blyumberg. Slowly, fluently press the fingers of hand on a front abdominal wall, and then they are taken away suddenly. At the irritation of peritoneum in this area, on the second stage of reception, pain sharply increases is a symptom positive.

Symptom of Ker. Sickliness on inhalation during palpation of right infracostal area.

Symptom of Voskresenskiy. Absence of pulsation of abdominal aorta at the clinic of acute pancreatitis.

Vі. Task for verification of eventual level of knowledges:

Situatioonal tasks

1. Patient A. (52 y. old) a hepatocirrhosis is diagnosed. During examination of patient, you determine the increase of stomach, that can be related to flatulence or presence in the abdominal region of free liquid. 1. What methods of inspection is it necessary to utillize for differentiation of the indicated states? 2. Tell characteristic for a ascites signs. 3. Tell characteristic for flatulence signs.

1. Answer: 1. A review and percussion of abdomen is in different positions of patient, palpation of abdomen. 2. The change of form of abdomen depends on the change of position of body (in position upright reminds a sack half, in horizontal position is a frog abdomen, changeability in the case of turn on a side), exumbilication. During percussion above a liquid a dull percussion sound is determined, above an intestine - tympanitis, in the case of turn on a side is changing of area of dull percussion sound. Positive symptom of fluctuation during palpation. 3. Even increase of abdomen, stable form during the change of position of body, belly-button of it smoothed. During percussion above all of surface of abdomen a tympanic sound is determined, during palpation is absence of fluctuation.

2. Patient T. grumbles about periodic pain and swelling of abdomen, that is localized in a counter-clockwise iliac area. During palpation of sigmoid bowel the dense is determined, uneven, immobile, a few sickly education, by sizes 3x4 sm you diagnose the tumour of sigmoid bowel. 1. What complication did arise up at patient as a result of tumour of sigmoid bowel? 2. What signs can it find out during examination of stomach? 3. At what yet pathosiss, except for a tumour can there be the complication indicated by you?

2. Answer: 1. Partial intestinal impassability. 2. The local thrusting out and visible peristalsis is higher than place of impassability. 3. At the cicatrical narrowing, indigitation, twist of bowel and other.

3. Patients during superficial palpation of abdomen feels a sickliness and resistance of abdominal wall is determined in right subcostal near-by the external edge of direct muscle of stomach. 1. About pathology of what organs is it possible to think? 2. Name the palpation signs of resistance of abdominal wall. 3. What diagnostic value does have resistance?

3. Answer: 1. About pathology of gall-bladder or duodenum. 2. Local resistance of abdominal wall during palpation. 3. Localization of resistance shows a pathological process in a subject organ.

4. At patient the ulcer of duodenum suddenly was a «whinger» pain in abdomen. During palpation the sharp poured out sickliness and tension of muscles of abdominal wall is determined. 1. What complication did arise up at patient? 2. What can be marked during examination of abdomen? 3. What diagnostic value does have resistance?

4. Answer: 1. Perforation of ulcer with development of diffuse peritonitis. 2. Absence of participation of abdomen is in the act of breathing. 3. Positive symptom of Schetkin-Blyumberg; disappearance of noises of intestine is conditioned paralysis of his muscles, that is related to development of peritonitis.

5. A patient grumbles about that when he swallows bread, meat, a meal passes laboured. 1. What symptoms of dyspepsia does speech go about? 2. What can the complaint of patient be conditioned? 3. What the additional methods have of research be appointed ?

5. Answer: 1. Odynophagia. 2. Presence of dyscynesia, strictures, achalasia, shrine of gullet, compression of gullet from outside by aneurysm of aorta, tumour of ediastinum. 3. Ezofagoskopiyu, a roentgenologic, эндоскопическое, ultrasonic esophagoprobe is a histological study of biomaterials of mucous membrane of gullet, cells research.

6. Patient K (34 years old) during 12 years is ill the ulcer of duodenum. In the morning felt a strong weakness, broke into perspiration, pale. In 10 minutes vomit appeared with the admixtures of blood. Objectively: pallor of skin covers, pulse 110 in a minute, an arteriotony 90/50 мм of рт. item A stomach takes part in the act of breathing, soft, painless. 1. How is this complication of ulcerous illness named? 2. What yet is a symptom characteristic for this complication? 3. What additional methods of inspection are needed above all things?

6. Answer: 1. Massive gastroenteric bleeding. 2. Melena. 3. Urgent fybrogastroscopy with the purpose of establishment of source of bleeding and his liquidation by means of endoscopic methods, determination of hematocrit.

7. A patient grumbles about inconstant pain in right subcostal area, nausea, bitter taste in to the mouth, belch, decline of appetite. 1. About the disease of what organs is it possible to think? 2. On what yet can a patient complain in the case of pathology of these organs? 3. What reason of origin of pain?

7. Answer: 1. About the disease of liver, gall-bladder ways. 2. Complaints from the side of cns, itch of skin, icterus, fever. 3. Engaging in the inflammatory process of peritoneum, that covers liver or gall-bladder, considerable tension of gall-bladder, discinesia of bilious ways.

8. A patient is delivered in a clinic with complaints about sharp pain in right subcostal and vomit. Pain arose up after the use of rich and sharp food. During palpation of abdomen tension and sickliness is marked in right subcostal. 1. About what pathosis is it possible to think? 2. What additional signs can be exposed during the physical inspection of patient? 3. Ground the mechanism of formation of pain in the case of the pathology indicated by you?

Answer: 1. About the presence of bilious colic. 2. Positive symptoms of Myusi, Ker, Ortner. 3. Spastic reduction of muscles of general bilious channel, increase in him of pressure, spasm of Oddi’s sphincter as a result illnesses or bad function of bilious ways.