Assessment of the severity of the condition of patients in the provision of emergency therapeutic and surgical medical care at the prehospital stage.

With diphtheria, dirty white films are observed in the pharynx area, on the palatine arches, the root and back of the tongue, and when removed, a bleeding surface is exposed. Dysentery is characterized by the appearance of a thick white-brown coating on the tongue.

Candidiasis (thrush), caused by the development of yeast flora, is accompanied by the formation of confluent plaques on the tongue, tightly adjacent to the back of the tongue and covered with a cheesy milky-white coating.

The state of dehydration of the body is accompanied by the formation of a dark, sometimes almost black (like cholera) coating, which is difficult to remove from the tongue. A characteristic plaque occurs with Vincent's stomatitis (fusospirochetosis) — it has a grayish-green color and a fetid putrefactive odor; after its removal, a loose, bleeding ulcer remains. With leptotrichosis, a dense, difficult to remove whitish-gray coating forms on the tongue; in some places, areas of loosened and easily bleeding mucous membrane are exposed under it.

Diseases of the gastrointestinal tract.

Gastritis, gastric ulcer, enterocolitis lead to a significant increase in plaque on the tongue; it is localized mainly in its posterior sections, and may even cover the entire back. In diseases of the stomach and digestive tract, the coating on the tongue has a grayish-white color. With a gastric ulcer, a whitish coating on the tongue, regardless of its abundance, can be easily removed. This may cause a burning sensation and pain. Due to its swelling, there may be teeth marks on the side surfaces of the tongue. If the plaque is too strong, it may be accompanied by a decrease in taste sensitivity. The color and consistency of plaque may vary depending on the intensity and severity of the manifestations of the disease.

With pathologies of the liver and biliary tract, plaque can acquire various shades of yellow (dirty yellow, brown). The appearance of yellow plaque can be caused by parasitic diseases, blockage of the bile ducts and stagnation of bile.

Pancreatitis is characterized by a yellow-white coating on the tongue that is difficult to brush off. The filiform papillae on the tongue are enlarged, and foci of exfoliation (desquamation) of the epithelium may appear on the back of the tongue.

Diabetes mellitus causes increased dry mouth. Insufficient saliva production leads to the formation of abundant dental plaque and white plaque. In addition, candidiasis develops in the oral cavity, which aggravates the severity of plaque.

Geographic tongue may be caused by neurotrophic disorders and diseases of the gastrointestinal tract.

Dyspepsia is a feeling of pain or discomfort in the upper abdomen; it is often recurrent in nature. Dyspepsia is described as indigestion in the stomach, excessive gas formation, a feeling of early satiety, sucking or burning pain.

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When digestion is disturbed, symptoms appear that are united by a common name — “gastric dyspepsia”, clinical manifestations arise:

–dysphagia;

–nausea and vomiting attacks;

–belching;

–pain in the stomach;

–heartburn;

–rumbling in the stomach;

–bloating;

–constipation, diarrhea.

Dyspepsia of the stomach and intestines causes pain in the epigastric region. They can be either quite intense or in the form of mild discomfort. There is a feeling of rapid satiety and fullness, and as a result, nausea, belching, and heartburn. Another alarming sign is loss of appetite, quickly and sharply. After this, the person begins to lose weight for no reason. Intestinal dyspepsia is accompanied by rumbling in the stomach, flatulence, diarrhea or constipation.

Disruption of the process of digesting food in the intestines may indicate pathologies such as dysbiosis, diverticulitis, enzymopathy, enteritis, colitis, tumors in the intestines, irritable bowel syndrome, pancreatic diseases, and metabolic pathologies. Also, intestinal dyspepsia may indicate that an infection is developing in it (dysentery, cholera, intestinal tuberculosis, salmonellosis, etc.).

There are two main groups of dyspeptic disorders — functional dyspepsia and organic. In the first case, only disturbances in the functioning of the organ are detected, i.e. functional lesions, while in the second they are exclusively organic in nature.

There are several forms depending on the reasons that cause the development of the syndrome:

1)simple dyspepsia. It is also called nutritional. Caused by nutritional problems. In turn, there is fatty (soapy), fermentative and putrefactive dyspepsia. In the latter case, it develops if the food is dominated by protein products or stale meat is used. Fermentation develops from excessive consumption of carbohydrates (bread, cabbage, legumes, sugar) and drinks that cause fermentation (beer and kvass). Fatty dyspepsia develops with excessive consumption of fatty foods, especially pork and lamb;

2)dyspepsia associated with a deficiency of enzymes secreted for digesting food in the intestines and stomach. In turn, it can be gastrogenic (lack of enzymes in the stomach), pancreatogenic (deficiency of pancreatic substances), enterogenic (lack of intestinal juices), hepatogenic (insufficient secretion of bile from the liver);

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3)dyspepsia, which is associated with problems with the absorption of food in the intestines with malabsorption syndrome. As a result, nutritional components do not flow from the intestines into the blood;

4)dyspepsia, which is associated with intestinal infections. Such conditions may be associated with dysentery or salmonellosis;

5)intoxication. It manifests itself due to poisoning in various diseases, including influenza, acute surgical pathologies, and also when consuming poisons.

Assessment of nausea and vomiting in adults.

Nausea and vomiting are extremely common symptoms that can be caused by a variety of diseases and conditions. Their manifestation can be acute or chronic, and severity can range from moderate to life-impairing or life-threatening.

There are two mechanisms for the development of nausea and vomiting:

1. Neurological:

– stimulation of the posterior field, which is sensitive to the effects of noxious chemicals (e.g., poisons, chemotherapy drugs, digoxin), provokes further stimulation of the vagus nucleus, which causes nausea and coordinates the gag reflex;

– central nervous system (CNS) diseases, such as infections or brain tumors, stimulate central nervous system structures and can cause nausea and vomiting by affecting the vagus nerve.

2. Peripheral:

– diseases and disorders occurring in peripheral organ systems, such as the gastrointestinal tract, stimulate the vagus or spinal cord afferent nerves that contact the vagus sensory (single fasciculus) and efferent motor nuclei. Ultimately, through the efferent pathways, the cortical centers are stimulated, which are responsible for the occurrence of nausea;

– tumors, infections and medications, if they affect peripheral organ systems, can cause local dysfunction of the latter, which is manifested by a feeling of nausea, which then causes vomiting.

Belching is a reflex contraction of the muscles of the diaphragm, abdominals and stomach walls, during which air and gases from the stomach are expelled through the mouth.

Dysbacteriosis is the occurrence of an imbalance of microflora. The ratio of normal and opportunistic microorganisms is disrupted. This phenomenon can occur in the intestines (most often) and in the reproductive organs. Dysbacteriosis is characterized by belching of air, with a bitter or rotten taste.

Esophageal hernia (diaphragmatic hernia, hiatal hernia) is a common chronic recurrent pathology in which the initial abdominal section of the digestive tube moves into the supradiaphragmatic zone through the esophageal opening of the diaphragm.

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Gastroenterocolitis (foodborne toxic infection) is a disease in which an inflammatory process occurs in several parts of the gastrointestinal tract — the mucous membranes of the stomach, small and large intestines, and digestive function is disrupted. With gastroenterocolitis, belching of food occurs or with a rotten taste; gastritis with high acidity is characterized by increased production of hydrochloric acid, which helps dissolve food. As a result, the walls of the mucous membrane become inflamed and erosion occurs. Belching with gastritis with high acidity has a sour taste.

Biliary pancreatitis is a chronic inflammatory disease of the pancreas that occurs as a result of pathologies of the liver and bile ducts. It is often combined with other diseases of the digestive system. Biliary pancreatitis is characterized by belching with a bitter taste and a characteristic odor of bile.

Acalculous cholecystitis is an inflammation of the gallbladder in which gallstones do not form. The motor function of the organ is impaired, and bile stagnation occurs. This disease occurs several times more often in women. Acalculous cholecystitis is characterized by belching of air and a bitter aftertaste.

Achalasia of the esophageal cardia is characterized by belching with a rotten taste.

Heartburn is a feeling of discomfort or burning behind the breastbone, spreading upward from the epigastric (epigastric) region, sometimes radiating to the neck area.

Gastroesophageal (gastroesophageal) reflux. Heartburn is caused by highly acidic stomach contents entering the esophagus.

Heartburn is most closely correlated with gastroesophageal reflux disease (GERD). Moreover, if heartburn is the main or only symptom, then in 75 % of patients the cause of heartburn is GERD. Heartburn often causes inflammation of the esophageal mucosa — esophagitis. If GERD is observed, the disease is called reflux esophagitis.

Heartburn can also signal peptic ulcers of the esophagus, esophageal strictures, Barrett's esophagus, and esophageal adenocarcinoma. Heartburn can also be caused by impaired motility of the esophagus, stomach and duodenum.

Vomiting is a complex reflex act in which an involuntary release of the contents of the gastrointestinal tract occurs. Frequent vomiting is always a symptom of the disease and requires timely medical care due to the risk of developing severe complications — dehydration, heart rhythm disturbances due to loss of electrolytes (salts) with vomit, thrombosis, acute kidney injury.

Esophageal vomiting is rare and occurs mainly in children with pathologies of the esophagus. In addition, it can occur as a result of swallowing a foreign body or large pieces of food, as well as in the case of cicatricial narrowing of the esophagus

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after a burn or injury. Vomit appears after every meal. In adulthood, esophageal vomiting can occur with tumors of the esophagus. With cirrhosis of the liver, varicose veins open on the esophageal mucosa, which often burst and cause severe esophageal bleeding. Vomit of esophageal origin has an unpleasant odor and contains impurities of mucus and blood.

Gastric vomiting occurs as a result of irritation of the gastric mucosa by bacterial toxins due to food poisoning or various chemicals.

If vomiting is a symptom of a gastric ulcer, then its contents have a sour taste and smell, the patient has belching, heartburn, nausea, and pain.

When bleeding from the stomach, vomiting of “coffee grounds” often occurs, and when bleeding from the esophagus, vomiting of unchanged blood occurs. Acute bleeding occurs with gastric ulcers, disintegrating stomach tumors, varicose veins of the esophagus with cirrhosis of the liver.

Intestinal vomiting or vomiting of feces is characteristic of intestinal obstruction; such patients require emergency surgical intervention.

If frequent vomiting (up to 10 times a day or more) is combined with severe headache, increased muscle tone, photophobia, increased sensitivity to sounds and high fever, then it may be a symptom of meningitis.

The central type of vomiting is characteristic of hypertensive crisis (sudden increase in blood pressure), brain tumors, lesions of the labyrinthine apparatus of the inner ear, and motion sickness. Vomiting resulting from a traumatic brain injury is also central in nature and is accompanied by loss of consciousness, dizziness, and headache. It occurs suddenly, happens up to 10–15 times a day, usually without nausea. When the temperature rises during colds, reflex vomiting is possible, especially in young children.

Many intestinal infections are manifested by frequent vomiting and diarrhea, but a rise in temperature is not necessary. In children under 3 years of age, rotavirus infection is accompanied by vomiting in 80 % of cases.

Some chronic diseases, for example, chronic kidney disease, decompensated diabetes mellitus (poorly controlled, with very high blood glucose values and the appearance of glucose in the urine), can cause frequent vomiting (up to 5–6 times a day). With these diseases, significant metabolic disorders occur and a slowdown in the elimination of toxic metabolic products from the body.

In some women, repeated vomiting is possible during menstruation (2–3 times a day). It occurs reflexively in response to painful contractions of the muscles of the uterus. Vomiting of pregnant women (toxicosis) usually occurs in the first trimester. Some women experience it once in the morning, while others suffer from vomiting and nausea throughout the day.

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Stomachache.

It is generally accepted that the cause of abdominal pain is most often a spasm of a smooth muscle organ (spastic) or inflammation. Spasmodic pain (colic) develops acutely, suddenly, and can be short-lived or long-lasting, depending on the source and cause of the pain.

Examples of spastic pain: intestinal, renal, biliary colic.

The pain as a result of inflammation increases gradually, and up to a certain point it can be tolerated. As an example: it is for this reason that patients with acute appendicitis often seek medical help late, already at the stage of phlegmonous or gangrenous appendicitis.

The nature of the pain has diagnostic significance. In order to make a correct diagnosis, the doctor asks questions about the nature of the pain the patient is experiencing. You should describe the nature and location of the pain as accurately as possible. Typically, the doctor asks the patient to lie on his back in order to relax the abdominal muscles, uses pressure movements to feel the abdomen with his fingertips, gently, without sudden movements, and determines the place where the pressure causes the most pain. Nature of the pain: dull, aching, sharp, cutting, bursting, radiating pain, intensified by coughing or walking, the appearance of pain — suddenly, or after eating, physical activity, defecation.

Localization of pain. There is no absolute connection between the location of pain and the damaged organ. Pain near the navel, moving to the right lower abdomen, is most often a symptom of appendicitis, and pain with inflammation of the pancreas can begin “in the pit of the stomach” and then become girdling. Pain in the upper abdomen on the right may indicate a disease of the liver, gall bladder, biliary tract, or duodenum. Pain in the upper left abdomen may be a symptom of gastritis, stomach ulcers, or hiatal hernia. Emergency medical care is required for sharp, rapidly growing pain in the right hypochondrium, epigastric region with irradiation to the right shoulder, collarbone, scapula, iliac region, lower back (symptoms of biliary colic); also, if the pain is sharp, occurs suddenly and is accompanied by fever, nausea, vomiting (symptoms of intestinal perforation, peritonitis), increasing pain, pain in the lower abdomen on the right (symptom of acute appendicitis). Dagger-like intense pain in the epigastric region occurs with a perforated stomach ulcer.

Pain in the lower abdomen on the right can be a symptom of appendicitis, mainly in the left or right half of the abdomen — diseases of the colon (colitis, acute intestinal obstruction, diverticulitis, Crohn's disease, ulcerative colitis), above the pubis — genital organs, bladder.

Abdominal pain in women.

Most often, women experience menstrual pain caused by contraction of the muscles of the uterus, as well as pain as a result of gynecological diseases and in-

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flammation due to sexually transmitted infections. Pain can be felt in the lower abdomen above the pubis, in the groin areas on the left/right. If the next menstruation is delayed and severe pain occurs in the lower abdomen on the right or left, not accompanied by vomiting and fever, it should be excluded ectopic pregnancy.

Before going to see a doctor, you should follow three main rules: hunger, cold and rest. Under no circumstances should you warm your stomach. If pain is a symptom of an inflammatory process, its development may accelerate. You should not (however, this is not mandatory) take painkillers and antispasmodics before seeing a doctor — these drugs smooth out the clinical picture and complicate diagnosis.

When assessing abdominal pain, the following clarifications are relevant:

–the pain appeared suddenly, severe and lasts more than 3 hours;

–the pain resulted from an abdominal injury — a strong blow to the stomach or a fall;

–there was an acute cutting pain, stabbing pain, which shifted to the right hypochondrium;

–there is a girdling pain;

–pain is accompanied by fever, dark urine, nausea or vomiting;

–pain is accompanied by bleeding from the rectum or vomiting of blood;

–pain is accompanied by bleeding from the vagina;

–the pain is accompanied by dizziness, increased heart rate, general severe weakness, pallor and sweating of the skin;

–any abdominal pain during pregnancy.

Diagnosis of esophageal damage is based on a history and characteristic symptoms, and fits into the following scheme:

1.Collect complaints and medical history, pay attention to dysphagia, hoar-

seness.

2.General therapeutic visual examination of the patient.

3.Visual examination of the face, neck and chest to determine subcutaneous emphysema.

4.Visual examination of the abdomen.

5.Body temperature measurement.

6.Heart rate measurement.

7.Blood pressure measurement in peripheral arteries.

8.Auscultation of the lungs and detection of weakened breathing and wheezing.

9.Percussion of the pleural cavities from the back and determination of

“dullness”.

10.Palpation of the abdomen.

11.Percussion of the abdomen and determination of “liver dullness”.

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12.Checking the Shchetkin — Blumberg symptom of peritoneal irritation.

13.Auscultation of abdominal peristalsis.

14.Give a sip of chilled water to drink and note the nature of the pain in the sternum when swallowing.

15.Determining blood oxygen saturation using a pulse oximeter.

Peritonitis is an inflammation of the parietal and visceral layers of the peritoneum, which is accompanied by a severe general condition of the body. Peritonitis occurs as a result of exposure to infectious or chemical irritants due to the entry of gastric contents (containing hydrochloric acid), bile, urine, and blood into the free abdominal cavity.

The most common cause of bacterial peritonitis is perforation of a hollow organ of the gastrointestinal tract, as a result of which gastric or intestinal contents and microflora, i.e. bacteria that live in the lumen of the stomach/intestines, enter the abdominal cavity.

Perforation of a hollow organ can occur due to:

–rupture of the appendix (complication of acute appendicitis);

–perforation of a stomach or duodenal ulcer;

–ulceration of the lymphoid plaque in typhoid fever;

–damage to the intestinal wall by a foreign body;

–perforation of intestinal diverticulum;

–intestinal necrosis due to hernia;

–overstretching of the intestine with intestinal obstruction;

–perforation of a malignant tumor and other reasons.

In addition, peritonitis can occur due to suppuration of excess free fluid in the abdominal cavity, formed due to sweating due to increased venous pressure (ascites), inflammation of the abdominal organs (for example, with intestinal obstruction, gynecological diseases), intra-abdominal bleeding.

Classification of peritonite by Yu.M. Lopukhin and V.S. Savelyev:

1)by clinical course:

– spicy;

– chronic;

2)by the nature of infection:

–primary (hematogenous or lymphogenous infection);

–secondary (infection due to trauma and surgical diseases of the abdominal cavity): infectious-inflammatory, perforated, traumatic, postoperative;

–tertiary (in weakened patients who have undergone severe operations, injuries, with pronounced depletion of anti-infective defense mechanisms);

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3)by microbiological characteristics:

– microbial (bacterial);

– aseptic;

4)special forms of peritonitis: carcinomatous, parasitic, rheumatoid, granulomatous;

5)by the nature of the exudate:

–serous;

–fibrinous;

–purulent;

–hemorrhagic;

6) by the nature of the damage to the peritoneum:

a)by delimitation: delimited — abscess or infiltrate, undelimited — has no clear boundaries and tendencies towards delimitation;

b)by prevalence:

–local (delimited and non-delimited) — occupies only one anatomical section of the abdominal cavity;

–common — occupies 2–5 anatomical sections of the abdominal cavity;

–total (total) — total damage to the peritoneum — 6 or more parts of the abdominal cavity.

An objective determination of the severity of a patient’s condition with peritonitis and the probable prognosis of the disease is essential in identifying patients in need of more active treatment. One of the most common methods for objectively assessing the severity of peritonitis is the Mannheim peritonitis index (MPI).

Table 1

Mannheim Peritonitis Score Scale

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The MIP consists of eight risk factors, which are scored from 0 to 12, with index values ranging from 0 to 47 points. A score greater than 26 predicts the likelihood of death with high sensitivity (84 %), specificity (79 %) and accuracy (81 %) (Table 2).

Table 2

Indicators of organ failure for Mannheim peritonite index

The diagnosis of acute peritonitis has a characteristic clinical picture that fits into the following scheme:

1.Collection of complaints and medical history.

2.Visual examination of the patient for general medical purposes and the ab-

domen.

3.Body temperature measurement.

4.Heart rate measurement.

5.Blood pressure measurement in peripheral arteries.

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