O.O. Bogomolets National Medical University Department of General Surgery N1 “Approved” at the Methodist General Surgery Department #1 Council “___“________2006, protocol #________ Head of General Surgery Department #1 Professor _________O.DronovStudy Guide for Practical Work for Teachers and Students Topic: “Examination of surgical patient (part II). Objective examination of surgical patient. Methods of diagnosis establishment” Course 3 Foreign Students’ Medical Faculty Duration of the lesson – 90 min. Worked out by assistant S.V. Zemskov, MD Kyiv 2006
I. Priorities of the subject Objective examination of the surgical patient is one of the most important steps inestablishment of correct diagnosis, especially if the patient is unconscious. The diagnosis shouldalways be proved by data of objective examination. These data are also a basis for indications forsurgical treatment. Compilation of data of subjective and objective examination brings one to thediagnosis establishment. Life and health of the patient depends on knowledge and attentivenessof the doctor who manages with his objective examination. II. The aim of training A.1. Student should be acquainted with the following subjects: – symptoms of surgical diseases – main acute abdominal surgical pathology – differentiating diagnosis – pattern of investigation of surgical patient – systems of evaluation of objective status of the patient (APACHE, RANSON, SAPS) A.2. Scope of the knowledge: – basic method of objective examination of the patient – definition of local status and its role in surgery – consequence of objective examination – inspection – palpation – percussion – auscultation – additional methods of investigation of surgical patient – method of establishment of diagnosis A.3 Student should be able to: - perform an inspection of patient - perform a palpation - percussion percussion - perform auscultation - write down the results of objective examination into the patients natural history III. Training and educational objectives 1. To facilitate understanding the importance of complete objective examination of the patient in order to establish correct diagnosis and indications for surgical treatment 2. To facilitate learning the principles of the medical ethics and the deontology in patients’ examination. 3. The exemplify the importance of the knowledge of the subject. IV. Interdisciplinary integrationSubject for study and Scope of knowledge Scope of skillscorresponding chairAnatomy Topography of visceral organs To be able to define the size and margins of the organs by objective examinationBiochemistry and Normal rates of in biological To be able to comment ratesorganic chemistry liquids of organism. Reasons and of biological liquids of
effects of deviation of this rates organismPhysiology Physiological rates of Comment the rates of hemodynamics and breathing hemodynamics and breathingPropedeutics Methodic of investigation of the Gather anamnesis, perform patient inspection and objective examination V. Content of training The patient’s objective examination (status praesens objectivus) is performed by meansof inspection (inspectio), palpation (palpatio), percussion (percussio), auscultation (auscultatio),and measuring. This topic is thoroughly studied by students during the course of Propaedeuticsof internal diseases. Performing the objective examination doctor should use all his sense organs, he shouldtake into consideration the patient’s status and the time that surgeon has. The peculiarity of the surgical patient’s objective examination, especially in urgentsituations, consists in examination of the morbid area (locus morbi, status localis). Through theexamination of the morbid area the form, symmetry, presence of pathological formations shouldbe discovered. The inspection should be performed either during daytime or in the well-lightedroom. Usually, status localis demonstrates the symptoms typical for proper disease or itscomplications. Data, obtained at diseased area examination should be separately filled in the casehistory. The second important task of surgeon is to determine the severity of the patient’s generalstate, which can be satisfactory, medium severe (bad) and bad. Determination of the patient’sstate severity is important for admission to the intensive care unit. The patient’s inspection (inspectio) is quite an informative method of examination whichstarts with the moment of surgeon’s and patient’s meeting. Doctor should pay attention at thepeculiarities of patient’s walk, his face expression, body position, manner of speech, color ofsclera and skin, presence of rash and hemorrhages. Palpation (palpatio) should be performed carefully and started with the body areas notdamaged by p0athoological process. Palpation can reveal presence, localization and intensity ofthe tenderness in different body zones, muscles contraction and tension, local temperature risingand falling, presence, consistence, configuration and size of pathological malformations, specialsymptoms etc. Measuring – is an important method to determine the extremities’ real length, joints’mobility, extremities’ edema, tumor size and others. The laboratory and instrumental examination methods provide the objective confirmationof the diagnosis. Diagnosis (identification) – is an accurately determined definition of the patient’s diseasebased on the examination results and according to the State register of the diseases nomenclature. A. Laboratory testsBasic laboratory tests for surgical patient are: - hemoglobin, hematocrit, leucocytes, platelets - fibrin, fibrinogen, prothrombin index, partial activated thromboplastin time - blood coagulation time - sodium, potassium, chloride, transaminases (AlT, AsT) - blood glucose A. Chest X-ray
- indicated to all patients with cardiovascular and pulmonary pathology, immune suppression, malignancies, specific anamnestic data (imprisonment, homeless), as well as to all patient indicated for major surgical procedures. B. Electrocardiography Indicated to all patients elder then 40 years, as well a to all patients with signs of cardiac insufficiency, rhythm disorder, coronary diseases (inc. myocardial infarction). In cardiosurgical patients cardiosonography and coronaroangiography. C. Spirometry Is performed in order to define vital capacity of lungs and forced expiratory volume ( per 1 second). These test together wit blood gas analysis are important in patients who undergo laparoscopic procedures. Methods as perfusion and inhalation scintigraphy, whole body platismography, loaded blood gas analysis, pulmonary artery barometry, bronchoscopy are indicated to patients who undergo pulmonary surgery. D. Ultrasonography Abdominal and pelvic ultrasound is very valuable method in investigation of parenchymal organs. It is also a golden standard in diagnosis of cholelithiasis. Doplerography allows examination of blood flow in major vessels and in organs. E. Endoscopy Is standard in investigation of hollow organs. These methods are: fibroesophagogastroduodenoscopy, rectoscopy, colonoscopy, bronchoscopy. Modern endoscopes allow investigation of choledochus, pancreatic duct and air sine of skull. Endoscopy also allows performance of microsurgical manipulations. F. Other visualization methods Accept for ultrasound and X-ray, there are radioscintigraphy, computer tomography, magnet- resonance tomography, positron-emission tomography (golden standard in diagnostics of malignancies). These methods investigate either precise size, localization of organ or lesion, or its function and character. In all surgical patients endocrine pathology should be excluded (diabetes mellitus, hypo-or hyperthyroidism, pathology of adrenal glands) because it may provoke bench of complicationsintra- and postoperatively.VI. Structure and Organization of the Lesson:6.1. Duration of the lesson – 3 academic hours6.2. Lesson Stages (table)№ Basic lesson stages and their Study Training and Materials for the Tim contents objectives control methods methodic supply e in and their min mastering levelI Preliminary stage Students’ assessment1. Lesson organization A-I register 2’2. Study objectives setting 9’3. Control of basic A - II Oral questions Control questions on 25’ knowledge, experiences, A - III on topic, test topic, A- Form tests skills computer or standard-paper
programII Basic stage1. Objective examination A - III Individual Surgical patient 30’ together with the teacher of A - IV control the surgical patient2. Individual students’ A - III Individual Surgical patient 45’ examination of the surgical A - IV control patientIII Final stage1 Control and correction of A - III 5’ professional skills and A - IV experience2 Making conclusion of the A - II Out-patient card of the 15’ lesson (individual A – III in-patient, students’ questioning, discussion of A - IV assessment register, A- the examined patient’s Form questions cases, revision of the establishment diagnosis methods) Theme outline of3 Home task A - IV practical lessons, study 5’ guides for practical workV11. Materials for the methodic lesson supply.1. Materials for the lesson preliminary stage.A. Lesson topic control questions:The surgical patient’s objective examination, diagnosis and its substantiation1. What are the counterparts and peculiarities of the surgical patient’s objective examination?2. What is a sequence of the surgical patient’s objective examination?3. Give the definition of the term and meaning of “locus morbi” in the surgical patient’sobjective examination.4. What instrumental methods of examination are important for establishing the diagnosis of thesurgical patient?5. What are the indices to determine the severity of the patient’s general status?6. Give the definition of the term “diagnosis”.7. What types of diagnoses are there?8. What is a sequence of the diagnosis establishment?9. Name the diagnoses related to the urgent surgical pathology. B. Format A tests 1 45 years old male presents pale skin on one foot and shank. Puls on a. dorsalis pedis and a. tibialis posterior is absent. Puls on a. femoralis is preserved. Which artery is affected? A. A. Genis descendes B. A. Iliaca externa C. A. Fibularis D. A. Femoralis profunda. E. A. Poplitea
2 60 years old male presents dilatation of subcutaneous vein of anterior abdominal wall. Circulation in which vein is affected? A. v. cava superior B. v. hemiazigus C. v. portae hepatis D. v. mesenterica superior E. v. mesenterica inferior3. 48-years old male presents dilated subcutaneous veins in paraumbilical region (head ofmedusa). Chronic alcohol consumptions in anamnesis. Which organ is affected and throughwhich venous anastomoses venous blood flows? A. Liver. Porto-caval anastomosis of v. mesenterica B. Pancreas. Cava-caval anastomosis of v.mesenterica C. Spleen. Cava-caval anastomosis of gastric vein system D. Liver. Cava-caval anastomosis of superior and inferior mesenteric vein system E. Stomach. Porto-caval anastomosis of gastric4. Patient presented swelling on medial side of the hip, increase in subcutaneous veins volume,venous nodes formation. Which vein is affected?A. . V. popliteaB. V. saphena parvaC. V. femoralisD. V. saphena magnaE. V. iliaca externa 5. Emergency case: patient presents bloody vomiting at admission. The patient has livercirrhosis in anamnesis. Which veins are affected? A. liver portal vein B. superior mesenteric vein C. hepatic veins D. esophageal veins E. splenic veins6. Female presented sign of acute abdomen at admission. After the investigation abdominalpregnancy is suspected. Which anatomical region should be punctured in this case?A. Excavatrio rectouterinaB. Excavatio vesicouterinaC. excavatio rectovesicalisD. Fossa ishiorectalisE. Processus vaginalis peritonei7. X-ray examination shows the signs of air in stomach of a patient. In which part of the stomachis it located? A. corpus B. fundus C. cardia D. pylorus E. small curvature8. What is the anatomical feature in duodenum that helps identifying the papilla Vateri duringgastroduodenoscopy?
A. duodenal glands B. circular plicae of duodenum C. bulbus of duodenum D. longitudinal plicae of duodenum E. ligamentum hepatoduodenalis9.45 years old male presented acute severe pain in epigastrium at admission. After examinationdiagnosis is established: Perforation of ulcer of posterior wall of stomach. Where is gastriccontent localized after the perforation? A. bursa omentalis B. bursa hepatica C. bursa antegastrica D. left mesenterial sac E. right mesenterial sac 10. In which peritoneal space first spreads transudate in patient with acute necrotizing pancreatitis? A. bursa omentalis B. bursa subhepatica C. bursa antegastrica D. left lateral chanal E. right lateral channel Correct answers:Правильні відповіді:1–E 4–D 7–B 10 - A2–C 5–D 8-D3–A 6–A 9–A VIII. Supporting materials required for teaching 1. Participation in clinical duties on admission 2. Working in library IX. Literature 1. „ Загальна хірургія”, ред. С.П.Жученка, М.Д. Желіби, С.Д.Хіміча – Київ, „Здоров”я”, 1999 р. 2. „ Загальна хірургія”, ред. М.П.Черенька – Київ, „Здоров”я”, 1996 р. 3. „Методичні рекомендації до практичних занять з загальної хірургії з доглядом за хворими”. В.О.Шидловський. – Тернопіль, 1994 р. 4. „Пропедевтика хірургічних захворювань”. В.О.Шидловський.- Тернопіль, 1999 р. 5. „Общая хирургия”, В.К.Гостищев,М., „Медицина”,1997 р. 6. „Общая хирургия”, В.С.Голованов,М., „Медицина”,1997 р. 7. „Практика хірургії”, ред. К.В.Манна, Р.Г.Русселя, Н.С.Вільямса, пер. з англ. М., „Медицина”, 2000 р. 8. Тематичний лекційний матеріал та тематичний цикл практичних занять кафедри загальної хірургії №1 НМУ.