Danylo Halytskyi Lviv State Medical University
Recommendations for
Obstetrics and Gynecology, Surgery
(Part II)
for the 6 Year Students
of the General Medicine Faculty
Lviv – 2003
“Recommendations for Obstetrics and Gynecology, Surgery” for clinical practice for students of
general medicine faculty.
Edited by Prof. Sklyarov E.J., Bilohan N.P., Lemishko B.B., Bohonko O.
Editor-in-chief: Vice-Rector of Education, Professor M.Gzhegotskyi.
Discussed and approved during the Department of Outpatient and Family Medicine
methodological meeting, protocol № 8 dated 6.02.2003.
Table of contents
1
Prophylaxis, diagnosis and treatment of the specific inflammatory diseases of the female sexual
organs in outpatient clinic. ............................................................................................................... 3
Prophylaxis, diagnosis and treatment of the non-specific inflammatory diseases of the female
sexual organs in outpatient clinic. .................................................................................................... 5
Marriage and family. Family planning. Contraception of pregnancy. ............................................. 7
Preeclampsia and eclampsia. ............................................................................................................ 9
Prevention of infertility. Diagnosis and treatment at the outpatients department. ......................... 11
Prevention of miscarriage. Diagnosis and treatment at the outpatients department. ..................... 13
Bibliography (obstetrics and gynecology) ..................................................................................... 15
Acute suppurative diseases of the sleek tissues ............................................................................. 16
Whitlow and phlegmon of hand. .................................................................................................... 18
Mastitis ........................................................................................................................................... 20
Indications for surgical management in ulcer disease .................................................................... 22
Differential diagnosis of abdominal pain ....................................................................................... 24
Inflammatory rectal diseases. Hemorrhoids. .................................................................................. 26
Bibliography (surgery) ................................................................................................................... 28
2
Prophylaxis, diagnosis and treatment of the specific inflammatory diseases of the female
sexual organs in outpatient clinic.
Introduction
Last years the increase in quantity of specific etiology inflammatory diseases of female
genitals is marked. Specific inflammatory diseases of female genitals frequently result in
temporary disability, operative interventions, female infertility, spontaneous abortions,
complications of pregnancy and deliveries, intrauterine fetal infection and child infection during
delivery.
Prophylaxis and purposeful treatment with the account of pathogenesis under out-patient
conditions results in prevention and reduction of complications.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, symptoms and signs,
complications, methods of diagnosis and differential diagnosis of specific inflammatory diseases
of the female sexual organs. Properties of medicament treatment according to pathogenetic
variants of diseases. Modern approaches in conservative and surgical treatment, and prevention
of specific inflammatory diseases.
To have good practical knowledge of:
- vaginal examination
- laboratory investigation
- deciding the diagnosis
Define the indications for hospitalization if needed.
Tasks for students selfpreparation
Structure and consistence of training
1. Etiologic factors of specific
inflammatory diseases
2. Types of vaginitis
3. Bacterial vaginosis
4. Trichomonas vaginitis
6. Candidal vaginitis.
7. Diseases caused by N. gonorrhoeae
8. Diseases caused by C. trachomatis
9. Prevention of specific inflammatory
diseases
Instruction for the class
Count
Define and show criteria
Describe:
symptoms and signs
4 diagnostic criteria
treatment
Describe clinical symptoms, treatment
Enumerate typical symptoms, treatment
Set treatment protocol:
complications
uncomplicated infections
Tell about the:
- clinical picture
- methods of diagnosis
- complications
- treatment
Enumerate the risk factors
3
Student’s
answer
Self-control tests
Case 1
Patient is a 25-year-old woman who came to outpatient’s clinic with complaints about
malodorous yellow frothy discharge, dysuria, dyspareunia, vaginal erythema during two days.
During vaginal examination is established: cervix and vagina have a strawberry appearance; pH =
5-6; Whiff (Amine) test – positive.
Evaluation tests?
Diagnosis?
Plan of treatment?
Case 2
Patient is a 27-year-old woman who came to outpatient’s clinic with complaints about
thick, white discharge; pruritus with vulvar itching, burning, irritation during four weeks.
Symptoms increase the week before menses. pH is < 4.5; Whiff (Amine) test – negative.
Diagnosis?
Evaluation tests?
Plan of treatment?
Tasks for students during the class
1. Observing patients with specific inflammatory diseases in outpatient’s clinic.
2. Evaluate the laboratory and instrumental tests results.
3. Formulate diagnosis.
4. Study the scheme of conservative treatment.
Self preparation plan
1. Medications for treatment of candidal vaginitis (essay).
2. Treatment for uncomplicated infections caused by C. trachomatis (essay).
4
Prophylaxis, diagnosis and treatment of the non-specific inflammatory diseases of the
female sexual organs in outpatient clinic.
Introduction
Inflammatory diseases of female genitals occupy one of the first places among
gynecological diseases which result in temporary disability, surgical interventions, female
infertility. Prophylaxis and purposeful treatment with the account of pathogenesis under the outpatient conditions with application of physiotherapeutic methods reduces risk of complications
occurrence.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, risk factors, clinical
picture, methods of diagnosis and differential diagnosis, complications of nonspecific
inflammatory diseases of the female sexual organs. Properties of medicament treatment
according to pathogenetic variants of diseases. Modern approaches in conservative and surgical
treatment, indications to the surgical treatment. Prevention of specific inflammatory diseases.
To have good practical knowledge of:
- vaginal examination
- laboratory investigation
- deciding the diagnosis
- providing emergency help
Define the indications for conservative treatment, and for hospitalization if needed.
Tasks for students selfpreparation
Structure and consistence of training
1. Etiologic factors of nonspecific
inflammatory diseases
2. Acute vulvitis
3. Atrophic vaginitis
4. Chronic vulvar inflammation
6. Salpingitis
7. Differential diagnostic of acute
salpingitis with other gynecological
diseases
8. Tuboovarian abscess
Instruction for the class
Enumerate factors
Describe clinical symptoms, methods of
treatment
Describe:
clinical picture
treatment
Set treatment protocol
Enumerate typical symptoms, criteria for
diagnosis, treatment of:
acute salpingitis
- chronic salpingitis
Differential diagnostic with:
-tubal pregnancy
-fibroid
-tuboovarial tumors
- criminal abortions
Tell about the:
- differential diagnosis
- complications
- conservative treatment
5
Student’s
answer
9. Prevention of nonspecific inflammatory
diseases
- indications to the surgical treatment
Enumerate the risk factors
Self-control tests
Case 1
Patient is a 34-year-old woman who came to outpatient’s clinic with complaints about
intensive pain in the lower abdomen and in waist, mild fever, yellow discharge during two days.
Patient was treated 2 times in out-patient conditions concerning pelvic inflammatory disease (
acute salpingitis ), at vaginal examination found: size of uterus is normal, ovaries and tubes
enlarged as tuboovarial tumors, the size is 10х8 cm, painful at physical examination. Discharge
from vagina is yellow.
Evaluation tests?
Diagnosis?
Plan of treatment?
Tasks for students during the class
1. Observing patients with nonspecific inflammatory diseases in outpatient’s clinic.
2. Evaluate the laboratory and instrumental tests results.
3. To formulate diagnosis and differential diagnosis.
4. Study the scheme of conservative treatment.
5. Define indications for surgical treatment.
Selfpreparation plan
1. Antibiotic therapy in treatment of tuboovarian abscess (essay).
2. Differential diagnostic of acute salpingitis with other gynecological diseases (essay).
3. Differential diagnostic of acute salpingitis with other non-gynecological diseases
(essay).
6
Marriage and family. Family planning. Contraception of pregnancy.
Introduction
A half of maternal mortality among the women in age from 15 to 35 is connected with the
reproductive system pathology, unwanted pregnancies, abortions, deliveries in the adverse
conditions. Using the family planning methods improves women’s situation. Number of abortion
and postabortional complications (bleeding, sepsis, inflammatory diseases, traumas) decreases by
using contraceptives. Family planning and activity of reproductive health protection services may
decrease the number of unwanted pregnancies and high risk pregnancies.
Learning objectives
Good theoretical knowledge about classification of contraception methods, mechanism of
action, effectiveness of different methods, examining before prescribing of contraceptives,
adverse effects and complications, benefits, drug interactions, using of contraceptives after
pregnancy, emergency contraception.
To have good practical knowledge of:
- vaginal examination
- deciding the diagnosis
- providing emergency help
Define the indications for conservative treatment, and for hospitalization if needed.
Tasks for students selfpreparation
Structure and consistence of training
Instruction for the class
1. Classification of contraception methods
2. Methods for examination
Tell about classification
Enumerate
3 Barrier contraceptives
Describe the methods
4. Methods of natural family planning
Describe the methods:
- calendar rhythm method
- basal body temperature
- cervical mucus
- symptothermal method
Define:
- action
- adverse effects
- complications
Describe their major adverse effects
5. Oral contraceptives
6. Subdermal implants and progestin
injections
7. Intrauterine devices
Describe:
-
7
action
adverse effects
complications
Student’s
answer
Self-control tests
Case 1
Patient is a 28-year-old woman who came to outpatient’s clinic for intrauterine devices
insertion. Patient was treated 3 times in out-patient conditions concerning pelvic inflammatory
disease, at vaginal examination found: size of uterus is normal, ovaries and tubes enlarged as
tuboovarial tumors, the size is 3.5х4.5х4.5 cm, painful at physical examination. Discharge from
vagina is transparent, liquid, in small amounts.
Diagnosis?
Evaluation tests?
Define contra-indications for intrauterine devices insertion.
Case 2
Patient is a 23-year-old woman who came to outpatient’s clinic with complaints about
bleeding during three days in the middle of the menstruation cycle. Patient take oral
contraceptives during two months. Until that time for contraception she was using methods of
natural family planning.
Diagnosis?
Evaluation tests?
Plan of treatment?
1.
2.
3.
4.
5.
Tasks for students during the class
Observing patients in outpatient’s clinic.
Evaluate the laboratory and instrumental tests results.
Formulate diagnosis.
Study the scheme of treatment.
Contraception methods selection.
Self preparation plan
1. Drug interactions while using oral contraceptives (essay).
2. Adverse effects and complications of oral contraceptives (essay).
3. Methods of emergency contraception (essay).
8
Preeclampsia and eclampsia.
Introduction
Preeclampsia develops in 5% of pregnant women, usually in primigravidas and in women
with preexisting hypertension or vascular disease. If untreated, preeclampsia characteristically
smolders for a variable time, then suddenly progresses to eclampsia. Eclampsia develops in 1 of
200 patients with preeclampsia and is usually fatal if untreated. A major complication of
preeclampsia is abruptio placentae, apparently caused by vascular disease.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, risk factors,
symptoms and signs, complications (abruptio placentae, HELLP syndrome), methods of
diagnosis and differential diagnosis of preeclampsia and eclampsia. Different methods of
medicament treatment accordingly to variants of diseases (mild preeclampsia, severe
preeclampsia, eclampsia). Indications to the vaginal delivery, cesarean section. Prophylaxis.
To have good practical knowledge of:
- vaginal examination
- blood pressure measuring
- deciding the diagnosis
- providing emergency help
Define the indications for conservative and surgical treatment, and for hospitalization if
needed.
Tasks for students selfpreparation
Structure and consistence of training
1. Etiologic factors of preeclampsia and
eclampsia
2. Classification of preeclampsia
3. Special methods for examination
4. Clinical symptoms of preeclampsia
6. Symptoms and signs of eclampsia
7. Complications
8. Indications to the vaginal delivery,
cesarean section
9. Prevention of preeclampsia and
eclampsia
Instruction for the class
Student’s
answer
Enumerate risk factors
Define and show criteria
Describe
Set treatment protocol:
mild preeclampsia
severe preeclampsia
Describe symptoms and signs, methods for
examination
Define and show criteria of HELLP
syndrome
Enumerate indications
Describe
Self-control tests
Case 1
Patient is a 24-year-old woman who came to outpatient’s clinic with complaints about
edema of the face and hands during two days. During physical examination, pregnancy for 32
weeks is established. BP – 140/90 mm Hg, albuminuria = 1. Two previous pregnancies had
9
resulted in induced abortions in early terms (6-8 wk gestation).
Diagnosis?
Evaluation tests?
Plan of treatment?
Case 2
Patient is a 32-year-old woman who came to outpatient’s clinic with complaints about
edema of the face and hands during two weeks, visual disturbances, abdominal pain. During
physical examination, pregnancy for 37 weeks is established. BP – 160/110 mm Hg, albuminuria
= 3 is present. The previous pregnancy was ended by induced abortion.
Diagnosis?
Evaluation tests?
Plan of treatment?
1.
2.
3.
4.
5.
Tasks for students during the class
Observe patients with preeclampsia in outpatient’s clinic.
Evaluate the laboratory and instrumental tests results.
Formulate diagnosis.
Study the scheme of conservative treatment.
Define indications for the vaginal delivery.
Self preparation plan
1. Role of BUN and creatinine levels tests for kidney disease diagnostics
(essay).
2. Prophylaxis of HELLP syndrome (essay).
10
Prevention of infertility. Diagnosis and treatment at the outpatients department.
Introduction
Infertility affects about 1 in 5 couples; its increasing incidence partly reflects deferment of
marriage and of birth of the first child. The reason of infertility in 40-50 % of cases is due to the
pathology of reproductive system of one partner, or in 5-10 % - of both. Diagnosis and treatment
require thorough assessment of both partners; the extend and course of treatment should be
individualized. Counselling and psychologic support are important adjuncts to the treatment.
Prevention and early diagnosis of infertility plays on important role in the success of solving this
problem.
Learning objectives
Good theoretical knowledge in etiologic factors, classification, clinical signs, methods of
diagnosis and differential diagnosis of infertility. Modern approaches in conservative and surgical
treatment, assisted reproductive techniques, prevention of infertility.
To have good practical knowledge of:
- vaginal examination
- decide the diagnosis
- provide emergency help
Define the indications for conservative and surgical treatment, and for hospitalization if
needed.
Tasks for students selfpreparation
Structure and consistence of training
1. Classification of infertility.
2. Etiologic factors
3. Special methods for examination
4. Tubal dysfunction
5. Ovulatory dysfunction
6. Sperm disorders
Instruction for the class
Define and show criteria
Enumerate causes of:
primary infertility
secondary infertility
Describe the methods of:
monitoring ovulation
semen analysis
hysterosalpingogram
postcoital test
Count causes, indications for surgical
treatment
Set treatment protocol:
polycystic ovary
syndrome
chronic anovulation
hypothalamic
amenorrehea
luteal phase deficiency
Define causes, treatment of:
azoospermia
varicocele
retrograde ejaculation
11
Student’s
answer
7. Assisted reproductive techniques
endocrine disorders
genetic disorders
Describe the methods:
in vitro fertilization
GIFT
intracytoplasmic sperm
injection
Self-control tests
Case 1
Patient is a 28-year-old woman who came to outpatient’s clinic with complaints about
infertility during 3 years. A history is obtained and physical examination is performed in
searching for the causes of infertility: the patient was treated 2 times in out-patient conditions
concerning pelvic inflammatory disease, at vaginal examination found: the size of uterus is
normal, ovaries and tubes enlarged as tuboovarial tumors, the size is 6х8х5.5 cm, painful at
physical examination. Discharge from vagina is transparent, liquid, in small amounts.
Diagnosis?
Evaluation tests?
The plan of treatment?
1.
2.
3.
4.
5.
Tasks for students during the class
Observing patients with infertility in outpatient’s clinic.
Evaluate the laboratory and instrumental tests results.
To formulate diagnosis and differential diagnosis.
Study the scheme of conservative treatment.
Define indications for surgical treatment.
Self preparation plan
1. Causes of secondary infertility in women with pelvic inflammatory disease (essay).
2. Using of assisted reproductive techniques for patients with tubal disease and unexplained
infertility (essay).
12
Prevention of miscarriage. Diagnosis and treatment at the outpatients department.
Introduction
About 20 to 30% of women bleed or have cramping at some time during the first 20 wk of
pregnancy; half of these women spontaneously abort. In up to 60% of spontaneous abortions, the
fetus is either absent or grossly malformed, and in 25 to 60%, it has chromosomal abnormalities
that is incompatible with life; thus spontaneous abortion in > 90% of cases may be a natural
rejection of a maldeveloping fetus.
About 85% of spontaneous abortions occur in the 1st trimester and tend to have fetal
causes; those occurring in the 2nd trimester are more likely to have maternal causes. Early
diagnosis of complications of pregnancy has great value in the successful treatment and
prevention of miscarriages.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, symptoms and signs,
complications, methods of diagnosis and differential diagnosis of miscarriage. Modern
approaches in conservative and surgical treatment, and prevention of miscarriage.
To have good practical knowledge of:
- vaginal examination
- decide the diagnosis
- provide emergency help
Define the indications for conservative and surgical treatment, and for hospitalization if
needed.
Tasks for students selfpreparation
Structure and consistence of training
1. Etiologic factors of abortion
2. Classification of abortion
3. Diagnostic investigation of habitual
abortion
4. Clinical symptoms of missed abortion
6. Septic abortion
7. Threatened abortion
8. Inevitable and incomplete abortions
9. Prevention of miscarriage
Instruction for the class
Count:
maternal causes
fetal causes
Define and show criteria
Decide.
Set treatment protocol:
up to 18 wk gestation
up to 28 wk gestation
after 28 wk gestation
Describe symptoms and signs, special
methods for examination
Define the indications for conservative and
surgical treatment
Define the indications for:
suction curettage
cervical cerclage
Count the risk factors of high-risk pregnancy
13
Student’s
answer
Self-control tests
Case 1
Patient is a 30-year-old woman who came to outpatient’s clinic with complaints about
bloody discharges, pain in the lower abdomen and in waist during two days. During physical
examination, pregnancy for 10 weeks is established. The diagnosis is confirmed by
ultrasonography: cardiac activity has disappeared. Two previous pregnancies had resulted in
spontaneous abortions in early terms (8-12 wk gestation). No diagnostic investigation after
previous abortions have been carried out.
Diagnosis?
Evaluation tests?
The plan of treatment?
Case 2
Patient is a 25-year-old woman who came to outpatient’s clinic with complaints of fever,
pains in the lower abdomen, plentiful discharge of yellowish-green color with unpleasant smell.
Leukocytosis (WBC count, 19,000/µL) is present. During physical examination, pregnancy for
12 weeks is established. The previous pregnancy was ended by induced abortion.
Diagnosis?
Evaluation tests?
The plan of treatment?
1.
2.
3.
4.
5.
Tasks for students during the class
Observing patients with miscarriage in outpatient’s clinic.
Evaluate the laboratory and instrumental tests results.
To formulate diagnosis.
Study the scheme of conservative treatment.
Define indications and methods of surgical treatment for miscarriage.
Selfpreparation plan
1.Role of urogenital infection in the etiology of miscarriages (essay).
2.Prophylaxis of spontaneous abortions (essay).
14
Bibliography (obstetrics and gynecology)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Pastorek J. Obstetric and gynecologic infections disease. – New York, 1994.
Clinical reproductive medicine / Ed. by Cowan B. - New York, 1997. – 292p.
Medicine of the fetus, mother / Ed. by Reece E. - New York, 1993. – 1605p.
Handbook of in vitro fertilization / Ed. Trounson A. Gardner D. – New York, 1999.
– 560 p.
Pregnancy loss: medical therapeutics and practical considerations / Ed. by I.R.
Woods, I.Z. Esposito. – Baltimore ets.: Williams and Wilkins, 1987. – 355 p.
Ultrasound in obstetrics and gynecology. Vol. 1,2. Ed. by Cherrenak F. – Boston,
1993. – 882 p.
Human reproduction: growth and development / Ed. by goustan D. - New York,
1995. – 498 p.
Benson R., Pernoll M. Handbook of obstetrics and gynecology. - New York, 1994.
– 317 p.
Benson M. Gynecologic pearls. – Philadelphia. – 2000. – 245 p.
Danforth’s obstetrics and gynecology / Scott J. Disaia Ph. Hammond Ch. et. - New
York, 1997. – 1121 p.
Behrman S. Patton G. Holtz. Progress in infertility - New York, 1994. – 413 p.
15
Acute suppurative diseases of the sleek tissues
Introduction
Near one third of the patients who need surgical help are the ones with acute suppurative
diseases of sleek tissues. In connection with wide and sometimes inefficient antibiotics usage
clinical features of disease changed considerably. The cases of acute forms transition into chronic
and relapses in festering infection became more frequent. Quick recognition, proper treatment
and prevention of such diseases matter very much in work of outpatient clinic.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis and classification is needed.
Clinical features, diagnosis and differential diagnosis of acute suppurative infection (furuncle,
carbuncle, abscess, etc.), methods of conservative and surgical treatment are also have to be
known.
To have good practical knowledge in setting diagnosis, define indications and methods of
surgery treatment. Make decision on hospitalization need.
Tasks for student’s self preparation
Structure and consistence of training
1. Classification of the acute
suppurative infections
2. Clinical features (local and
general);
3. Main principles of antibacterial
Instruction for the class
Student’s answer
Specify the criteria of surgical
infection
Describe
Describe
therapy;
4. Enzyme and immunologic
therapy in treatment scheme
5. Indications and methods of
surgical interference
6. Prevention of complications
during antibiotics use
7. Peculiarities of surgical
infections
Define the indications
Define them
Work out a plan
Explain
Tasks for students during the class
1. Observation of the patients with the acute suppurative diseases of sleek tissues in the
outpatient clinic.
2. Interpret the laboratory and additional test results.
3. Prescribe conservative treatment.
4. Determine surgery treatment indications and methods.
16
Self control tests
Case1
The patient is 18 years old man, who appealed to physician on a 6th day from the
beginning of disease. On itch on the front surface of middle third of right high extremity were the
first displayed. Later the skin on this area turned red, the painful compression with measure 2 on
2 cm with a blackish dot in center determined.
Define diagnosis.
Prescribe treatment.
Case 2
The patient is 33 years old man. For past 2 days a general weakness, headache were
marked. On the third day suddenly the body temperature rose to 40C, there vomit was. It is
marked during physical examination that on the skin of the overhead third of left shin is a red
spot with the unequal japged edges. The skin was swollen, hot and sharply painful on touch.
Define diagnosis.
Prescribe treatment.
Define the type of medical establishment.
Case 3
The patient is 17 years old man, who appealed into clinic with complaints about sharply
painful compression in a left in a left inguinal area, evening rise of body temperature to 37.6C.
He is sick for 5 days, during which he oiled painful area by 3% solution of iodine.
Define diagnosis.
Prescribe treatment.
Self preparation plan
1. Features of medical tactics at a festering infection in diabetes mellitus patients.
2. Analyze the origin causes and prevention methods for acute suppurative infection of
the sleek tissues.
17
Whitlow and phlegmon of hand.
Introduction
A whitlow and phlegmon of hand in majority are the complications of microtrauma.
Looking at the quantity of days of the disability this group of patients occupies one of the first
places among outpatient clinic patients with the festering diseases. They also make up large
number among hospitalized patients. Organization of festering diseases prevention of brush and
fingers is the important task in work of general physician.
Quantity reduction of such patients relies on the correctly organized sanitary and
educational work and fulfillment of simple preventive actions.
Learning objectives
Good theoretical knowledge in anatomic features of hand and fingers after distribution of
festering-inflammatory process, pathogenesis, classification, diagnosis of festering diseases of
brush and fingers. It’s prevention, methods of conservative and treatment.
To have good practical knowledge in stating diagnosis and providing emergency surgical
help. Define the indications and methods of surgical treatment. Make decision on hospitalization.
Tasks for students self-preparation
Structure and consistence of training
Instruction for the class
1. Anatomical and topographical features
of hand and fingers after distribution
of festering process
Work on table
2. Whitlow classification
Count them
3. Principles for treatment of different
whitlow forms
Define
4. Phlegmon of palm’s surface hand
classification, clinical features,
diagnosis, treatment
5. Phlegmon of back surface of hand
classification, clinical features,
diagnosis, treatment
6. V-similar and Parona-Pirogova
spacious clinical features, diagnosis,
treatment
Define and work out table
Indicate
Describe
7. Antibiotics therapy
Work out a plan
8. Enzyme and immunotherapy in
treatment plan
Define the indications
9. Prevention
Work out a plan
18
Student’s
answer
Self-control tests
Case 1.
The patient is 40 years old man, inflicted a superficial sword-cut on palm’s surface of
the V finger basis. The day before appeal, suddenly he noticed a strong pain in the area of
the V finger and the body temperature rose to 38º C. Objectively: there is oedema of the V
finger, painful motion of the V finger flexor tendon that disseminates on a forearm. The
swelling and pain in the area of lower third of palm’s surface of forearm are marked.
Define diagnosis. Prescribe treatment.
Case 2.
The patient is 60 years old man. One week ago he run a splinter into II finger of hand,
after that deleted splinter himself. Two days later the man felt pain in the II finger. The body
temperature rose to 39º C. The patient complains of sharp pain in left hand. There is oedema on
the back surface of left hand. Second finger is evenly stilled, there is hyperaemia at the finger and
hand back surface skin. Active movements of the finger are limited. Examination by sound
testifies sharp pain of the finger palm surface.
Define diagnosis. Prescribe the treatment.
Task for students during the class
1. Observing outpatient clinic patients with the acute purulent diseases of hand and
fingers in the conditions.
2. Working out the plan of different forms of whitlow treatment.
3. Working out the plan of phlegmon of hand palm’s surface treatment and surgery
interference.
4. Methods of hand back surface phlegmon treatment.
Self-preparation plan
1. Peculiarities of the Parona-Pirogova cavity and V-similar phlegmons of hand and
forearm, treatment and tactics.
2. Analyse causes and method of prevention for purulent infection of hand and fingers.
19
Mastitis
Introduction
Mastitis is mainly diagnosed at women. More frequently it develops at mothers who
breast-fed their children (87%), especially at birth of the first child (65%). Mastitis can arise up
also at pregnant women in the last weeks before births and very rarely at girls and women in a
climacteric period. Frequency of acute mastitis (5-15%) grows and the level of lethality does not
diminish (1,7%).
Therefore prevention and management of mastitis are the issues of the day.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, clinical features,
differential diagnosis of mastitis.
To have good practical knowledge in setting diagnosis and conducting differential
diagnosis. Provide emergency help, work out a plan of clinical tests and treatment principles.
Define the necessity of hospitalization.
Tasks for students self preparation
Structure and consistence of training
1.Risk factors of mastitis development
2. Classification of mastitis
3. Clinical features
4. Differential diagnosis
5. Methods of laboratory and special tests
6. Treatment principles
Instruction for the class
Student’s
answers
To count down.
Point out the classification criteria.
To name signs.
To count down the diseases which have
similar symptoms.
To define the indication for their
conducting.
To work out a plan of treatment:
А) at stagnation of milk
B) at the cracks of nipple
C) at the initial stage of mastitis (infiltration)
D) on the stage of abscess formation.
Task for self-control
Case 1.
Patient, 25 year-old-woman, appealed with complaints on ache and increase of left
mammary gland, headache, evening rise of body temperature to 38oC. Months ago normally
delivered a child. Two weeks ago a crack on left nipple appeared. The patient was treated in
ambulance, oiled nipples by methilen dark blue, used the ultraviolet rays.
As the result of physical examination it is set that a left mammary gland is bigger than
right, condensed and painful. Milk secretes from nipple.
Define diagnosis.
Work out plan of examination and treatment.
Task for students during the class
1. Observing patients with mastitis in the outpatient clinic.
20
2.
3.
4.
5.
Define of diagnosis.
Interpretation of the results of laboratory and additional tests.
Work out the plan of conservative treatment.
Decide for indications and methods of surgery treatment.
Self-preparation plan
1. The major mastitis causes.
2. Modern methods for mastitis prevention and treatment.
21
Indications for surgical management in ulcer disease
Introduction
The outpatient clinic physician is the first person to meet patient with gastrointestinal
complaints. It is very important for physician to make preliminary diagnosis, and to choose
appropriate treatment. Especially in terms of possible complications from gastric and duodenal
ulcer disease: -choosing appropriate time for surgical consultation and treatment is important for
the patient.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, clinical features and diagnosis of
gastric and duodenal ulcer disease is required. Modern approaches to conservative and surgical
treatments.
To have good practical knowledge in anamnesis collection, performing clinical tests,
physical examination and give correct interpretation of collected test results. Perform differential
diagnosis for gastric and duodenal ulcer; identify the possible complications. Decide on the
diagnosis and further indications for conservative or surgical treatments.
Tasks for students selfpreparation
Structure and consistence of training
Instruction for the class
1. Describe the structure and function of
stomach and duodenum
Draw stomach and duodenum. Describe it’s
parts and it’s relation to other organs.
2. Describe blood and lymph supply to these
organs
Draw the scheme
1. What are the patient’s major complaints?
Define them
2. Clinical features of gastric and duodenal
ulcer disease
Describe
3. Complaints in gastric and duodenal ulcer
disease
Count all of them and describe clinical
features.
4. What are the major complaints if ulcer
disease complications occur
Describe them
5. Indications for surgical treatment
Describe
6. Types of operations
Draw the scheme
7. Gastric and duodenal ulcer disease
hemorrhage treatment
Prescribe haemostatic therapy.
22
Student’s
answer
Self-control tests
Case 1
Patient is a 40-year-old man. 4 hours ago he had nausea, general weakness, dizziness,
hematemesis. During physical examination, the state of the patient is tough. Skin is pale, cold
sweat on his face, pulse 120 per minute, blood pressure 90/60 mmHg. Blood hemoglobin 42g/l.
One month ago he experience heartburn, sour belch and pain in epigastrium was decreasing after
taking baking soda per os.
Diagnosis?
Treatment?
Case 2
Patient is a 60-year-old woman. She has proven gastric ulcer for 2 years. She received
advanced conservative treatment as an inpatient in hospital for several times. Worsening of
disease happens in the spring and fall. During last 3 months – decrease in appetite, weight loss –
5 kg. Quick fatigability, drowsiness, general weakness, apathy, dull pain in the lower back, foulsmelling eructation.
What complication should you think of?
What further diagnostic tests must be performed?
What are the treatment tactics?
1.
2.
3.
4.
5.
Tasks for students during the class
Physical examination of patients with gastric and duodenal ulcer disease in outpatient clinic.
Defining preliminary diagnosis.
Take part in X-ray scanning and endoscopic examination of digestive system.
Define the indications and possible surgical methods.
Observation of the patient as an outpatient.
Selfpreparation plan
1. Functional substantiation of surgical methods in patients with gastric and duodenal ulcer
disease.
2. The causes of complication in such patients.
23
Differential diagnosis of abdominal pain
Introduction
Late hospitalization due to outpatient clinic physician is one of the major causes for bad
surgical outcomes in patients with acute abdomen.
The patient with an acute abdomen poses a diagnostic challenge to the physician. In
approaching such patient, it is necessary to form a broad set of differential diagnosis. Monitoring
the patient, complete examination, well-collected anamnesis, correct tests interpretation – are
basic for an acute abdomen determination. As soon as such diagnosis is determined surgeon
should further consult the patient. Or referred to inpatient clinic.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, clinical features and differential
diagnosis for diseases that can cause abdominal pain.
To have good practical knowledge in recognizing pain syndrome in cases of acute abdomen.
Perform differential diagnosis make decision on hospitalization and immediate surgical or other
specific treatment. Provide emergency help.
Tasks for student’s selfpreparation
Structure and consistence of training
Instruction for the class
1. Diseases which have abdominal pain as a
symptom
2. Types of colic
3. Types of abdominal syndrome
4. Indications for immediate hospitalization
5. Emergency help
6. Differential diagnosis for abdominal pain
Define and describe them using reference
literature
Define and describe clinical features
Describe
Define them
Describe
Compile a table, using reference literature
Student’s
answer
Self-control tests
Case 1
Patient is a 40-year-old man, who had appendectomy 1 year ago and abdominal drainage
because of destructive appendicitis.
Now the complains of abdominal pain, mostly in the right lower iliac region, which
occurred after hard physical effort. Patient’s skin is pale, he’s anxious; abdomen is asymmetric
due to the expansion of the right part over abdomen surface, tachycardia.
What kind of disease will you suspect in such patient?
Case 2
Patient is a 25-year-old man. He felt acute pain in epigastric region during tough physical
effort. During 2 hours the intensity of pain decreases, but localized in right lower iliac region.
Body temperature is 37.5C. Patient doesn’t want to move, lays down on the right side with his
feet flexed towards abdomen. The abdominal wall is tense, mostly in right lower iliac region. The
pain is concentrated in the same region, involuntary guarding, rebound and peritoneal irritation.
What disease should you think of?
What other symptoms you have to check?
24
Should you perform stomach lavage for the patient?
1.
2.
3.
4.
Tasks for students during the class
Observing patients with acute abdominal pain
Define diagnosis
Perform differential diagnosis
Decide the treatment principles
Selfpreparation plan
1. Compile a table of differential diagnosis for abdominal colic based on etiologies.
2. Analize the causes of late hospitalization in patient with acute abdominal pain due to the
mistakes in pain syndrome evaluation.
25
Inflammatory rectal diseases. Hemorrhoids.
Introduction
Inflammatory rectal diseases appear most often in elderly patients. 10 percent of
population suffers hemorrhoids and it makes up to 40 percent of rectal and anal canal pathology.
More than half of all colon cancers is found in the rectum, and about 80 percent of intestinal
cancers are located in the rectum and the sigmoid colon. Physician should be strongly aware that
success in the treatment is closely related to its early diagnosis.
Learning objectives
Good theoretical knowledge in etiology, pathogenesis, classification, clinical, diagnosis
and differential diagnosis of rectal disease is required, especially hemorrhoids, anal fissure and
cancer. Modern approaches to conservative and surgical treatments.
To have good practical knowledge of:
-rectal examination (by finger, anoscopy, rectoromanoscopy).
decide on the diagnosis
provide emergency help
Define the indications for conservative and surgical treatment, and for hospitalization if
needed.
Tasks for students selfpreparation
Structure and consistence of training
Instruction for the class
1. Classification of rectal disease
Define and show criteria
2. Health hazards of hemorrhoids, anal fissure
and cancer
Count them
3. Clinical symptoms and factors, which
determine hemorrhoids, anal fissure and
cancer clinical features
Describe
4. Special methods for rectal examination
Define indications
5. Hemorrhoids, anal fissure treatment
Set treatment protocol:
a) uncomplicated hemorrhoids
b)complicated hemorrhoids
c)anal fissures
6. Indications and operative surgical methods
for intestinal cancer
Decide. Draw the scheme
7. Indications for surgery treatment
Define
8. Methods of operation
Draw the scheme of basic operations.
26
Student’s
answer
Self-control tests
Case 1
Patient is a 40-year-old woman. She came to family-medicine practitioner with the
complaints of pain in the rectal area and drops of red blood on feces at the end of defecation.
Similar complaints were present 1 year ago.
The state of patient is fair good. Abdomen examination showed no pathology. During
rectal examination were found hemorrhoid nods, blood filled with hyperemic mucous on 3 and
11 hours positions. Blood hemoglobin 100g/l.
Diagnosis?
Evaluation tests?
Treatment?
Case 2
Patient is a 43-year old man who came to outpatient clinic with sharp pain in the rectum
after defecation took place, blood stir in feces. Have proven hemorrhoids for 5 years. For week
pain did not decrease. During rectal examination, anal fissure is found, size - 2 on 1 cm.
Diagnosis?
Treatment?
Case 3
Patient is a 60-year-old man who came to proctologist complaining on dull pain in rectal
area, serous-pus egestion from rectum with some blood, feelling of incomplete defecation and
general weakness. He has these complaints for the last 3 months.
Diagnosis?
Evaluation tests?
Treatment?
1.
2.
3.
4.
Tasks for students during the class
Observing patients with rectal pathology in outpatient clinic.
Evaluate the laboratory and instrumental tests results.
Study the scheme for conservative and surgical hemorrhoids treatment.
Define indications and surgical methods for rectal cancers.
Selfpreparation plan
1. Causes of anal fissures (essay).
2. Modern methods for hemorrhoids prophylaxis and hemorrhoids treatment (essay).
27
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