Danylo Halytsky Lviv National Medical University
Faculty of Medicine
Department of Propedeutics of Internal Medicine №1
Discipline: Propedeutics of Internal Medicine
Methodological Guidelines for English-speaking Students of Medical Faculty
(3-d Year of Study)
“Main methods of patients examination in the clinic of internal diseases”
Module №1
Lviv-2014
Approved at the department meeting Propaedeutics of Internal Medicine №1
“
“ of ____________ 20___ year
Head of the chair ______________ Prof. MD Dutka R.J.
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CONTENT
1. Basis of clinical diagnostics. Diagnostics value of symptoms and syndromes.
Clinical examination methods: subjective examination (inquiry, present
complaints, anamnesis morbi, anamnesis vitae), objective examination
(general inspection, palpation, percussion, auscultation). Deontological
ethics…………………………………………………………………………5
2. General inspection of the patient (general patient’s condition, consciousness,
posture of the patients, gait, habitus, face of the patient, skin, edema,
subcutaneous fat, lymph nodes, muscular system, bones system, joints
system, examination of the spine, head, eyes, mouth, neck, thyroid
gland)………………………………………………………………………9
3. The main complaints of the patients with disease of the respiratory system.
Inspection of the chest. Static and dynamic inspection of the chest. Palpation
of the chest…………………………………………………………………17
4. Percussion of the lungs. The technique of comparative percussion. The
technique of topographic percussion……………………………………….22
5. Auscultation of the lungs. The main respiratory sounds (vesicular and
bronchial breath sounds). The adventitious sounds (rales, crepitation, pleural
friction sounds)……………………………………………………………..25
6. Instrumental (tests of ventilatory function, bronchoscopy, roentgenography)
and laboratory (collection of the sputum, study of the pleural fluid) methods
of examination the patients with respiratory system disease........................29
7. Inquiring (specific and nonspecific complaints) and general inspection of the
patients with cardiovascular system disorders. Inspection and palpation of
the heart region and peripheral vessels…………………………………….32
8. Percussion of the heart: determination of the borders of the relative and
absolute cardiac dullness. Transverse length of the heart. The borders of the
vascular bundle. Configuration of the heart. Study of pulse and blood
pressure……………………………………………………………………..37
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9. Auscultation of the heart. Technique and points of auscultation. Normal
heart sounds. Splitting and additional heart sounds. Cardiac murmurs:
systolic murmur and diastolic murmur……………………………………..43
10.Clinical electrocardiography. Basic physiological principles. Cardiac
automaticity function Cardiac conductivity function Depolarization,
repolarization. Recording ECG. The ECG leads. Basic ECG principles. The
electrical axis of the heart. Examination of waves, intervals. Interpretation of
the ECG. ECG-signs of atrial and ventricular hypertrophy. ECG-signs of the
coronary heart disease and myocardial infarction……………………….....49
11.ECG in abnormalities of the impuls formation…………………………….56
12.ECG in abnormalities of conduction. Echocardiography……………….….60
13.Inquiry of the patients with gastrointestinal disorders. Inspection and
palpation (superficial tentative, penetrative, deep sliding systematic) of the
abdomen. Methods of ascites detection………………………………….....62
14.Laboratory (studies of gastric secretions, coprological study) and
instrumental (X-ray examination, Fibrogastroscopy) methods of examination
of digestion system…………………………………………………………67
15.Inquiring and clinical examination of the patients with pathology of liver
and gallbladder. Percussion and palpation of the liver according Kurlov.
Palpation of gallbladder. Laboratory (functional study of the liver and bile
ducts) and instrumental (cholecyctography, ultrasound examination)
methods
of
examination
of
pathology
of
liver
and
gallbladder………………………………………………………………….71
16.Inquiring and clinical examination of the patients with pathology of
pancreas. Percussion of pancreas. Laboratory (coprological study) and
instrumental
(ultrasound
examination) methods
of
examination
of
pancreas…………………………………………………………………….75
17.Inquiring (disorders of urination) and general examination of the patients
with pathology of urinary system. Palpation and percussion of
kidneys……………………………………………………………………79
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18.Laboratory (urine analysis) and instrumental (ultrasound, excretion
urography) methods of examination of urinary system…………………....82
19.Inquiring and clinical examination of the patients with blood system
disorders. Palpation of spleen………………………………………………85
20.Laboratory (clinical blood analysis, tests for plasma factors involved in
coagulation and fibrinolisis) and instrumental methods of examination of
blood system. Sternal puncture…………………………………………….88
21.Clinical, laboratory and instrumental methods of examination of patients
with endocrine pathology……………………………………….………….91
22.Clinical, laboratory and instrumental methods of examination of patients
with musculoskeletal and connective tissues disorders……………………94
23.The final module. Control test of theoretical knowledge. Control of practical
skills. Analysis skills of laboratory and instrumental methods of examination
in therapeutic clinic………………………………………………………...98
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Topic 1
BASIS OF CLINICAL DIAGNOSTICS
DIAGNOSTICS VALUE OF SYMPTOMS AND SYNDROMES
CLINICAL EXAMINATION METHODS: SUBJECTIVE EXAMINATION
(INQUIRY,
ANAMNESIS
PRESENT
VITAE),
COMPLAINTS,
OBJECTIVE
ANAMNESIS
EXAMINATION
MORBI,
(GENERAL
INSPECTION, PALPATION, PERCUSSION, AUSCULTATION)
DEONTOLOGICAL ETHICS
Type of a lesson – theoretical and practical
Contents:
1. Deontological ethics in medical professions.
2. The main methods of examination.
3. The auxiliary examinations methods.
4. The inquiry of the patient.
5. Signs or symptoms of the disease. Subjective and objective symptoms.
Specific and nonspecific symptoms.
6. Syndromes and complexes of symptoms.
7. Parts of The History of the disease:
- Identification
- Patients present complaints
- History of the presence disease (anamnesis morbi)
- Past history (anamnesis vitae)
- Habits
- Family history and familial tendency
6. Present Complaints.
7. Anamnesis Morbi.
8. Anamnesis Vitae.
I.
Please answer the following questions (Theoretical knowledge).
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1. Give the definition for such science as propedeutics.
2. Give the definition for such science as diagnostics.
3. Give the definition of such concept as diagnosis.
4. What types of diagnosis do you know? Give the definition for all types of
diagnosis. What structure has diagnosis?
5. Give the definition for signs or symptoms of the disease.
6. Specify which symptoms we can call subjective and which objective.
7. Give the definition for pathological symptoms and compensatory symptoms.
8. Give the definition for specific or pathognomic, nonspecific and relative
symptoms.
9. Give the definition for early and late symptoms.
10.Please define the concept of syndrome.
11.Please define the concept of symptomocomlex.
12.What in your opinion is deontological ethics?
13.Please specify the purpose of inquiring of patient. What aspects include
inquiring of patients?
14.What special scheme you should comply during questioning the patient
about present complains? What it is “Anamnesis morbi”? What it includes?
What it is “Anamnesis vitae”? What it includes?
15.Give the definition for objective examination. On which examinations
methods is divided objective examination?
16.What determined by the method of palpation? What types of palpation
techniques are known to you (surface or tentative deep or sliding by
Obraztsov-Strazhesko), indicate their purpose?
17.What types of percussion techniques are known to you? Indicate the main
purpose of loud, light, and lightest percussion. Give the definition for
comparative and topographic percussion.
18.Indicate the main purpose of such diagnostic method as auscultation. What
helps us to perform auscultation? Specify the key points of auscultation.
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II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct inquiring of the patient. Make conclusion about the received
information.
2. Conduct general inspection of exemplary patient. Identify the major
symptoms.
3. Show the technique of palpation of the patient and determine the clinical
significance of received symptoms.
4. Show the technique of comparative percussion and determine the clinical
significance of received symptoms.
5. Show the technique of topographic percussion and determine diagnostic
value of received symptoms.
6. Show the technique of auscultation of the patient and determine diagnostic
value of received symptoms.
III.
Control Test of theoretical knowledge.
1. Prapedeutics to internal discases is:
a) the science atbout methods of clinical examination of the patient and
diagnosis basing;
b) the study of the physical structure of organisms;
c) the study of the normal functioning of the body and the underlying
regulatory mechanisms;
d) the study of disease—the causes, course, progression and resolution
thereof.
2. Laboratory examination includes all listed except:
a) Blood analysis;
b) Sonography;
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c) Urine analysis;
d) Sputum analysis.
3. Syndrome is:
a) combination of symptoms that are interrelated and give rise to one
another;
b) abnormal phenomena as pain, dizziness, nausea, vomiting, etc, occurring
in sick persons;
c) summarize clinical examinations.
4. The past history involves all listed except:
a) habits;
b) history of present disease;
c) family history;
d) social history;
e) allergological history.
5. Palpation is:
a) the method of clinical examination, which is used to determine elasticity
and dryness of the skin, to assess condition of the subcutaneous fat, to
detect edema;
b) method of physical examination, which helps to determine whether the
underlying tissues are air-filled, fluid-filled, or solid;
c) method of physical examination which means listening the sound inside
the body.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
9
Topic 2
GENERAL INSPECTION OF THE PATIENT (GENERAL PATIENT’S
CONDITION, CONSCIOUSNESS, POSTURE OF THE PATIENTS, GAIT,
HABITUS, FACE OF THE PATIENT, SKIN, EDEMA, SUBCUTANEOUS
FAT, LYMPH NODES, MUSCULAR SYSTEM, BONES SYSTEM, JOINTS
SYSTEM, EXAMINATION OF THE SPINE, HEAD, EYES, MOUTH,
NECK, THYROID GLAND).
Type of a lesson – theoretical and practical
Contents:
1. The main methods of examination (inspection, palpation, percussion,
auscultation).
2. The general patient’s condition.
3. Consciousness of the patient.
4. The posture of the patients.
5. The habits (the body-built, height, body weight, BMI).
6. Face of the patient.
7. Examination of the skin (color, eruption, turgor, moisture and elasticity).
8. The skin derivates (nails, hair).
9. Examination of subcutaneous fat. Types of obesity according to the fat
distribution).
10.Examination of lymph nodes.
11.The muscular system.
12.The bones system.
13.The joints system.
14.Examination of the head (size, shape, position, movements).
15.Examination of the eyes (eyelids, eye slit, eyeball, sclera, cornea of the eye,
pupils).
16.Examination of the mouth (size, shape, symmetry of the angles, form, color
of the lips and mouth mucosa, teeth, tongue, gums).
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17.Examination of the neck (the shape, size, symmetry, skin color, presence of
scars and visible pulsation).
18.The auxiliary examinations methods (instrumental and laboratory methods).
I.
Please answer the following questions (Theoretical knowledge).
1. What types of general patient’s condition may be? What are the criteria’s of
patient’s condition?
2. List types of consciousness (sensorium). What causes of deranged
consciousness you know? Into what two groups is divided deranged
consciousness? What are most common forms of coma? What causes and
symptoms of this coma are known to you?
3. What types of posture of the patients may be? What forced posture or
specific patients position are known to you? What are the possible causes
and symptoms of this forced posture?
4. What specific gaits according to the pathological processes are known to
you, please list?
5. What criteria includes concept of habitus? Indicate the normal height for
men and women. What may be pathological changes of height and what can
cause it? Specify how we calculate body mass index (BMI). Specify the
classification of overweight and obesity in adults. On which two groups is
divided body-build?
6. What faces of patient with pathology of respiratory,
cardiovascular,
nervous, blood, digestive, kidney, endocrine system are known to you,
describe them? What faces of patient with infectious pathologies are known
to you, describe them? What faces of patient that not associated with
systemic diseases and infections are known to you, describe them?
7. During the inspection of the skin on what we should pay attention. Describe
the skin of a healthy person. What are pathological changes of the skin
color? Please indicate physiological and pathological causes of pale color of
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the skin. Please indicate physiological and pathological causes of red color
of the skin. What forms of cyanosis are known to you, describe what can
cause them? Please indicate physiological and pathological causes of yellow
skin and mucosa. Who can have physiological jaundice and when it occurs?
Exogenic jaundice or xanthosis what it is and due to what reasons it occurs?
Please indicate physiological and pathological causes of brown or bronze
skin. Please indicate causes of local hyperpigmentation (chloasmus), grayish
(“dirty”) color and depigmentation (depigmintatio) of the skin.
8. What eruptions of the skin did you know, indicate their manifestations and
causes?
9. How we have to determine the turgor and elasticity of the skin and what
diagnostic meanings have diminished turgor? Indicate diagnostic value for
moisture of the skin. What physiological and pathological causes for dry
(xeroderma) and moist skin (hyperhydrosis) you know?
10.What include skin derivates? Describe nails in normal conditions. What
pathological changes of nails are known to you? What types of hair growth
indicates disorder?
11.What did you know about general and local edema? Please list the causes of
edema and their types. Transcribe the following terms: ascitis, hydrothorax,
hydropericardium, anasarca.
12.How we measure the degrees of subcutaneous fat, also indicate the size of
subcutaneous fat for normosthenic person, for obesity and for sign of
cachexia. Specify types and causes of obesity and weight loss.
13.What signs of pathological changes in lymph nodes can be determined
during their palpation? Describe lymph nodes in normal conditions. Please
specify main reasons for enlarged lymph nodes. Specify diseases which are
manifested by increasing of occipital, cervical, axillary, inguinal, cubital
(local) lymph nodes.
14.What main methods of examination of muscular system you know? On what
key points you should pay attention during the examination of muscular
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system? Describe muscular system in normal conditions. What pathological
manifestations of muscular system you can find during the examination?
15.What main methods of examination of bones system you know? On what
key points you should pay attention during the examination of bones
system? What common causes of the bones system abnormalities you can
find during the examination?
16.What consequence we should perform during examination of the joints
system. What two kinds of movement are distinguished? What inflammatory
diseases develop to affection of the joints?
List all known about
pathological changes of the spine?
17.What are the signs that you as a doctor have to pay attention during the
examination of the head? What pathological state can cause macrocephalia
and microcephalia? List shapes of the head that you know. What diseases or
conditions can lead to changes in head position? Transcribe such symptoms
as st. Vitus’s dance and Musset’s sign? When they occur?
18.What are the signs that you as a doctor have to pay attention during the
examination of the eyes? What pathological conditions can be displayed on
eyelids? What pathological changes can happen whith sclera, conjunctiva
and cornea of the eye and they can be as a result of what causes? Transcribe
such terms as myosis, mydriasis, anisocoria, pupilla pulsation.
19.What are the signs that you as a doctor have to pay attention during the
examination of the mouth? What causes changes in the size, shape and
symmetry of the angles of the mouth and how it manifests? Color of the lips
may vary as a result of disease, provide reasons.
20.On what key points you should pay attention during the examination of
cavity of the mouth? What pathological signs of disease may be detected
during the examination of color of the mucous membrane? In whiat diseases
and poisonings may exhibit changes of the gums?
21.On what key points you should pay attention during the examination of
tongue? Describe tongue of a healthy person. What diagnostic significance
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has fur of the tongue in pathological conditions? Describe the possible
pathological changes surface of the tongue.
22.What signs of pathological changes on neck can be determined during
palpation? On what key points you should pay attention during the
examination of neck?
23.Were we palpate thyroid gland and how?
Specify diseases which are
manifested by increasing of thyroid gland.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. General inspection of habitus. Specify basic signs that you need to pay
attention during general inspection. Identify changes that are possible to
detect during general inspection.
2. General inspection of skin and subcutaneous tissue. Specify basic signs that
you need to pay attention during general inspection. Identify changes that
are possible to detect during general inspection.
3. General inspection of head and neck. Specify basic signs that you need to
pay attention during general inspection. Identify changes that are possible to
detect during general inspection.
4. General inspection of the oral cavity and eyes. Specify basic signs that you
need to pay attention during general inspection. Identify changes that are
possible to detect during general inspection.
5. Conduct inspection of body, legs and hands of exemplary patient. Identify
the clinical significance of symptoms.
6. Conduct palpation of the thyroid gland to evaluate the findings.
7. Palpation of lymph nodes. Specify main lymph nodes. Determine signs of
lymph nodes that need to be determined during palpation and pathological
causes leading to enlarged lymph nodes.
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III.
Control Test of theoretical knowledge.
1. Satisfactory patient ’s condition (status morboacili) is characterized by
a) clear consciousness, active or active with restriction posture, free or
partial deranged (specific) gait, sensible facial expression, and adequate
mental reaction;
b) deranged consciousness, alteration of facial expression and posture
(forced), uncertain gait, partial deranged mental state and may be
observed in patients with recurrence of chronic disease, acute diseases, or
due to the traumas and poisoning;
c) disorders of practically all clinical features: deranged consciousness,
changed facial expression (fear, suffer, hopelessness, indifference). The
patients have forced or passive posture, loss o f weight, edema, and
inadequate mental state;
d) unconsciousness, passive posture, and indifferent facial expression and
observes in the patient with coma, shock, and agony.
2. Unconsciousness with absence of response to external stimuli, absence of
reflexes, deranged vital function it is:
a) Cloudiness;
b) Stupor;
c) Sopor;
d) Coma.
3. Specify the name of the patient's posture that is typical for states listed
below – tumor of pancreas, acute thrombosis of lien vein, trauma and
tuberculosis of spine:
a) standing upright position;
b) orthopnea;
c) supine posture;
15
d) position lying on the side;
e) prone position.
4. Vitiligo is:
a) symmetrical white spots on the face, trunk, limbs;
b) the redness located on checks;
c) cyanotic color of the skin;
d) yellow color of the skin.
5. Disorientation in surroundings, loss of memory (amnesia), patient is exited,
has pathologically high spirits, is anxious, sometimes even aggressive, all
that is signs of:
a) Twilight state;
b) Delirium;
c) Stupor;
d) Coma.
6. Enlarged superciliary arches, zygomatic bones, ears, auricles nose, lips,
tongue, growth and putting forward of low jaw (prognotism) is also called:
a) facies in patients with Cushing’s syndrome ;
b) facies Hyppocratica;
c) facies as a “wax-doll”;
d) facies Corvisara;
e) facies acromegalica.
7. Purpura (hemopurpura) is:
a) small pointed hemorrhages;
b) large black and blue spots;
c) red spots of different size;
d) a swelling from gross bleeding.
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8. Chronic
tonsillitis,
tuberculosis,
infectious
mononucleosis,
chronic
lympholeucosis, lymphogranulomatosis, lymphosarcoma may lead to
increased:
a) Occipital lymph nodes;
b) Cervical lymph nodes;
c) Axillary lymph nodes;
d) Cubital (local) lymph nodes.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
17
Topic 3
THE MAIN COMPLAINTS OF THE PATIENTS WITH DISEASE OF THE
RESPIRATORY SYSTEM
STATIC AND DYNAMIC INSPECTION OF THE CHEST
PALPATION OF THE CHEST
Type of a lesson – theoretical and practical
Contents:
1. The dyspnea. Types of the dyspnea – physiological and pathological;
subjective and objective; inspiration, expiration and mixed dyspnea.
2. The clinical analysis of cough. Dry and moist cough. The timing of
coughing. Periodic or permanent cough.
3. The sputum expectoration and its characteristics: the amount, the time of
day, posture of the patient, properties of sputum (color, odor).
4. The clinical analysis of the hemoptysis. Characteristics of the blood from the
respiratory tree.
5. The clinical analysis of the chest pain: the pleural pain, the chest-wall pain,
tracheobronchial tree sensations.
6. Static inspection of the chest. Normal and pathological shapes of the chest.
The symmetry of the chest.
7. Dynamic inspection of the chest. Type, rate, depth, rhythm of respiration.
8. Palpation of the chest. Identification of the tender areas. Elasticity of the
chest. The tactile fremirus.
I.
Please answer the following questions (Theoretical knowledge).
1. What includes upper respiratory tract? What includes lower respiratory
tract?
2. Where we have median (or midsternal) line? How we estimate midclavicular
line? How we estimate anterior, posterior and midaxillary lines? Where we
18
have vertebral line? Where we have paraspinal lines? How we estimate
scapular lines?
3. What types of pleurae you know and what it is?
4. What lobes have left lung? What lobes have right lung? Hove divided
bronchi?
5. What topographic regions and lines of the chest you know?
6. What are the main complaints of the patients with disease of the respiratory
system?
7. Please describe the concept of dyspnea. Add a possible causes for
physiological and pathological dyspnea.
8. Define a term as subjective and objective dyspnea. Define a term such as
inspiratory, expiratory and mixed dyspnea. Add five categories of dyspnea
based on the speed and duration of its occurrence.
9. Please describe the concept of cough. List the main causes of cough. What
cough is called dry and moist? Specify the causes of dry cough?
10.List the diseases that cause periodic and permanent cough. What four points
you should try to determine if the patient complains on cough with sputum?
11.Define the concept of hemoptysis. By what signs we distinguish blood that
entered from the respiratory tract and not from the digestive tract? List
pulmonary and extrapulmonary diseases that can cause hemoptysis.
12.Specify the parts of the lungs that are sensitive to pain. List pulmonary
diseases that can cause chest pain.
13.Indicate extrapulmonary disease manifested by pain in the chest and
wrongly treated as chest pain of lung disease.
14.Describe the scheme that you have to comply during the inspection of the
chest.
15.Indicate signs that we define during static inspection. Indicate signs that we
define during dynamic inspection.
16.Please indicate normal shapes of the chest. Describe normosthenic chest.
Describe hypersthenic chest. Describe asthenic chest.
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17.Please indicate pathological shapes of the chest. What main causes of
pathological shapes of the chest you know?
18.Please indicate pathological shapes of the chest caused by chronic
pulmonary diseases. Describe emphysematous chest. List the diseases that
can cause such shape of the chest. Describe paralytic chest. List the diseases
that can cause such shape of the chest.
19.Please indicate pathological shapes o f the chest caused by pathology of the
thorax costal skeleton. Describe rachitic chest. List the diseases that can
cause such shape of the chest. Describe funnel chest. List the diseases that
can cause such shape of the chest.
20.Please indicate pathological shapes o f the chest caused by various
deformities of the spin as a result o f injuries, tuberculosis o f the spine,
rheumatoid arthritis, etc. Give them a brief description
21.Indicate possible causes and describe the signs for enlarged volume of one
half of the chest. Indicate possible causes and describe the signs for
decreased volume o f the one part of the chest.
22.What respiration types are known to you? What are the signs typical for
thoracic (costal) respiration? What are the signs typical for abdominal
respiration? What are the signs typical for mixed respiration?
23.Describe the method for determining the respiratory rate. Specify standards
of respiratory rate for adult and newborn.
24.How do we call rapid shallow and slow breathing? What respiratory rate is
typical for tachypnea and bradypnea? Specify causes of tachypnea and
bradypnea.
25.What types of respiration depth are known to you? Indicate their main
characteristics and causes.
26.What are the signs that characterized respiratory rhythm in norm? List
known to you periodic types of respiration. Describe the typical signs and
causes for these types of periodic breathing.
27.What are the main points we need to define during palpation of the chest?
20
28.Describe the basic method for identification of the tender areas.
29.Describe the basic method for assessment of elasticity of the chest.
30.Describe the basic method for assessment of tactile fremitus.
31.Indicate causes for increased, decreased and absent vocal fremitus.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of patients with disorders of respiratory system.
Identify the main complaints.
2. Conduct inspection of the chest of patient with pathology of the respiratory
system. Identify the main symptoms and signs that are established during
static inspection.
3. Conduct inspection of the chest of a patient with pathology of the respiratory
system. Identify the main symptoms and signs that are established during
dynamic inspection.
4. Palpation of the chest. Indicate three basic key points that are established by
palpation of the chest, and the method of their determination.
III.
Control Test of theoretical knowledge.
1. Moderate expressed visible interspaces, epigastric angle near 90° typical for:
a) normosthenic chest;
b) hypersthenic chest;
c) asthenic chest;
d) there is no correct answer.
2. “Cobbler chest” also called:
a) emphysematous;
b) paralytic;
21
c) rachitic;
d) funnel.
3. What kind of blood is typical for hemoptysis?
a) bright red;
b) dark brown;
c) black;
d) with the content of food.
4. Pigeon chest is typical for:
a) emphysema of the lungs;
b) rheumatoid arthritis;
c) pneumosclerosis;
d) rachitis.
5. Absent vocal fremitus typical for:
a) significant amount of fluid accumulated in the pleural cavity;
b) very thick chest wall;
c) lungs infarction;
d) compressive atelectasis.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
22
Topic 4
PERCUSSION OF THE LUNGS
THE TECHNIQUE OF COMPARATIVE PERCUSSION
THE TECHNIQUE OF TOPOGRAPHIC PERCUSSION
Type of a lesson – theoretical and practical
Contents:
1. Topographic regions and lines of the chest.
2. The physiological principles of the percussion.
3. The intensity of the percussion.
4. The task and technique of the comparative percussion.
5. The basic qualities of the percuss sound: intensity, pitch and duration.
6. The task and technique of the topographic percussion.
7. The upper borders of the lung. The lower borders of the lung. Respiratory
excursion.
I.
Please answer the following questions (Theoretical knowledge).
1. What types of percussion of the lungs you know?
2. What is the main task of comparative percussion of the lungs?
3. Describe the main points of technique of comparative percussion.
4. Describe the technique of comparative percussion on anterior view.
5. Describe the technique of comparative percussion on axillary regions.
6. Describe the technique of comparative percussion on posterior view.
7. What basic qualities of percussion sound you need to distinguish?
8. What characteristics of intensity, pitch, and duration of percussion sound are
known to you?
9. Provide main causes of sound changes during percussion.
10.Physiological changes of the percussion sounds over the lungs.
23
11.Define the concept of intermediate sound.
Specify main causes of the
intermediate sound.
12.Define the concept of dullness. Specify main causes of the dullness.
13.Indicate the main purpose of topographic percussion.
14.Indicate basic technique in determination of the upper borders of the lungs.
15.Indicate basic technique in determination of the lower borders of the lungs.
16.Indicate types of displacement of the lower borders of the lungs.
17.Indicate causes for bilateral lowering of the lower borders of the lungs.
18.Indicate causes for unilateral lowering of the lower borders of the lungs.
19.Indicate causes for bilateral elevation of the lower borders of the lungs.
20.Indicate causes for unilateral elevation of the lower borders of the lungs.
21. For what purpose and with what technique determined respiratory excursion
of the lungs.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Comparative percussion of the lungs. Indicate main tasks of this method and
show the technique of its performance.
2. Topographic percussion of the lungs. Indicate main tasks of this method and
show the technique of its performance.
3. Determine the active mobility of the lower edge of the lungs, evaluate
diagnostic value of symptoms.
III.
Control Test of theoretical knowledge.
1. Patients with grave diseases should be percussed in:
a) standing position;
b) sitting position;
c) lying position;
24
d) does not matter.
2. Clear pulmonary percussion sound mast be:
a) softer, higher, shorter;
b) loud, low, long;
c) very loud, lower, longer;
d) soft (medium), high (medium), short.
3. Dullness sound can be coursed by all except:
a) pulmonary tumor (airless tissue);
b) when fluid occupies the pleural space (over fluid):
c) pleural accumulation of serous blood (hemothorax)
d) compressive atelectasis.
4. Lower border of the right lung by parasternal line localized:
a) 5th interspace;
b) 6th interspace;
c) 7th interspace;
d) 8th interspace.
5. Respiratory excursion of the lower border of leftt lung by scapular line:
a) 1 – 2 cm;
b) 2 – 3 cm;
c) 4 – 6 cm;
d) 6 – 8 cm.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
25
Topic 5
AUSCULTATION OF THE LUNGS
THE MAIN RESPIRATORY SOUNDS
(VESICULAR AND BRONCHIAL BREATH SOUNDS)
THE ADVENTITIOUS SOUNDS
(RALES, CREPITATION, PLEURAL FRICTION SOUNDS)
Type of a lesson – theoretical and practical
Contents:
1. Auscultation technique. Points of auscultation.
2. The main respiratory sounds (vesicular and bronchial breath sounds).
3. Physiological difference of the vesicular breath sound over lungs.
4. Pathologic changes of the vesicular breathing: pathologically decreased and
pathologically increased of the vesicular breathing.
5. Bronchial breath sounds.
6. Pathological bronchial breathing.
7. The adventitious sounds (rales, crepitation, pleural friction sounds).
8. Dry and moist rales.
9. Mechanism of crepitation. Auscultatory phenomenon in crepitation
10.Pleural friction sound. Differential diagnosis of crepitation and Pleural
friction sound.
I.
Please answer the following questions (Theoretical knowledge).
1. Which is the correct position of the patient during auscultation? How should
the patient breathe during auscultation?
2. Types of auscultation and their characteristic. General rules for auscultation
of lungs. Is auscultation comparative method? What areas should be
listened?
3. What types of sounds can be heard coming from the lungs?
26
4. What main respiratory sounds do you know?
5. Please describe vesicular breathing.
6. Please characterize physiological difference of the vesicular breath sound
over lungs. Under what physiological conditions vesicular respiration can
vary? Under what pathological conditions vesicular respiration can vary?
7. What is the physiology of the formation of bronchial breathing?
8. What is the pathophysiology of formation of pathological bronchial
breathing? What is amphoric respiration?
9. What is bronchovesicular or mixed breathing?
10.What types of added respiratory sounds do you know?
11.What is mechanism and site of dry rales generation? On which types are
divided dry wheezing? What is mechanism and site of moist rales
generation? What types of moist rales do you know?
12.What is mechanism of crepitation generation?
13.What is mechanism of pleural friction sound generation?
14.What is different between crepitation and pleural friction sound?
15.Vesicular breath sounds, its characteristic, changes of vesicular breath
sounds.
16.Bronchial breath sounds, its characteristic, changes of bronchial breath
sounds.
17.Adventitious breath sounds, classification of adventitious breath sounds.
18.Wheezes (sibilant rales), characteristics, mechanism of their appearance.
Diagnostic meaning of wheezes.
19.Rhonchi (sonorous rales), characteristics, mechanism of their appearance.
Diagnostic meaning of rhonchi.
20.Crackles (moist rales), characteristics, and mechanism of their appearance.
Diagnostic meaning of crackles.
21. Pleural rubs, characteristics, mechanism of their appearance. Diagnostic
meaning of pleural rub.
27
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Auscultation of the lungs. Show the technique of auscultation (anterior view,
posterior view, axillary regions). Tell about the main respiratory sounds
(breath sounds).
2. Auscultation of the lungs. Show the technique of auscultation (anterior view,
posterior view, axillary regions). Tell about the main respiratory sounds
(breath sounds) namely about vesicular (alveolar) breath sounds.
3. Auscultation of the lungs. Show the technique of auscultation (anterior view,
posterior view, axillary regions). Tell about the adventitious (added) sounds
namely about bronchial (laryngotraheal) breath sounds.
III.
Control Test of theoretical knowledge.
1. "Puerile respiration":
a) physiological intensification of vesicular breathing
b) pathologically decreased vesicular respiration;
c) physiological intensification of bronchial breathing;
d) pathologically decreased bronchial breathing;
e) stenotic respiration.
2. Harsh breathing:
a) short jerky inspiration efforts interrupted by short pauses between them
the expiration is usually normal;
b) deeper
vesicular
breathing
during
which
the
inspiration
and
expiration phases are intensified;
c) inspiratory sounds last longer than expiratory ones.
3. What lung pathology is characterized by coarse bubbling rales:
28
a) dry pleurisy;
b) emphysema;
c) bronchitis;
d) pneumonia;
e) cavern.
4. How also called vesicular breathing:
a) bronchial;
b) amphoric;
c) alveolar;
d) laryngotracheal;
e) metallic.
5. Where appears crepitation:
a) in the small bronchi:
b) in the large bronchiin;
c) in the alveoli;
d) in the pleural cavity.
6. What lung pathology is characterized by dry rales:
a) dry pleurisy;
b) emphysema;
c) bronchitis;
d) pneumonia;
e) the attack of bronchial asthma.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
29
Topic 6
INSTRUMENTAL
(TESTS
OF
VENTILATORY
BRONCHOSCOPY,
ROENTGENOGRAPHY)
AND
FUNCTION,
LABORATORY
(COLLECTION OF THE SPUTUM, STUDY OF THE PLEURAL FLUID)
METHODS OF EXAMINATION THE PATIENTS WITH RESPIRATORY
SYSTEM DISEASE
Type of a lesson – theoretical and practical
Contents:
1. Imaging studies used to examine the patients with disorders of the
respiratory system: roentgenoscopy, radiography, computed tomography,
magnetic resonance imaging, bronchography, pulmonary angiography,
ultrasound examination.
2. Examination
of
biological
specimens:
collection
of
the
sputum,
thoracocentesis, bronchoscopy.
3. Sputum analisis: macroscopic, microscopic and bacterioscopic studies.
4. Study of the pleural fluid. Transudates and exudates.
5. Methods of functional studies. Tests of ventilatory function.
I.
Please answer the following questions (Theoretical knowledge).
1. What method is routine for assessing the patients with disorders of the
respiratory system?
2. What method is more sensitive to distinguish small focuses?
3. What is the physics basement of computer tomography?
4. What is principle of the pulmonary angiography?
5. In what cases ultrasound can be helpful for evaluation of pulmonary system
disorders?
II.
Control Test of theoretical knowledge.
30
1. The routine method for assessing the patients with disorders of the
respiratory system is:
a) computer tomography;
b) ultrasound examination;
c) bronchoscopy;
d) radiography.
2. To distinguish small focuses in pulmonary tissue more sensitive is:
a) magnetic resonance imaging;
b) radiography;
c) computer tomography;
d) pulmonary angiography.
3. Mucopurulent sputum is:
a) mixture of mucus and pus;
b) consists of mucus;
c) consists of mucus with streaks of blood;
d) consists of pus.
4. Single erythrocytes in sputum can be visible in:
a) inflammatory process in bronchi;
b) lung infarction;
c) any sputum;
d) tumor endobronchially.
5. The criteria of classification of exudate and transudate are:
a) the relative density;
b) protein level;
c) qualitative protein content;
d) all of the above.
31
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
32
Topic 7
INQUIRING (SPECIFIC AND NONSPECIFIC COMPLAINTS) AND
GENERAL
INSPECTION
OF
THE
PATIENTS
WITH
CARDIOVASCULAR SYSTEM DISORDERS
INSPECTION AND PALPATION OF THE HEART REGION AND
PERIPHERAL VESSELS
Type of a lesson – theoretical and practical
Contents:
1. Functional and clinical anatomy of the cardiovascular system.
2. Specific and nonspecific complaints in the cardiovascular disease.
3. Characteristics of the pain in cardiac ischemia. Atypical forms of the pain in
cardiovascular disease.
4. Heart rhythm disorders.
5. Dyspnea, orthopnea and other respiratory symptoms in cardiovascular
disease.
6. Syncope.
7. General inspection of the patients.
8. Posture of the cardiac patients. Orthopnea.
9. Skin and visible mucosa color.
10.Inspection of the face and neck.
11.Specificity of the edema in cardiovascular disease. Methods of edema
revelations.
12.Inspection of the heart region.
13.Palpation of the heart region. The apex beat.
I.
Please answer the following questions (Theoretical knowledge).
1. What are specific and nonspecific complaints in the cardiovascular disease?
2. What is typical to the heart pain?
33
3. What is difference between intermissions and palpitation?
4. What are specific sings of the edema in cardiovascular disease?
5. What causes of the syncope do you know?
6. What forced postures in patients with cardiovascular disease are
distinguished?
7. What changes of skin and visible mucosa color in patients with
cardiovascular pathology are distinguished?
8. What special features can be found in the inspection of the face in patients
with cardiovascular pathology?
9. What are mechanisms of edema formation in patients with cardiovascular
pathology?
10.What methods of edema revelation can be used in patients with
cardiovascular pathology?
11.Dyspnea in patients with disorders of the cardiovascular system.
12.Palpitation in patients with disorders of the cardiovascular system.
13.Cough in patients with disorders of the cardiovascular system.
14.Hemoptysis in patients with disorders of the cardiovascular system.
15.Edema in patients with disorders of the cardiovascular system.
16.Headache in patients with disorders of the cardiovascular system.
17.What position is occupied by patients with exudative pericarditis?
18.Why they hold such position?
19.Patients with what pathological condition occupy a sitting position with legs
drooping down? What is the name of this position?
20.Cyanosis, what is it? What are the conditions under which arises cyanosis?
21.Anasarca, what is it? What are the conditions under which arises cyanosis?
22.What signs can be detected during the inspection area of the heart?
23.Please describe technique of palpation of heart region. Where is found a
normal apex beat?
24.What are causes of the apex beat displacement?
25.What are apex beat properties?
34
26.Heart hump what is it? What are the conditions under which arises heart
hump?
27.Pulsation of the aorta. Where it can be seen and under what conditions?
28.Cardiac impulse. Where located and under what pathological conditions it
arises?
29.Apex beat. Where is located in norm? Name pathological changes that lead
to a change of localization of the apex beat.
30.Symptom of systolic and diastolic trembling. Where is defined? What
pathological changes cause this symptoms?
31.Configuration of the heart, what is it? Name the pathological conditions
when the heart has mitral configuration, and when there is aortic
configuration?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of patients with disorders of the cardiovascular system.
Identify the main (specific) complaints.
2. Conduct questioning of patients with disorders of the cardiovascular system.
Identify the nonspecific complaints.
3. Conduct inspection of the heart region. Determine examination plan, specify
the clinical symptoms.
4. Conduct palpation of the heart region. Determine examination plan, show
the technique of palpation the apex beat. Specify the basic signs of
pathological changes of the heart region.
III.
Control Test of theoretical knowledge.
1. Anasarca - is:
a) edema on the legs;
35
b) edema on the lower back;
c) edema on the neck;
d) abdominal hydrops;
e) edema of the all body.
2. Diastolic trembling ("cat purring") on apex of the heart palpated in case of:
a) insufficiency the aortic valve;
b) aortic stenosis;
c) mitral stenosis;
d) insufficiency left atrioventricular valve;
e) insufficiency the right atrioventricular valve.
3. Resistant apical beat indicates:
a) insufficiency of the mitral valve;
b) aortic insufficiency;
c) aortic stenosis;
d) left ventricular hypertrophy;
e) dilated left ventricular cavity.
4. Character of cyanosis in cardiovascular disease:
a) diffuse;
b) on the face;
c) acrocyanosis;
d) in the lower extremities;
e) in some parts of the body.
5. What is the cardialgia:
a) pain in the liver;
b) pain in the heart;
c) feeling of "disruptions" in the heart;
36
d) muscle pain;
e) heartbeat.
6. Edema in patients with cardiovascular failure occurs on:
a) lower extremities;
b) the face;
c) back;
d) the eyelids;
e) the upper extremities.
7. Resistant apical beat indicates:
a) insufficiency of the mitral valve;
b) aortic insufficiency;
c) aortic stenosis;
d) left ventricular hypertrophy;
e) dilated left ventricular cavity.
8. Character of cyanosis in cardiovascular disease:
a) diffuse;
b) on the face;
c) acrocyanosis;
d) in the lower extremities;
e) in some parts of the body.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
37
Topic 8
PERCUSSION OF THE HEART: DETERMINATION OF THE BORDERS
OF THE RELATIVE AND ABSOLUTE CARDIAC DULLNESS
TRANSVERSE LENGTH OF THE HEART
THE BORDERS OF THE VASCULAR BUNDLE
CONFIGURATION OF THE HEART
STUDY OF PULSE AND BLOOD PRESSURE
Type of a lesson – theoretical and practical
Contents:
1. Percussion of the heart. Relative and absolute cardiac dullness.
Configuration of the heart.
2. Study of arterial pulse: palpation, symmetry, rhythm, rate, tension, volume.
3. Blood pressure measurement. Classification of hypertension by blood
pressure level.
I.
Please answer the following questions (Theoretical knowledge).
1. What is examination plan of percussion of the heart?
2. How to determine relative and absolute cardiac dullness, configuration of
the heart.
3. What types of heart configuration do you know?
4. How to determine transverse length of the heart and borders of the vascular
bundle?
5. Increase of borders of relative cardiac dullness. Name the pathological
conditions that cause it?
6. Decrease of borders of relative cardiac dullness. Name the pathological
conditions that cause it?
7. Displacement of the right border of relative cardiac dullness. Name the
pathological conditions that cause it?
38
8. Displacement of the left border of relative cardiac dullness. Name the
pathological conditions that cause it?
9. Displacement of the upper border of relative cardiac dullness. Name the
pathological conditions that cause it?
10.Decrease and increase of the area of absolute cardiac dullness. Name the
pathological conditions that cause it?
11.On which arteries pulse can be assessed? Demonstrate the technique of pulse
examination.
12.Describe the characteristics of the pulse: symmetry, rhythm, rate, correlation
of the pulse and heart rate, tension, filling, size, speed and pulse wave
shapes.
13.What causes of an irregular pulse do you know?
14.What can you estimate indirectly according to the pulse tension?
15.What is diagnostic value of characteristics of pulse?
16.What can be causes of tachycardia and bradycardia?
17.What method of using for measuring of blood pressure?
18.What reading is systolic and what is diastolic BP?
19.What is optimal and high normal BP?
20.Specify in which normal conditions (no pathological changes of the body)
possible changes in the level of blood pressure (may increase or decrease).
21.Indicate pathological changes in the body that lead to the appearance of
hypotension.
22.Indicate pathological changes in the body that lead to the appearance of
hypertension.
23.What vessels are used for the study of pulse
24.Which are the cause of various of pulse during the measurement it in both
hands
25.During the study of pulse, which its properties is determine
26.Indicate normal pulse rate. Under what normal conditions pulse rate may be
increased or reduced
39
27.Indicate pathological causes leading to increased arterial pulse.
28.Indicate pathological causes leading to decreased arterial pulse.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Percussion of the heart: specify examination plan of percussion. Show the
percussion technique to determine the relative cardiac dullness of the heart.
Identify normal borders of the relative cardiac dullness.
2. Percussion of the heart: specify examination plan of percussion. Show the
percussion technique to determine the absolute cardiac dullness of the heart.
Identify normal borders of the absolute cardiac dullness.
3. Determine by percussion the vascular bundle, evaluate findings.
4. Determine by percussion configuration of the heart. Identify normal
configuration of the heart.
5. Palpation of the pulse. Show the technique of palpation. Identify the main
characteristics of pulse and their normal manifestations.
6. Blood pressure measurements. Specify examination plan of blood pressure
measurement. Identify normal findings of blood pressure.
7. Blood pressure measurements. Specify examination plan of blood pressure
measurement. Identify common abnormalities of blood pressure.
III.
Control Test of theoretical knowledge.
1. Unequal pulse often typical for:
a) hole aortic stenosis;
b) myocarditis;
c) atrial fibrillation;
d) exudative pericarditis;
e) aortic heart defects.
40
2. The upper border of absolute cardiac dullness is located:
a) the lower edge of III- th rib on the left midclavicular line;
b) the lower edge of the IV-th rib on the left parasternal line;
c) the lower edge of the V- th rib on the left midclavicular line;
d) the top edge of the III-th rib on the left parasternal line;
e) the top edge of the IV-th rib on the left midclavicular line.
3. Displacement left border of cardiac dullness to the left can occur in case of:
a) hypertrophy of the right atrium;
b) hypertrophy of the left atrium;
c) hypertrophy of the right and left atrium;
d) hypertrophy and dilatation of left ventricular;
e) mitral valve stenosis.
4. Grade III hypertension established at the level:
a) 120-129 SBP (mm Hg) and/or 80-84 DBP (mm Hg);
b) 130-139 SBP (mm Hg) and/or 85-89 DBP (mm Hg);
c) 140-159 SBP (mm Hg) and/or 90-99 DBP (mm Hg);
d) 160-179 SBP (mm Hg) and/or 100-109 DBP (mm Hg);
e) 180 SBP (mm Hg) and/or > 110 DBP (mm Hg).
5. Sings of Stage III hypertension:
a) No objective signs of organic changes;
b) At least one of the following signs of organ involvement without
symptoms or dysfunction;
c) Both symptoms and signs have appeared as result of organ damage;
d) Signs of a absence of consciousness and / or failure of organs.
6. Increasing area of absolute cardiac dullness observed in case of:
a) left-sided pneumothorax;
41
b) emphysema;
c) attack of bronchial asthma;
d) pneumopericarditis;
e) hydropericarditis.
7.
Studying of the properties of the pulse we start from:
a) filling;
b) frequency;
c) rhythm;
d) stress;
e) synchronicity pulse on both radial arteries.
8.
What is the sequence of examination of pulse rate:
a) synchronicity, rhythm, frequency, voltage, filling;
b) rhythm, frequency, synchronicity, content, stress;
c) the frequency, rhythm, synchronicity, content, stress;
d) filling, strain, frequency, rhythm, synchronicity;
e) tension, filling rate, rhythm, synchronicity.
9. On what level should be systolic arterial blood pressure (SBP) for
establishing arterial hypertension?
a) to 200 mmllg and higher;
b) to 140 mmllg and higher;
c) to 120 mmllg and higher;
d) to 100 mmllg and higher.
10. How many times should be measured blood pressure to establish arterial
hypertension?
a) 2-3 times in different days during 4 weeks;
b) 2-3 times in different days during 8 weeks;
42
c) 2-3 times in different days during 1 week;
d) 2-3 times in one day.
11.
Normal BP established at the level:
a) 120-129 SBP (mm Hg) and/or 80-84 DBP (mm Hg);
b) 130-139 SBP (mm Hg) and/or 85-89 DBP (mm Hg);
c) 140-159 SBP (mm Hg) and/or 90-99 DBP (mm Hg);
d) 160-179 SBP (mm Hg) and/or 100-109 DBP (mm Hg);
e) 180 SBP (mm Hg) and/or > 110 DBP (mm Hg).
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
43
Topic 9
AUSCULTATION OF THE HEART
TECHNIQUE AND POINTS OF AUSCULTATION
NORMAL HEART SOUNDS
SPLITTING AND ADDITIONAL HEART SOUNDS
CARDIAC
MURMURS:
SYSTOLIC
MURMUR
AND
DIASTOLIC
MURMUR
Type of a lesson – theoretical and practical
Contents:
1. The plan of examination.
2. The technique of the auscultation of the heart.
3. Points of projection of heart valves on the chest wall.
4. Standard listening points of the heart.
5. Normal heart sounds. Different sings of the first and second sound.
Components of heart sounds.
6. Cardiac rhythm.
7. Heart rate.
8. Loudness of heart sounds. Decreasing and increasing of heart sounds.
9. Reduplication and splitting of the heart sounds.
10.Cardiac murmurs. Organic cardiac murmurs. Systolic and diastolic
murmurs.
11. Functional and organic murmurs.
12.Systolic and diastolic murmurs.
13.A configuration of the cardiac murmurs.
14.The duration of the cardiac murmurs.
15.The location and radiation of the cardiac murmurs. Best auscultatory areas
of cardiac murmurs.
I.
Please answer the following questions (Theoretical knowledge).
44
1. What is plan of auscultation of the heart?
2. Where are the sites of valves projection on the chest wall?
3. Where are points of auscultation of heart valves? Why we separate sites of
valves projection and sites of auscultation?
4. Projection of the heart valves on the chest wall.
5. Standard listening point of the heart.
6. How many and what components have S1?
7. How many and what components have S2?
8. Third and fourth heart sounds (S3, S4), where we can heard them and under
what conditions they appears?
9. Please describe characteristics of two heart sounds and two pauses between
them.
10.Please describe changes of heart sounds in physiological and pathological
conditions.
11.Increase and decrease of heart sounds (causes).
12.Both heart sounds increased.
13.Both heart sounds decreased.
14.At the heart apex
a. increased loudness of the first heart sound
b. decreased loudness of the first heart sound
15.Over aorta
c. accentuated second heart sound
d. decreased second heart sound
16.Over pulmonary artery
e. accentuated second heart sound
f. decreased second heart sound
17.At the base of the sternum
g. decreased loudness of the first heart sound
18.What is a cause of reduplication and splitting of the heart sounds?
45
19.In what conditions we can observe physiological splitting of the heart
sounds?
20.First heart sound
a. physiological splitting
b. pathological splitting
21.Second heart sound
a. physiological splitting
b. pathological splitting
22.What additional sounds can be auscultated over heart? Describe three-sound
rhythms and systolic clicks.
23.Three-sound rhythm (indicate the characteristics of following additional
soud)
a. Triple rhythm
b. Gallop rhythm
c. Systolic clicks
24.Please describe systolic murmur which occurs with appearance of aortic
stenosis.
25.Please describe systolic murmur which occurs with appearance of
pulmonary stenosis.
26.Please describe diastolic murmur which occurs with appearance of aortic
regurgitation.
27.Please describe diastolic murmur which occurs with appearance of
pulmonary regurgitation.
28.How can you explain the mechanisms of cardiac mutmurs?
29.What is difference between decrescendo murmur, crescendo murmur,
diamond-shaped and plateau murmur?
30.What is systolic and diastolic murmur? Which types of duration of murmurs
do you know?
31.Please describe the specificity of duration and radiation of cardiac murmurs.
32.Which valves disorders can cause the systolic and diastolic murmurs?
46
33.Which positions of the transducer can be useful to examine the heart?
34.What is ejection fraction of the left ventricle? What methods of the
assessment of the ejection fraction of the left ventricle do you know?
35.How do you understand diastolic function of the left ventricle?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct auscultation of arteries to determine the diagnostic value of
symptoms.
2. Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the normal heart sounds (heart tones) and their changes.
3. Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the three-sound rhythms (additional heart sounds).
4. Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the heart murmurs.
III.
Control Test of theoretical knowledge.
1. S1 occurs during:
a) ventricular systole;
b) ventricular diastole;
c) auricular systole;
d) auricular diastole;
e) dilatation of the left ventricle.
2. S2 consists of:
47
a) one component;
b) two components;
c) three components;
d) four components;
e) five components.
3. The simultaneous closure of aortic and pulmonary trunk form:
a) S1;
b) S2;
c) sound of mitral valve opening;
d) S3;
e) S4.
4. Listening point of left atrioventricular valve located in:
a) heart apex;
b) 2nd intercostal space to the right of the sternum;
c) to the left of the sternum at the 3rd costosternal articulation;
d) 2nd intercostal space to the left of the sternum;
e) base of the xiphoid process.
5. Decreasing of both heart sounds typical for
a) aortic heart defects;
b) mitral heart defects;
c) myocarditis;
d) hypertension;
e) thyrotoxicosis.
6. Decrease S2 at the aortic valve typical for:
a) atherosclerosis of the aorta;
b) aortic defects;
48
c) syphilitic mezoartryt;
d) hypertension;
e) hyperthyroidism.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
49
Topic 10
CLINICAL ELECTROCARDIOGRAPHY
BASIC PHYSIOLOGICAL PRINCIPLES
CARDIAC AUTOMATICITY FUNCTION CARDIAC CONDUCTIVITY
FUNCTION DEPOLARIZATION, REPOLARIZATION
RECORDING ECG, THE ECG LEADS, BASIC ECG PRINCIPLES, THE
ELECTRICAL AXIS OF THE HEART, EXAMINATION OF WAVES,
INTERVALS, INTERPRETATION OF THE ECG
ECG-SIGNS OF ATRIAL AND VENTRICULAR HYPERTROPHY
ECG-SIGNS
OF
THE
CORONARY
HEART
DISEASE
AND
MYOCARDIAL INFARCTION
Type of a lesson – theoretical and practical
Contents:
1. Echocardiography: modalities, standard positions. Clinical application of the
echocardiography.
2. Basic physiological principles of ECG.
3. Physiology of cardiac conduction system, cardiac automaticity, Cardiac
conductivity function.
4. Graduation of the ECG paper. Speed of ECG paper.
5. The ECG leads.
6. The triangle of Einthoven. The electrical axis of the heart.
7. The waves and intervals on ECG.
8. The algorithm of reading of normal ECG.
9. Diagnostic ECG sings of atrial and ventricular hypertrophy.
I.
Please answer the following questions (Theoretical knowledge).
1. Cardiac conduction system, please list the structural elements that it
includes.
50
2. Sinoatrial (SA) node, please list its function and location.
3. Atrioventricular (AV) node please lists its function and location.
4. Bundle of His please list its function and location.
5. Cardiac automaticity function.
Please indicate the main accents of this
function of the heart.
6. Cardiac conductivity function. Please indicate the main accents of this
function of the heart.
7. Depolarization. What this means?
8. Repolarization. What this means?
9. Refractoriness. What this means?
10.What you know about ECG paper? On what speeds can be made ECG
recording?
11.What (bipolar) Standard leads you know? Please list.
12.What (unipolar) Augmented leads you know? Please list.
13.What (unipolar) Chest leads you know? Please list.
14.Please indicate placement of electrode in Standard Limb lead.
15.Please indicate placement of electrode in Standard Chest lead.
16. Please indicate normal position of the heart direction. What values of R
wave amplitude in normal position of the heart?
17.Please indicate horizontal position of the heart direction. What values of R
wave amplitude in horizontal position of the heart?
18.Please indicate vertical position of the heart direction. What values of R
wave amplitude in vertical position of the heart?
19.What reflects P wave, indicate its main characteristics?
20.What reflects P-Q interval, indicate its main characteristics?
21.What reflects QRST complex, indicate its main characteristics?
22.What reflects Q wave, indicate its main characteristics?
23.What reflects R wave, indicate its main characteristics?
24.What reflects S wave, indicate its main characteristics?
25.What reflects QRS interval, indicate its main characteristics?
51
26.What reflects ST segment, indicate its main characteristics?
27.What reflects T wave, indicate its main characteristics?
28.What reflects Q-T interval, indicate its main characteristics?
29.What reflects T-P interval, indicate its main characteristics?
30.What included interpretation of the ECG? Please list.
31.ECG sights of Coronary heart desease.
32.What additional (instrumental) methods of examination can be used for
establishing of myocardial infarction?
33.Instrumental diagnosis of myocardial infarction: ECG sights of myocardial
infarction.
34.Please indicate ECG sights of right ventricular hypertrophy.
35.Please indicate ECG sights of left ventricular hypertrophy.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
Analyze the ECG by the following scheme: Determination of the Cardiac
Rhythm Regularity, Calculation of the Heart Rate, Measurements of the ECG
Amplitude, Determination of the Cardiac Rhythm Pacemaker Site,
Estimation of the conductivity, Determination of the Electrical Axis of the
Heart, Measurements of the duration and amplitude of the ECG waves and
intervals and make the following ECG conclusion:
a) The cardiac rhythm pacemaker (sinus or nonsinus rhythm)
b) Regularity of cardiac rhythm (regular or irregular)
c) The heart rate
d) Position of electrical axis of the heart
e) Presence of the four ECG syndromes: arrhythmias, conduction
disturbances, atrial or ventricular hypertrophy, myocardial injury
(ischemia, injury, necrosis, scar).
52
Situation task №1: Іndicate on the picture the place of attachment electrodes in
Standard Limb lead.
Situation task №2: Іndicate on the picture the place of attachment electrodes in
Standard Chest lead.
53
Situation task №3: Іndicate schematic representation of cardiac conduction system.
Situation task №4: Indicate the location of waves, segments and their normal
duration.
54
Situation task №5: Count on this ECG time of intervals knowing the size of cells.
III.
Control Test of theoretical knowledge.
1. Sinus rhythm is called right (normal) if:
a) P wave is negative and present before each complex QRS;
b) P wave is positive and present before each complex QRS;
c) P wave before each complex QRS - not equal in amplitude and shape;
d) P wave is not present before each QRS complex, PQ interval is 0.25 0.35.
2. What is normal heart rate:
a) 40 - 60 per 1 min;
b) 90 - 120 per 1 min;
c) 60 - 80 per 1 min;
d) 120-240 per 1 min;
e) 30 - 40 per 1 min.
55
3. P wave on the ECG is:
a) ventricular excitation;
b) excitation of interventricular septum;
c) atrial excitation;
d) ventricular repolarization;
e) excitation atrio-ventricular node.
4. In what lead T wave is always normally negative:
a) I standard lead;
b) II standard lead;
c) III standard lead;
d) AVR;
e) AVF.
5. Electrical axis of the heart is not rejected if:
a) in the I standard lead is highest R wave, in the III standard lead is deepest
S wave;
b) in the III standard lead is highest R wave, in the I standard lead is deepest
S wave;
c) the highest R wave in the II standard lead;
d) the highest R wave in the III standard lead;
e) the highest R wave in the I standard lead.
Suggested Reading:
Propaedeutics yo Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
56
Topic 11
ECG IN ABNORMALITIES OF THE IMPULS FORMATION
Type of a lesson – theoretical and practical
Contents:
1. Abnormalities of the Impulse Formation. Sinus tachycardia, bradycardia,
arrhythmia, sick sinus syndrome.
2. Increasing of automaticity of an ectopic pacemaker: atrial rhythm, junctional
rhythm, idioventricular rhythm, wandering pacemaker.
3. Ectopic arrhythmias: premature heart contraction, paroxysmal tachycardias,
atrial and ventricular flutter and fibrillation.
I.
Please answer the following questions (Theoretical knowledge).
1. Please indicate meaning of P-mitrale.
2. Please indicate meaning of P-pulmonale.
3. Please list abnormalities of the impulse formation.
4. Please list abnormalities of conduction.
5. Describe the characteristics of normal sinus rhythm.
6. Describe the signs of sinus tachycardia. Indicate pathological factors and
conditions that can cause it.
7. List ECG-sings of sinus tachycardia.
8. Which diagnostic ECG sings of junctional rhythm do you know?
9. Describe the signs of sinus bradycardia. Indicate pathological factors and
conditions that can cause it.
10.Describe the signs of sinus arrhythmia. Indicate pathological factors and
conditions that can cause it.
11.Describe the signs of junctional (atrioventricular) rhythm. Indicate
pathological factors and conditions that can cause it.
12.Describe the characteristics of atrial rhythm.
57
13.Describe the signs of idioventricular rhythm. Indicate pathological factors
and conditions that can cause it.
14.Describe the signs of wandering pacemaker.
15.ECG signs of premature atrial contruction (AVCs). How you understand this
violation.
16.ECG signs of junctional premature contruction. How you understand this
violation.
17.ECG signs of ventricular premature contruction (PVCs). How you
understand this violation.
18.Describe the supraventricular paroxysmal tachycardia.
19.Describe the ventricular paroxysmal tachycardia.
20.Specify the main characteristics of atrial fibrillation and flutter.
21.Specify the main characteristics of ventricular fibrillation and flutter.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
Analyze the ECG by the following scheme: Determination of the Cardiac
Rhythm Regularity, Calculation of the Heart Rate, Measurements of the ECG
Amplitude, Determination of the Cardiac Rhythm Pacemaker Site, Estimation
of the conductivity, Determination of the Electrical Axis of the Heart,
Measurements of the duration and amplitude of the ECG waves and intervals
and make the following ECG conclusion:
a) The cardiac rhythm pacemaker (sinus or nonsinus rhythm)
b) Regularity of cardiac rhythm (regular or irregular)
c) The heart rate
d) Position of electrical axis of the heart
e) Presence of the four ECG syndromes: arrhythmias, conduction
disturbances, atrial or ventricular hypertrophy, myocardial injury
(ischemia, injury, necrosis, scar).
58
III.
Control Test of theoretical knowledge.
1. The cause of heart rate less than 40 beats per minute may be:
a) ventricular rhythm;
b) sinus baradycardia;
c) heart sick syndrome;
d) all of the above.
2. Wave P is hidden in QRS in
a) sinus premature contraction;
b) an upper nodal extrasystole;
c) an midnodal extrasystole;
d) an lower nodal extrasystole.
3. Does P-wave precede to QRS-complex in case of ventricular premature
contraction?
a) yes, always;
b) no;
c) if ventricular premature contraction generates in upper part of
ventricular septum.
4. Sings of wandering pacemaker are:
a) changes of P-wave configuration from cycle to cycle;
b) PQ-interval duration is not constant, depend on the site of pacemaker;
c) the morphology of QRS-complex is normal;
d) all of the above.
5. Brady-tachy syndrome is typical to
a) idioventricular rhythm;
b) sinus arrhythmia;
59
c) sick sinus syndrome;
d) heart blockades.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
60
Topic 12
ECG IN ABNORMALITIES OF CONDUCTION
ECHOCARDIOGRAPHY
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. How you understand the concept of sinoatrial block. Indicate its ECG signs.
2. How you understand the concept of atrioventricular block. What types of it
you know.
3. What you know about first degree atrioventricular block? Indicate its ECG
signs.
4. What you know about second degree atrioventricular block? What types of it
you know.
5. What you know about Mobitz type I second degree atrioventricular block?
Indicate its ECG signs.
6. What you know about Mobitz type II second degree atrioventricular block?
Indicate its ECG signs
7. What you know about type III second degree atrioventricular block? Indicate
its ECG signs.
8. What you know about third degree atrioventricular block? Indicate its ECG
signs.
9. Describe the concept of bundle branch block.
10.Describe the concept of right bundle branch block. Indicate its ECG signs.
11.Describe the concept of left bundle branch block. Indicate its ECG signs.
12.Describe Wolff-Parkinson-White syndrome. Indicate its ECG signs.
13.Specify which parameters determined by echocardiography.
14.Which you know ways of performing echocardiography, what their values.
15.Where sensors are installed during echocardiography.
61
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
Analyze the ECG by the following scheme: Determination of the Cardiac
Rhythm Regularity, Calculation of the Heart Rate, Measurements of the ECG
Amplitude, Determination of the Cardiac Rhythm Pacemaker Site,
Estimation of the conductivity, Determination of the Electrical Axis of the
Heart, Measurements of the duration and amplitude of the ECG waves and
intervals and make the following ECG conclusion:
a) The cardiac rhythm pacemaker (sinus or nonsinus rhythm)
b) Regularity of cardiac rhythm (regular or irregular)
c) The heart rate
d) Position of electrical axis of the heart
e) Presence of the four ECG syndromes: arrhythmias, conduction
disturbances, atrial or ventricular hypertrophy, myocardial injury
(ischemia, injury, necrosis, scar).
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
62
Topic 13
INQUIRY
OF
THE
PATIENTS
WITH
GASTROINTESTINAL
DISORDERS
INSPECTION
AND
PALPATION
(SUPERFICIAL
TENTATIVE,
PENETRATIVE, DEEP SLIDING SYSTEMATIC) OF THE ABDOMEN
METHODS OF ASCITES DETECTION
Type of a lesson – theoretical and practical.
I.
Please answer the following questions (Theoretical knowledge).
1. Diarrhea. Describe the symptom, indicate reasons of appearance?
2. Acute diarrhea. Describe the symptom, indicate reasons of appearance?
3. Chronic diarrhea. Describe the symptom, indicate reasons of appearance?
4. Inflammatory diarrhea. Describe the symptom, indicate reasons of
appearance?
5. Osmotic diarrhea – describe the symptom, indicate reasons of appearance?
6. Secretory diarrhea. Describe the symptom, indicate reasons of appearance?
7. Constipation. Describe the symptom, indicate reasons of appearance?
8. What Drugs may lead to constipation?
9. Causes o f weight gain?
10.Causes o f weight loss?
11.What it is melena? When occurs?
12.Indicate causes o f upper gastrointestinal bleeding.
13.Indicate causes o f lower gastrointestinal bleeding.
14.On what signs we pay attention during the abdominal inspection?
15.Indicate the most common causes of protuberant abdomen?
16.Provide main symptoms of gas in the abdomen.
17.Provide main symptoms of tumor in the abdomen.
18.Provide main symptoms of fat in the abdomen.
63
19.Provide main symptoms of pregnancy.
20.Provide main symptoms of ascitic fluid in the abdomen.
21.Indicate main features of localized bulges in the abdominal cavity such as
umbilical hernia.
22.Indicate main features of localized bulges in the abdominal cavity such as
incisional hernia.
23.Indicate main features of localized bulges in the abdominal cavity such as
epigastric hernia.
24.Indicate main features of localized bulges in the abdominal cavity such as
lipoma.
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of patients with disorders of digestive system. Identify
the main complaints.
2. Conduct inspection of abdomen. Determine examination plan, specify signs
of
abdomen in the normal conditions and pathological causes that lead to
abdomen changes.
3. Superficial palpation of the abdomen. Show the technique of palpation.
Indicate main signs that are defined during superficial palpation of the
abdomen.
4. Penetrative palpation of the abdomen. Indicate main points that are
determined during penetrative palpation of the abdomen.
5. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the sigmoid colon.
6. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the caecum colon.
64
7. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the ascending colon.
8. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the descending colon.
9. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the transverse colon.
10.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the stomach.
11.Penetrative palpation of appendix point (McBurne point).
12.Penetrative palpation of site of the duodenum bulb projection.
13.Penetrative palpation of Shchetkin-Blumberg symptom.
III.
Control Test of theoretical knowledge.
1. Specify the basic characteristic signs of damage the esophagus:
a) pain, weight loss, diarrhea, steatorrhea;
b) dysphagia, odynophagia, heartburn, chest pain, hematemesis/melena;
c) nausea and vomiting, epigastric pain, hematemesis/melena, early
satiety;
d) pain, nausea/ vomiting, nematemesis;
e) pain urgency, hematochezia, tenderness, pruritus.
2. Vomiting that arose through 4-6 hours after eating is a consequence of:
a) ulcer or cancer of cardiac part of the stomach acute gastritis;
b) ulcer or cancer of the stomach body;
c) ulcer of the pylorus or duodenum.
65
3. Heartburn (pyrosis) is
a) as a sensation of “sticking” or obstruction of the passage of food
through the mouth, pharynx, or esophagus;
b) a specific burning sensation behind the sternum associated with
regurgitation of gastric contents into the inferior portion of the
esophagus;
c) return of the part of swallowed food into the mouth due to backward
movement of esophagus and stomach with open cardia without
contraction of diaphragm and abdominal muscles;
d) reflex act associated with irritation of the vagus nerve;
e) the forceful oral expulsion of gastric contents.
4. Melena may indicate:
a) Botkin's disease;
b) hemorrhoids;
c) chronic pancreatitis;
d) cirrhosis complicated
e) bleeding from the veins of the esophagus;
f) tumor of the bladder.
5. In case of what disease most often observed fresh blood in feces:
a) colitis;
b) duodenal ulcer disease;
c) a stomach ulcer;
d) gastric cancer;
e) hemorrhoids?
6. From what of the intestines segment begins deep palpation by ObraztsovStrazhesko:
66
a) cecum;
b) the transverse colon;
c) appendix cecum;
d) the sigmoid colon;
e) ascending colon?
7. What is the difference between gastric vomiting and vomiting that appeared
because of other reasons:
a) is not associated with meals;
b) are clearly associated with eating;
c) lots of vomiting with acid content;
d) vomiting on an empty stomach?
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
67
Topic 14
LABORATORY
(STUDIES
OF
GASTRIC
COPROLOGICAL
STUDY)
AND
EXAMINATION,
FIBROGASTROSCOPY)
SECRETIONS,
INSTRUMENTAL
(X-RAY
METHODS
OF
EXAMINATION OF DIGESTION SYSTEM
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What diagnostic methods are used for examination of patients with diseases
of the digestive system?
2. What pathological changes can be found thanks to X-ray? What bodys of
digestive system we can inspect using Roentgenography?
3. What pathological changes can be found thanks to Endoscopy? What bodys
of digestive system we can inspect using Endoscopy?
4. What pathological changes can be found thanks to Computed tomography?
What bodys of digestive system we can inspect using Computed
tomography?
5. What pathological changes can be found thanks to Magnetic resonance
imaging? What bodys of digestive system we can inspect using Magnetic
resonance imaging?
6. What includes study o f the gastric content?
7. What do you know about amount of gastric juice?
8. What do you know about amount of gastric juice?
9. What do you know about color, consistency, and admixtures of gastric
juice?
10. What values determined by the chemical study of gastric contents?
11.How performed method of endogastric pH-metry?
12.What can be found in the gastric contents during microscopic study?
68
13.What includes coprological analysis of stool?
14.What you know about daily faeces amount? (when it can be decreased and
increased).
15.What you know about color o f the faeces?
16.What you know about odor of the faeces?
17.What you know about admixtures of food origin in faeces?
18.What you know about pathological admixtures in faeces?
19.What indicators investigated by chemical examination of stool?
20.What indicators investigated by microscopic study of stool?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of patients with disorders of digestive system. Identify
the main complaints.
2. Conduct inspection of abdomen. Determine examination plan, specify signs
of
abdomen in the normal conditions and pathological causes that lead to
abdomen changes.
3. Superficial palpation of the abdomen. Show the technique of palpation.
Indicate main signs that are defined during superficial palpation of the
abdomen.
4. Penetrative palpation of the abdomen. Indicate main points that are
determined during penetrative palpation of the abdomen.
5. Penetrative palpation of appendix point (McBurne point).
6. Penetrative palpation of site of the duodenum bulb projection.
7. Penetrative palpation of Shchetkin-Blumberg symptom.
8. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the sigmoid colon.
69
9. Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the caecum colon.
10.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the ascending colon.
11.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the descending colon.
12.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the transverse colon.
13.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the stomach.
III.
Control Test of theoretical knowledge.
1. For the diagnosis of peptic ulcer disease primarily used?
a) Duodenal intubation;
b) X-rays;
c) Fractional study of gastric contents;
d) Fibrogastroscopy.
2. What method of investigation in suspected peptic ulcer disease should be
used to study fractional gastric contents?
a) Fibrogastroscopy;
b) X-rays;
c) Examination of stool for occult blood;
d) Ultrasound.
70
3. For what disease is typical an admixture of mucus in the stool?
a) Colitis;
b) Enteritis;
c) Hemorrhoids;
d) Gastric ulcer and duodenal ulcer.
4. How do we call low content of free hydrochloric acid in gastric juice?
a) achlorhydria;
b) hypoacidity;
c) normoacidity;
d) hyperacidity.
5. What means the large number of red blood cells in the gastric contents
a) duodenal ulcer;
b) gastritis;
c) stenosis;
d) gastric cancer?
6. What is the pH in case of maximal histamine stimulation typical for chronic
gastritis with decreased secretion of stomach?
a) pH more than 4.5;
b) pH more than 2.5;
c) pH less than 2.1;
d) pH less than 5.4;
e) pH more than 5.0.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
71
Topic 15
INQUIRING AND CLINICAL EXAMINATION OF THE PATIENTS WITH
PATHOLOGY OF LIVER AND GALLBLADDER
PERCUSSION AND PALPATION OF THE LIVER BY KURLOV
PALPATION OF GALLBLADDER
LABORATORY (FUNCTIONAL STUDY OF THE LIVER AND BILE
DUCTS)
AND
INSTRUMENTAL
(CHOLECYCTOGRAPHY,
ULTRASOUND EXAMINATION) METHODS OF EXAMINATION OF
PATHOLOGY OF LIVER AND GALLBLADDER
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What pathological changes can be found thanks to Radionuclide studies?
What bodys of digestive system we can inspect using Radionuclide studies?
2. What pathological changes can be found thanks to Angiography? What
bodys of digestive system we can inspect using Angiography?
3. What pathological changes can be found thanks to Computed tomography?
What bodys of digestive system we can inspect using Computed
tomography?
4. What pathological changes can be found thanks to Magnetic resonance
imaging? What bodys of digestive system we can inspect using Magnetic
resonance imaging?
5. What pathological changes can be found thanks to Ultrasonography? What
bodys of digestive system we can inspect using Ultrasonography?
6. What pathological changes can be found thanks to Cholecyctography? What
bodys of digestive system we can inspect using Cholecyctography?
7. What you know about bilirubin, about what indicates change of its levels in
the blood?
72
8. What you know about protein (total protein and its fraction), about what
indicates change of its levels in the blood?
9. What liver enzymes are examined in the blood?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
14.Palpation of the liver. Show the technique of palpation. Identify the main
basic signs that are determined during palpation of the liver.
15.Percussion of the liver (by M.G. Kurlov). Show the percussion technique to
determine the liver borders. Identify normal sizes of the liver. Indicate
pathological causes that lead to liver borders changes.
16.Penetrative palpation of gall bladder point (Ker`s point).
III.
Control Test of theoretical knowledge.
1. Sizes of the liver by Kurlov normally (in cm):
a) 10-7, 8-6, 9-5;
b) 12-9, 11-8 , 10-7;
c) 11-9, 10-8, 9-7;
d) 8-6, 7-5, 6-4.
2. For what disease typical reduce size of liver:
a) liver cirrhosis;
b) subacute macular degeneration
c) liver;
d) acute hepatitis;
e) chronic hepatitis;
f) persistent hepatitis?
73
3. For chronic cholecystitis is typical:
a) Ker`s symptom;
b) Shchetkin-Blumberg symptom;
c) pain in the zone of Chauffard;
d) tenderness at the Desjardin`s point.
4. What method of examination has the greatest value in diagnosis of gallstone
disease:
a) questioning;
b) palpation;
c) cholecystography;
d) irrigoscopy;
e) duodenal intubation?
5. By using what method can be examine in vivo the morphology of the liver:
a) scan;
b) biopsy;
c) laparoscopy;
d) splenoporto graphy?
6. How denoted the hepatitis B virus:
a) HbsAg;
b) HBV;
c) anti-HBs;
d) HBeAg;
e) Anti- HBc?
7. How we indicate antibody against the protein of hepatitis C virus:
a) HCV;
b) HCAg;
74
c) anti-HCV;
d) HCV-RVA?
8. How we indicate antibody against the virus of hepatitis D in the acute phase
of infection:
a) HDV;
b) HDVAg;
c) anti-HDV, Ig G;
d) anti-HDV, Ig M?
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
75
Topic 16
INQUIRING AND CLINICAL EXAMINATION OF THE PATIENTS WITH
PATHOLOGY OF PANCREAS
PERCUSSION OF PANCREAS
LABORATORY (COPROLOGICAL STUDY) AND INSTRUMENTAL
(ULTRASOUND EXAMINATION) METHODS OF EXAMINATION OF
PANCREAS
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What pathological changes can be found thanks to Computed tomography?
What bodys of digestive system we can inspect using Computed
tomography?
2. What pathological changes can be found thanks to Magnetic resonance
imaging? What bodys of digestive system we can inspect using Magnetic
resonance imaging?
3. What pathological changes can be found thanks to Ultrasonography? What
bodys of digestive system we can inspect using Ultrasonography?
4. What includes coprological analysis of stool?
5. What you know about daily faeces amount? (when it can be decreased and
increased).
6. What you know about color o f the faeces?
7. What you know about odor of the faeces?
8. What you know about admixtures of food origin in faeces?
9. What you know about pathological admixtures in faeces?
10.What indicators investigated by chemical examination of stool?
11.What indicators investigated by microscopic study of stool?
12.What pancreas enzymes are examined in the blood?
76
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Palpation of the pancreas. Show the technique of palpation. Identify the
main basic signs that are determined during palpation of the liver.
III.
Control Test of theoretical knowledge.
1. Specify the basic characteristic signs of damage the pancreas:
a) dysphagia, odynophagia, heartburn, chest pain, hematemesis/melena;
b) pain, weight loss, diarrhea, steatorrhea;
c) nausea and vomiting, epigastric pain, hematemesis/melena, early
satiety;
d) pain, nausea/ vomiting, nematemesis;
e) pain urgency, hematochezia, tenderness, pruritus.
2. Main features of pain in acute pancreatitis:
a) is epigastric, may radiate to the back, and is of variable quality:
gnawing, burning, boring, aching, pressing, or hunger like;
b) is epigastric, and of variable quality. The pain is persistent and slowly
progressive;
c) is epigastric, may radiate to the back or other parts of the abdomen or
may be poorly localized. The quality of the pain is usually steady;
d) is steady, deep epigastric pain, radiating through to the back. Pain is
chronic or of recurrent course;
e) is epigastric and in either upper quadrant steady and deep pain that
often radiates to the back. The pain is persistent, and can relieve in
leaning forward with trunk flexed.
3. How called feces with the large amount of fat:
77
a) steatorrhea;
b) melena;
c) acholic stool;
d) sheep feces?
4. Tendency to diarrhea typical for:
a) duodenal ulcer disease intestine;
b) erosive duodenitis;
c) chronic pancreatitis;
d) chronic gastritis with increased gastric acidity juice.
5. Main features of pain in chronic pancreatitis:
a) is epigastric, may radiate to the back, and is of variable quality:
gnawing, burning, boring, aching, pressing, or hunger like;
b) is epigastric, and of variable quality. The pain is persistent and slowly
progressive;
c) is epigastric, may radiate to the back or other parts of the abdomen or
may be poorly localized. The quality of the pain is usually steady;
d) is steady, deep epigastric pain, radiating through to the back. Pain is
chronic or of recurrent course;
e) is epigastric and in either upper quadrant steady and deep pain that
often radiates to the back. The pain is persistent, and can relieve in
leaning forward with trunk flexed.
6. What is early sign of pancreatic insufficiency:
a) The presence stercobilin in the stool;
b) Steatorrhea;
c) Black feces;
d) The presence of urobilin in the stool;
e) The normal color of stool?
78
7. Main features of the cancer of the pancreas:
a) is epigastric, may radiate to the back, and is of variable quality:
gnawing, burning, boring, aching, pressing, or hunger like;
b) is epigastric, and of variable quality. The pain is persistent and slowly
progressive;
c) is epigastric, may radiate to the back or other parts of the abdomen or
may be poorly localized. The quality of the pain is usually steady;
d) is steady, deep epigastric pain, radiating through to the back. Pain is
chronic or of recurrent course;
e) is epigastric and in either upper quadrant steady and deep pain that
often radiates to the back. The pain is persistent, and can relieve in
leaning forward with trunk flexed.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
79
Topic 17
INQUIRING
(DISORDERS
OF
URINATION)
AND
GENERAL
EXAMINATION OF THE PATIENTS WITH PATHOLOGY OF URINARY
SYSTEM
PALPATION AND PERCUSSION OF KIDNEYS
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. Functioning of the urinary system.
2. Structure of kidney?
3. Structure of nephron?
4. The main complaint.
5. Specify character and location of pain if the patient has pyelonephritis.
6. Indicate character and location of pain if the patient has cystitis.
7. Indicate known to you signs and causes of polyuria
8. Indicate known to you the basic signs of edema in patients with disorders of
the urinary system.
9. Specify character and location of pain if the patient has glomerulonephritis.
10.Indicate character and location of pain if the patient has urethritis
11.Indicate known to you signs and causes of anuria.
12.Indicate known to you secondary complaints that may occur in patients with
disorders of the urinary system.
13.Inspection of the patient.
14.Pasternatsky symptom: specify technique and purpose of this method.
15.Palpation accordingly to S. Botkin: indicate technique and the main purpose
of this method.
80
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of patients with disorders of urinary system. Identify
the main complaints.
2. Palpation (by Obraztsov-Strazhesko) and percussion (Pasternatsky`s
symptom) of the kidneys. Identify the basic signs that are determined during
palpation and percussion of the kidneys.
III.
Control Test of theoretical knowledge.
1. Where the primary urine is formed:
a) in glomerulus;
b) in the proximal tubules;
c) in the distal tubules;
d) in the loop of the nephron;
e) in glomerulus and proximal tubule?
2. Excretory anuria:
a) violation of urine formation by kidneys;
b) lack of urine because of constraints in the urinary tract;
c) daily urine output less than 500 ml;
d) urinary excretion of acetone.
3. What is the nocturia:
a) increased urine specific gravity;
b) night urine output;
c) the presence of glucose in urine;
d) violation of urine caused by kidneys;
81
e) inability to emptying urinary bladder as a result of compression or
damage to the spinal brain?
4. For what disease typical positive Pasternatsky symptom:
a) glomerulonephritis;
b) pyelonephritis;
c) liver disease;
d) cystitis?
5. In a healthy person kidneys are:
a) palpable in a position on the left or right side;
b) palpable in a position on the back;
c) inot palpable;
d) palpable just right kidney?
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
82
Topic 18
LABORATORY
(URINE
ANALYSIS)
(ULTRASOUND,
EXCRETION
AND
UROGRAPHY)
INSTRUMENTAL
METHODS
OF
EXAMINATION OF URINARY SYSTEM
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What is microhematuria? What you know about glomerular origin of
hematuria, what disease can cause it?
2. What is macrohematuria? What you know about non glomerular origin of
hematuria, what disease can cause it?
3. Please describe three-glasses test, what it determine?
4. Please describe Zimnitsky`s test, what it determine?
5. What you know about functional and organic proteinuria, please indicate?
6. What you know about selective and non-selective proteinuria, please
indicate?
7. Ultrasound as a diagnostic method in nephrological practice, please indicate
what you know about it? What we can find out during ultrasound of renals?
8. Provide main diseases that can cause glomerular transitory renal proteinuria?
9. Provide main diseases that can cause glomerular constant renal proteinuria?
10.Specify the underlying causes of pathological glycosuria?
11.Provide all you know possible changes of the urine color and disease that
caused them?
12.Provide known to you changing of urine concentration and their names?
13.Please indicate renal causes of urine specific gravity changes?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
83
1. Conduct questioning of patients with disorders of urinary system. Identify
the main complaints.
2. Palpation (by Obraztsov-Strazhesko) and percussion (Pasternatsky`s
symptom) of the kidneys. Identify the basic signs that are determined during
palpation and percussion of the kidneys.
III.
Control Test of theoretical knowledge.
1. Content of what substance in the urine significantly increases its specific
gravity:
a) urates;
b) protein;
c) bilious pigments;
d) glucose;
e) uric acid?
2. What changes in urine are typical for chronic pyelonephritis:
a) hematuria and cylindruria;
b) leucocyturia and proteinuria;
c) cylindruria;
d) hematuria and bacteriuria;
e) hematuria, cylindruria, proteinuria?
3. Specific gravity of urine depends of:
a) amount of food you eat;
b) nature of the food;
c) amount of salt in the urine;
d) amount of excreted urine and amount of solid substances in the urine;
e) temperature of the body?
84
4. Leucocyturia - the presence of large amounts in urine of:
a) cylinders;
b) epithelial cells;
c) leucocytes;
d) erythrocytes.
5. The appearance of fresh red blood cells in urine typical for:
a) pyelonephritis;
b) nephrotic syndrome;
c) glomerulonephritis;
d) urethritis.
6. The content of leucocytes in urine sediment of healthy individual (in vision
area):
a) till 40-60;
b) not contained;
c) 1-2;
d) 100 and more.
7. Glycosuria is often typical for:
a) misuse of sweet food;
b) emotional turmoil;
c) diabetes;
d) glomerulonephritis.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
85
Topic 19
INQUIRING AND CLINICAL EXAMINATION OF THE PATIENTS WITH
BLOOD SYSTEM DISORDERS
PALPATION OF SPLEEN
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What signs of pathological changes in lymph nodes can be determined
during their palpation?
2. Describe lymph nodes in normal conditions.
3. Please specify main reasons for enlarged lymph nodes.
4. Specify diseases which are manifested by increasing of occipital, cervical,
axillary, inguinal, cubital (local) lymph nodes.
5. During the inspection of the skin on what we should pay attention.
6. Describe the skin of a healthy person. What are pathological changes of the
skin color?
7. Please indicate physiological and pathological causes of pale color of the
skin.
8. Please indicate physiological and pathological causes of red color of the
skin.
II.
Please describe the following methods for patients care, that are
included in the duties of nurses assistant (Рractical skills).
1. Palpation of the spleen. Show the technique of palpation. Identify the main
basic signs that are determined during palpation of the spleen.
86
2. Palpation of lymph nodes. Specify main lymph nodes. Determine signs of
lymph nodes that need to be determined during palpation and pathological
causes leading to enlarged lymph nodes.
III.
Control Test of theoretical knowledge.
1. Increasing o f erythrocytes number is classified as:
a) erythrocytosis;
b) erythrocytopenia;
c) oligochromemia;
d) hyperchromemia;
2. Increased concentration of hemoglobin in the blood:
a) erythrocytosis;
b) erythrocytopenia;
c) oligochromemia;
d) hyperchromemia;
3. Normal value of Eosinophils:
a) 0.02-0.3 x 109 /1(0.5-5 %);
b) 0-0.065 x 109 /1 (0-1 %);
c) 1.2-3.0 x 109 /1(19-37%);
d) 0.09-0.60 x 109 /1 (3-11 %).
4. Normal rate of erythrocyte sedimentation rate in adult males:
a) 1 to 20 mm/hr;
b) 5 to 15 mm/hr;
c) 0,5 to 5 mm/hr;
d) 1 to 10 mm/hr.
87
5. Normal value of Lymphocytes:
a) 0.02-0.3 x 109 /1(0.5-5 %);
b) 0-0.065 x 109 /1 (0-1 %);
c) 1.2-3.0 x 109 /1(19-37%);
d) 0.09-0.60 x 109 /1 (3-11 %).
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
88
Topic 20
LABORATORY (CLINICAL BLOOD ANALYSIS, TESTS FOR PLASMA
FACTORS INVOLVED IN COAGULATION AND FIBRINOLISIS) AND
INSTRUMENTAL METHODS OF EXAMINATION OF BLOOD SYSTEM
STERNAL PUNCTURE
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. Erythrocytes. What it is? Describe their meaning? Indicate normal values of
this index. Erythrocytosis and erythrocytopenia. What it is? Under what
conditions these pathological states arise?
2. Hemoglobin. What it is? Describe its meaning? Indicate normal values of
this index. Color index. What it is? Describe its meaning? Indicate normal
values of this index.
3. Leukocytes. What it is? Describe its meaning? Indicate normal values of this
index. Leukocyte formula. Describe its meaning? Indicate normal values of
this index.
4. Indicate clinical significance o f leukocyte formula changes?
5. Neutrophilia. Please indicate pathological factors that cause it?
6. Leukemoid reactions. What it is and what pathological factors cause it?
7. Neutropenia. What it is? Please indicate pathological factors that cause it?
8. Eosinophilia and Eosinopenia. What it is? Please indicate pathological
factors that cause it?
9. Basophilia. What it is? Please indicate pathological factors that cause it?
10.Monocytosis. What it is? Please indicate pathological factors that cause it?
11.Lymphocytosis and Lymphopenia. What it is? Please indicate pathological
factors that cause it?
89
12.Indicate clinical significance o f thrombocytes changes? Indicate normal
values of this index.
13.Erythrocyte sedimentation rate (ESR). Indicate clinical significance of the
Erythrocyte Sedimentation Rate. Indicate normal values of this index.
14.Please indicate clinical significance o f hemoglobin changes. Please indicate
pathological factors that cause it?
15.Leukocytosis
and
Leukopenia.
Please
indicate
pathological
and
physiological factors that can cause them?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Palpation of the spleen. Show the technique of palpation. Identify the main
basic signs that are determined during palpation of the spleen.
2. Palpation of lymph nodes. Specify main lymph nodes. Determine signs of
lymph nodes that need to be determined during palpation and pathological
causes leading to enlarged lymph nodes.
III.
1.
Control Test of theoretical knowledge.
Normal values of erythrocytes count in women:
a) 3.8±1.0 x 1012/1;
b) 4.8±1.0 x 1012/1;
c) 6.8±1.0 x 1012/1;
d) 8.8±1.0 x 1012/1.
2.
Normal values of hemoglobin in men:
a) 10.5±2.5 g/dl;
b) 2.5±2.5 g/dl ;
c) 5.5±2.5 g/dl;
90
d) 15.5±2.5 g/dl.
3.
What color index values indicate the normochromia:
a) less than 0.8;
b) 1.2-1.5;
c) more than 1.1;
d) 0.85-1.1.
4.
Normal value of Eosinophils:
a) 0.02-0.3 x 109 /1(0.5-5 %);
b) 0-0.065 x 109 /1 (0-1 %);
c) 1.2-3.0 x 109 /1(19-37%);
d) 0.09-0.60 x 109 /1 (3-11 %).
5.
Normal number of thrombocytes (platelets) is:
a) 100.0-220.0 x 109/l ( 180000-320000 per 1 µl);
b) 120.0-320.0 x 109/l ( 180000-320000 per 1 µl);
c) 180.0-320.0 x 109/l ( 180000-320000 per 1 µl);
d) 200.0-420.0 x 109/l ( 180000-320000 per 1 µl).
6.
Normal rate of erythrocyte sedimentation rate in females:
a) 1 to 20 mm/hr;
b) 5 to 15 mm/hr;
c) 0,5 to 5 mm/hr;
d) 2 to 15 mm/hr.
Suggested Reading:
Propaedeutics yo Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
91
Topic 21
CLINICAL, LABORATORY AND INSTRUMENTAL METHODS OF
EXAMINATION OF PATIENTS WITH ENDOCRINE PATHOLOGY
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. Were we palpate thyroid gland and how?
2. Specify diseases which are manifested by increasing of thyroid gland.
3. What signs of pathological changes on neck can be determined during
palpation?
4. On what key points you should pay attention during the examination of
neck?
5. How we have to determine the turgor and elasticity of the skin and what
diagnostic meanings have diminished turgor?
6. Indicate diagnostic value for moisture of the skin.
7. What physiological and pathological causes for dry (xeroderma) and moist
skin (hyperhydrosis) you know?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. General inspection of head and neck. Specify basic signs that you need to
pay attention during general inspection. Identify changes that are possible to
detect during general inspection.
2. General inspection of skin and subcutaneous tissue. Specify basic signs that
you need to pay attention during general inspection. Identify changes that
are possible to detect during general inspection.
3. Conduct palpation of the thyroid gland to evaluate the findings.
92
III.
Control Test of theoretical knowledge.
1. Cachexia observed if the thickness of subcutaneous fat is:
a) 1.5-2 cm;
b) more than 2 cm;
c) less than 1.5 cm;
d) less than 0.5 cm.
2. Ginoid type of obesity is characterized by:
a) uniformly fat distribution with more pronounced accumulation at the buttock
and hip;
b) accumulation of fat mainly at the upper part of the body, abdomen, and
completely absence of fat at the butock and legs;
c) no change in subcutaneous fat in abdomen.
3. Aneroid type of obesity is characterized by:
a) uniformly fat distribution with more pronounced accumulation at the buttock
and hip;
b) accumulation of fat mainly at the upper part of the body, abdomen, and
completely absence of fat at the butock and legs;
c) no change in subcutaneous fat in abdomen.
4. Short stature is caused by all listed except:
a) Cherechewski-Tumer syndrome;
b) Cretinism;
c) Marfan’s syndrome ;
d) Chrohn’s disease.
5. High stature is caused by all listed except:
a) Acromegaly;
93
b) Marfan’s syndrome;
c) Kleinefelter’s syndrome;
d) Cushing’s syndrome.
6. Pathological reasons of dry skin (xeroderma) is
a) Myxedema;
b) Syncope;
c) Acute leukemia;
d) Thyrotoxicosis.
7. Pathological reasons of moist skin (hyperhydrosis) is
a) Cholera;
b) Thyrotoxicosis;
c) toxicity of pregnancy;
d) Myxedema.
8. Round or “moon-like” face, plethora, red cheeks is also called:
a) facies in patients with Cushing’s syndrome ;
b) facies Hyppocratica;
c) facies as a “wax-doll”;
d) facies Corvisara;
e) facies acromegalica.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
94
Topic 22
CLINICAL, LABORATORY AND INSTRUMENTAL METHODS OF
EXAMINATION OF PATIENTS WITH MUSCULOSKELETAL AND
CONNECTIVE TISSUES DISORDERS
Type of a lesson – theoretical and practical
I.
Please answer the following questions (Theoretical knowledge).
1. What main methods of examination of muscular system you know?
2. On what key points you should pay attention during the examination of
muscular system?
3. Describe muscular system in normal conditions.
4. What pathological manifestations of muscular system you can find during
the examination?
5. What main methods of examination of bones system you know?
6. On what key points you should pay attention during the examination of
bones system?
7. What common causes of the bones system abnormalities you can find during
the examination?
8. What consequence we should perform during examination of the joints
system?
9. What two kinds of movement are distinguished?
10.What inflammatory diseases develop to affection of the joints?
11.List all known about pathological changes of the spine?
12.What types of posture of the patients may be?
13.What are the possible causes and symptoms of this forced posture connected
with musculoskeletal diseases?
14.What specific gaits connected with musculoskeletal diseases are known to
you, please list?
95
15.What are the signs that you as a doctor have to pay attention during the
examination of the head?
16.What pathological state can cause macrocephalia and microcephalia? List
shapes of the head that you know.
17.How we measure the degrees of subcutaneous fat, also indicate the size of
subcutaneous fat for normosthenic person, for obesity and for sign of
cachexia.
18.Specify types and causes of obesity and weight loss.
19.What criteria includes concept of habitus? Indicate the normal height for
men and women.
20.What may be pathological changes of height and what can cause it?
21.Specify how we calculate body mass index (BMI). Specify the classification
of overweight and obesity in adults. On which two groups is divided bodybuild?
II.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. General inspection of head and neck. Specify basic signs that you need to
pay attention during general inspection. Identify changes that are possible to
detect during general inspection.
2. General inspection of skin and subcutaneous tissue. Specify basic signs that
you need to pay attention during general inspection. Identify changes that
are possible to detect during general inspection.
3. Conduct inspection of body, legs and hands of exemplary patient. Identify
the clinical significance of symptoms.
III.
Control Test of theoretical knowledge.
1. Rheumatoid arthritis is characterized by:
96
a) damage commonly knee in a form of monoarthritis;
b) transient and migratory or a more persistent polyarthritis;
c) affecting the distal interphalangeal joints;
d) pain on movement of joints, morning stiffness and symmetrical swelling of
small joints of the fingers and the toes;
e) symmetrical lesions of large joints with acute painful inflammation.
2. Arthritis of rheumatic fever is characterized by:
a) pain on movement of joints, morning stiffness and symmetrical swelling of
small joints of the fingers and the toes;
b) damage commonly knee in a form of monoarthritis;
c) symmetrical lesions of large joints with acute painful inflammation;
d) transient and migratory or a more persistent polyarthritis;
e) affecting the distal interphalangeal joints.
3. Specify the name of the patient's posture that is typical for states listed below –
attacks of bronchial asthma, cardiac asthma, spasm of bronchi; lung tumor,
pneumothorax:
a) standing upright position;
b) orthopnea;
c) supine posture;
d) position lying on the side
e) prone position.
4. Specify the name of the patient's posture that is typical for states listed below –
tumor of pancreas, acute thrombosis of lien vein, trauma and tuberculosis of
spine:
a) standing upright position;
b) orthopnea;
c) supine posture;
97
d) position lying on the side;
e) prone position.
5. Gait as “a duck” - is characterized by:
a) small, slow step with compensatory inclination trunk to the opposite side
due to the hypotonia of pelvis muscle
b) putting trunk backward for support balance
c) high rising of climb, reach the floor, limb continue to search fulcrum
d) abundance (superfluous) leg draw aside and the arm from the same side
bond to the trunk due to the increased muscle tone.
6. “Proud” gait is characterized by
a) small, slow step with compensatory inclination trunk to the opposite side
due to the hypotonia of pelvis muscle
b) putting trunk backward for support balance
c) high rising of climb, reach the floor, limb continue to search fulcrum
d) abundance (superfluous) leg draw aside and the arm from the same side
bond to the trunk due to the increased muscle tone.
7. For patients with Parkinsonism is typical:
a) Gait as “a duck”
b) “Proud” gait
c) Dolls/puppet gait
d) paretic gait.
Suggested Reading:
Propaedeutics to Internal Medicine: Diagnosics; textbook for English learning
Students of higher medical schools; Part 1.; Ed. 2 / O.N. Kovalyova, T.V.
Ashcheulova – Vinnytsya: Nova Knyha publishers, 2011. – 424 p.
98
Topic 23
EVALUATION OF STUDENT KNOWLEDGE ON FINAL MODULE
The final module control includes two situational tasks, practical skills and
control test of theoretical knowledge that are added.
Maximum points that can be earned for the module is 100 points:
- control test of theoretical knowledge – 50 points;
- 2 situational tasks – each task is rated at 20 points;
- practical skill – 10 points.
Minimum points that can be earned for the module is 50 points:
Module consists of two parts:
- First part of the module involves writing control test of theoretical
knowledge. Maximum – 50 points, minimum – 25 points. *
- Second part of the module consists of two situational tasks (each task is
rated at 20 points) and practical skill (10 points). Maximum – 50 points,
minimum – 25 points.
The final score of the module
Evaluation of a four-system
100……….85
"Excellent" – 5
84…….…70
"Good" – 4
69…….…50
"Satisfactory" – 3
49…….….0
"Unsatisfactory" – 2
* If student received less than 25 points on first part of the module this involves
re-writing of the first part (control test of theoretical knowledge). In this situation
student not permitted to the second part of the module and in convenient for
teacher and for student time again writes test control of theoretical knowledge. In
case of receiving 25 or more points for test control student is admitted to the
second part of the module.
99
I.
Demonstrate the following methods for objective examination of the
patient (Рractical skills).
1. Conduct questioning of the patient. Make conclusion about the received
information.
2. Conduct general overview of exemplary patient. Identify the major
symptoms.
3. Conduct palpation of the patient and determine the clinical significance of
symptoms.
4. Conduct comparative percussion and determine the clinical significance of
symptoms.
5. Conduct topographic percussion and determine diagnostic value of
symptoms.
6. Conduct auscultation of the patient and determine diagnostic value of
symptoms.
7. General inspection of head and neck. Specify basic signs that you need to
pay attention during general inspection. Identify changes that are possible to
detect during general inspection.
8. General inspection of skin and subcutaneous tissue. Specify basic signs that
you need to pay attention during general inspection. Identify changes that
are possible to detect during general inspection.
9. General inspection of the oral cavity and eyes. Specify basic signs that you
need to pay attention during general inspection. Identify changes that are
possible to detect during general inspection.
10.Conduct inspection of body, legs and hands of exemplary patient. Identify
the clinical significance of symptoms.
11.Conduct palpation of the thyroid gland to evaluate the findings.
12.Palpation of lymph nodes. Specify main lymph nodes. Determine signs of
lymph nodes that need to be determined during palpation and pathological
causes leading to enlarged lymph nodes.
100
13.Conduct questioning of patients with disorders of respiratory system.
Identify the main complaints.
14.Conduct inspection of the chest of patient with pathology of the respiratory
system. Identify the main symptoms and signs that are established during
static inspection.
15.Conduct inspection of the chest of a patient with pathology of the
respiratory system, Identify the main symptoms and signs that are
established during dynamic inspection.
16.Palpation of the chest. Indicate three basic key points that are established by
palpation of the chest, and the method of their determination.
17.Comparative percussion of the lungs. Indicate main tasks of this method
and show the technique of its performance.
18.Topographic percussion of the lungs. Indicate main tasks of this method and
show the technique of its performance.
19. Determine the active mobility of the lower edge of the lungs, evaluate
diagnostic value of symptoms.
20.Auscultation of the lungs. Show the technique of auscultation (anterior
view, posterior view, axillary regions). Tell about the main respiratory
sounds (breath sounds).
21.Auscultation of the lungs. Show the technique of auscultation (anterior
view, posterior view, axillary regions). Tell about the main respiratory
sounds (breath sounds) namely about vesicular (alveolar) breath sounds.
22.Auscultation of the lungs. Show the technique of auscultation (anterior
view, posterior view, axillary regions). Tell about the adventitious (added)
sounds namely about bronchial (laryngotraheal) breath sounds.
23.Conduct questioning of patients with disorders of the cardiovascular
system. Identify the main (specific) complaints.
24.Conduct questioning of patients with disorders of the cardiovascular
system. Identify the nonspecific complaints.
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25.Conduct inspection of the heart region. Determine examination plan,
specify the clinical symptoms.
26.Conduct palpation of the heart region. Determine examination plan, show
the technique of palpation the apex beat. Specify the basic signs of
pathological changes of the heart region.
27.Percussion of the heart: specify examination plan of percussion. Show the
percussion technique to determine the relative cardiac dullness of the heart.
Identify normal borders of the relative cardiac dullness.
28.Percussion of the heart: specify examination plan of percussion. Show the
percussion technique to determine the absolute cardiac dullness of the heart.
Identify normal borders of the absolute cardiac dullness.
29.Determine by percussion the vascular bundle, evaluate findings.
30.Determine by percussion configuration of the heart. Identify normal
configuration of the heart.
31.Conduct auscultation of arteries to determine the diagnostic value of
symptoms.
32.Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the normal heart sounds (heart tones) and their changes.
33.Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the three-sound rhythms (additional heart sounds).
34.Auscultation of the heart: specify examination plan of auscultation. Show
the technique of auscultation (five standard listening points of the heart).
Tell about the heart murmurs.
35.Palpation of the pulse. Show the technique of palpation. Identify the main
characteristics of pulse and their normal manifestations.
36.Blood pressure measurements. Specify examination plan of blood pressure
measurement. Identify normal findings of blood pressure.
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37.Blood pressure measurements. Specify examination plan of blood pressure
measurement. Identify common abnormalities of blood pressure.
38.Conduct questioning of patients with disorders of digestive system. Identify
the main complaints.
39.Conduct inspection of abdomen. Determine examination plan, specify signs
of abdomen in the normal conditions and pathological causes that lead to
abdomen changes.
40.Superficial palpation of the abdomen. Show the technique of palpation.
Indicate main signs that are defined during superficial palpation of the
abdomen.
41.Penetrative palpation of the abdomen. Indicate main points that are
determined during penetrative palpation of the abdomen.
42.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the sigmoid colon.
43.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the caecum colon.
44.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the ascending colon.
45.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the descending colon.
46.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the transverse colon.
47.Deep sliding palpation of the abdomen (by Obraztsov-Strazhesko). Indicate
recommended sequence of the examination. Show the technique of deep
sliding palpation of the stomach.
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48.Palpation of the liver. Show the technique of palpation. Identify the main
basic signs that are determined during palpation of the liver.
49.Percussion of the liver (by M.G. Kurlov). Show the percussion technique to
determine the liver borders. Identify normal sizes of the liver. Indicate
pathological causes that lead to liver borders changes.
50.Palpation of the spleen. Show the technique of palpation. Identify the main
basic signs that are determined during palpation of the spleen.
51.Conduct questioning of patients with disorders of urinary system. Identify
the main complaints.
52.Palpation (by Obraztsov-Strazhesko) and percussion (Pasternatsky`s
symptom) of the kidneys. Identify the basic signs that are determined during
palpation and percussion of the kidneys.
53.Analyze the ECG by the following scheme: Determination of the Cardiac
Rhythm Regularity, Calculation of the Heart Rate, Measurements of the
ECG Amplitude, Determination of the Cardiac Rhythm Pacemaker Site,
Estimation of the conductivity, Determination of the Electrical Axis of the
Heart, Measurements of the duration and amplitude of the ECG waves and
intervals and make the following ECG conclusion:
a) The cardiac rhythm pacemaker (sinus or nonsinus rhythm)
b) Regularity of cardiac rhythm (regular or irregular)
c) The heart rate
d) Position of electrical axis of the heart
e) Presence of the four ECG syndromes: arrhythmias, conduction
disturbances, atrial or ventricular hypertrophy, myocardial injury
(ischemia, injury, necrosis, scar).
II.
Analysis skills of laboratory and instrumental methods of examination
in therapeutic clinic: evaluate the following analysis (install the
changes in the analysis and indicate possible reasons for these
changes).
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1. Complete blood count: (man) Hemoglobin – 12,3±2,5 g/dl; erythrocytes –
4,3×1012/l; color index – 0,7; leukocytes – 5,7×109/l. Leukocytogramma:
band neutrophils – 4%; polymorphonuclear neutrophils – 56%; basophils –
1%; eosinophils –2%; lymphocytes –31%; monocyte – 6%; thrombocytes
(platelets) – 200,0×109/l; erythrocyte sedimentation rate (ESR) – 5 mm/hr.
Oligochromemia, erythrocytopenia, hypochromia.
2. Complete blood count: (man) Hemoglobin – 15,5±2,5 g/dl; erythrocytes –
5,5×1012/l; color index – 0,9; leukocytes – 15,6×109/l. Leukocytogramma:
band neutrophils – 4%; polymorphonuclear neutrophils – 56%; basophils –
1%; eosinophils –2%; lymphocytes –31%; monocyte – 6%; thrombocytes
(platelets) – 200,0×109/l; erythrocyte sedimentation rate (ESR) – 18 mm/hr.
Leukocytosis, increase of ESR
3. Complete blood count: (woman) Hemoglobin – 14,0±2,5 g/dl; erythrocytes
– 4,8×1012/l; color index – 0,9; leukocytes – 13,9×109/l. Leukocytogramma:
band neutrophils – 4%; polymorphonuclear neutrophils – 56%; basophils –
1%; eosinophils –2%; lymphocytes –31%; monocyte – 6%; thrombocytes
(platelets) – 200,0×109/l; erythrocyte sedimentation rate (ESR) – 22 mm/hr.
Leukocytosis, increase of ESR №6
4. Complete blood count: (man) Hemoglobin – 15,5±2,5 g/dl; erythrocytes –
5,5×1012/l; color index – 0,9; leukocytes – 7,6×109/l. Leukocytogramma:
band neutrophils – 5%; polymorphonuclear neutrophils – 49%; basophils –
0%; eosinophils –12%; lymphocytes –32%; monocyte – 2%; thrombocytes
(platelets) – 200,0×109/l; erythrocyte sedimentation rate (ESR) – 6 mm/hr.
Eosinophilia
5. Complete blood count: (man) Hemoglobin – 15,5±2,5 g/dl; erythrocytes –
5,5×1012/l; color index – 0,9; leukocytes – 5,6×109/l. Leukocytogramma:
band neutrophils – 2%; polymorphonuclear neutrophils – 65%; basophils –
0%; eosinophils – 2%; lymphocytes – 21%; monocyte – 10%; thrombocytes
(platelets) – 150,0×109/l; erythrocyte sedimentation rate (ESR) – 4 mm/hr.
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Thrombocytopenia №9
6. Urinalysis: (woman) color – straw yellow; specific gravity – 1018; reaction
of urine feebly acid; protein – 35 mg/24h; leukocytes – 15-20 in vision area;
erythrocytes – 1-2 in vision area.
7. Urinalysis: (man) color – straw yellow; clarity – clear; specific gravity –
1017; reaction of urine – feebly acid; protein – 140 mg/24h; leukocytes – 12 in vision area; erythrocytes – 1-2 in vision.
8. Urinalysis: (man) color – straw yellow; clarity – clear; specific gravity –
1018; reaction of urine – feebly acid; protein – 30 mg/24h; leukocytes – 1-2
in vision area; erythrocytes altered – 12-18 in vision area.
9. Blood chemistry: cholesterol –4,2 mmol/L; β- lipoproteins – 3,9 mmol/L;
total protein – 70 g/l; total bilirubin – 34 mkmol/l; aspartate
aminotransferase (АSТ) – 0,67 mmol/h×l; alanine aminotransferase (АLТ)
– 0,80 mmol/h×l; lactate dehydrogenase (LDG) – 6,2 mkmol/s×l; sorbitol
dehydrogenase (SDG) – 8,7 nmol/s×l; alkalayn phosphatase –1,3 mmol/h×l.
10.Blood chemistry: cholesterol – 9,2 mmol/L; β- lipoproteins – 8,9 mmol/L;
total protein – 82 g/l; total bilirubin – 29 mkmol/l; aspartate
aminotransferase (АSТ) – 0,38 mmol/h×l; alanine aminotransferase (АLТ)
– 0,48 mmol/h×l; lactate dehydrogenase (LDG) – 3,0 mkmol/s×l; sorbitol
dehydrogenase (SDG)
– 4,6 nmol/s×l; alkalayn phosphatase – 5,5
mmol/h×l.
Approved at the department meeting Propaedeutics of Internal Medicine №1
“
“ of ____________ 20___ year
Head of the chair ______________ Prof. MD Dutka R.J.
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