Metoduchka_II_kyrs._stomat._Modul_1

Lviv-2014

Danylo Halytsky Lviv National Medical University

Faculty of Dentistry

Department of Propedeutics of Internal Medicine №1

Discipline: Propedeutics of Internal Medicine

Methodological Guidelines for English-speaking Students of Dentistry Faculty

(2-d Year of Study)

“Main methods of patients examination in the clinic of internal diseases”

Module №1

1

CONTENT

1.

The subject of propedeutics of internal medicine. The plan of patients’ examination. The history of the disease. Patients interviewing. Diagnostics value of symptoms and syndromes. The concept of "health", "illness", "symptom", "syndrome", "diagnosis".

Types of diagnosis…………………………………………………………………………3

2.

General examination of the patient. Percussion and palpation as a diagnostics tools.

General rules and technique of percussion and auscultation. Diagnostic value…………...6

3.

Interviewing and examination of patients with diseases of the respiratory system.

Palpation of the chest. Percussion as a method of examination. Comparative and topographical percussion. Diagnostic value………………………………………….…..12

4.

Auscultation of the lungs. The main and side breathing noises formation mechanism.

Bronhofoniya. Diagnostic value…………………………………………………….……17

5.

Interviewing and examination of patients with diseases of the cardiovascular system.

Palpation and percussion of the heart. Heart configuration. Diagnostic value……….….22

6.

Auscultation of the heart. Point of auscultation. Mechanism of formation of sounds.

Diagnostic value………………………………………………………………………..28

7.

Heart murmurs. Formation and mechanism of murmurs. Diagnostic value.

Echocardiography…………………………………………………………………….32

8.

Examination of peripheral pulse. Diagnostic value. Examination of blood pressure.

Basic indicators. Diagnostic value. Clinical and functional methods of examination

(ECG)………………………………………………………………………………………35

9.

Examination of patients with diseases of the digestive system. Diagnostic value of questioning and examination of patients, palpation and percussion of the abdomen.

Study of gastric secretion, stool analysis. Changes in the oral cavity in diseases of the gastrointestinal tract………………………………………………………………….…40

10.

Examination of patients with diseases of the blood. Enquiry, inspection, palpation and percussion of the liver and spleen. Sternal puncture. Clinical analysis of blood. Blood coagulation. Diagnostic value…………………………………………………………..45

11.

Examination of patients with diseases of the urinary system. Questioning and examination of patients, palpation of the kidneys. Pasternatsky’s symptom. Diagnostic value. Manifestations of renal diseases in oral mucosa……………………..………….48

2

Topic 1

THE SUBJECT OF PROPEDEUTICS OF INTERNAL MEDICINE

THE PLAN OF PATIENTS’ EXAMINATION. THE HISTORY OF THE DISEASE

PATIENTS INTERVIEWING. DIAGNOSTICS VALUE OF SYMPTOMS AND

SYNDROMES. THE CONCEPT OF "HEALTH", "ILLNESS", "SYMPTOM",

"SYNDROME", "DIAGNOSIS". TYPES OF DIAGNOSIS

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. Anamnesis Morbi. Anamnesis Vitae.

I.

Please answer the following questions (Theoretical knowledge).

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.

3

5.

What structure has diagnosis?

6.

Give the definition for signs or symptoms of the disease.

7.

Specify which symptoms we can call subjective and which objective.

8.

Give the definition for pathological symptoms and compensatory symptoms.

9.

Give the definition for specific or pathognomic, nonspecific and relative symptoms.

10.

Give the definition for early and late symptoms.

11.

Please define the concept of syndrome.

12.

Please define the concept of symptomocomlex.

13.

What in your opinion is deontological ethics?

14.

Please specify the purpose of inquiring of patient. What aspects include inquiring of patients?

15.

What special scheme you should comply during questioning the patient about present complains?

16.

What it is “Anamnesis morbi”? What it includes?

17.

What it is “Anamnesis vitae”? What it includes?

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.

4

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; 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) social history; d) allergological history.

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.

5

Topic 2

GENERAL EXAMINATION OF THE PATIENT

PERCUSSION AND PALPATION AS A DIAGNOSTICS TOOLS

GENERAL RULES AND TECHNIQUE OF PERCUSSION AND AUSCULTATION

DIAGNOSTIC VALUE


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).

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.


6

1.

What types of general patient’s condition may be? What are the criteria’s of patient’s condition? List types of consciousness (sensorium).

2.

What types of posture of the patients may be? What forced posture or specific patients position are known to you? What specific gaits according to the pathological processes are known to you, please list?

3.

What pathological types of patient faces are known to you, describe them? What are the signs that you as a doctor have to pay attention during the examination of the eyes?

What are the signs that you as a doctor have to pay attention during the examination of the mouth? On what key points you should pay attention during the examination of cavity of the mouth? On what key points you should pay attention during the examination of tongue? Describe tongue of a healthy person. What signs of pathological changes on neck can be determined during palpation?

4.

What criteria includes concept of habitus? Specify how we calculate body mass index

(BMI). Specify the classification of overweight and obesity in adults.

5.

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? What eruptions of the skin did you know, indicate their manifestations and causes?

6.

How we have to determine the turgor and elasticity of the skin and what diagnostic meanings have diminished turgor? What include skin derivates?

7.

Please list the causes of edema and their types. Transcribe the following terms: ascitis, hydrothorax, hydropericardium, anasarca.

8.

Describe lymph nodes in normal conditions. Please specify main reasons for enlarged lymph nodes.

9.

What main methods of examination of muscular system you know? On what key points you should pay attention during the examination of muscular system?

10.

What main methods of examination of bones system you know? On what key points you should pay attention during the examination of bones system?

11.

What consequence we should perform during examination of the joints system. What inflammatory diseases develop to affection of the joints?

12.

What are the signs that you as a doctor have to pay attention during the examination of the head?

7

13.

Were we palpate thyroid gland and how? Specify diseases which are manifested by increasing of thyroid gland.

14.

Give the definition for objective examination. On which examinations methods is divided objective examination?

15.

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?

16.

What types of percussion techniques are known to you (immediate and mediate)?

Please indicate key points of mediate percussion. Indicate the main purpose of loud, light, and lightest percussion. Give the definition for comparative and topographic percussion.

17.

Indicate the main purpose of such diagnostic method as auscultation. What helps us to perform auscultation? Specify the key points of auscultation.

II.



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.

8

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.

III.


1.

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. Is very important in examination of the abdominal organs: intestine, liver, gall bladder, spleen; 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.

2.

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.

3.

Unconsciousness with absence of response to external stimuli, absence of reflexes, deranged vital function it is: a) Cloudiness;

9

b) Stupor; c) Sopor; d) Coma.

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; d) position lying on the side; e) prone position.

5.

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.

6.

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.

7.

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;

10

e) facies acromegalica.

8.

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.

9.

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.




11

Topic 3

INTERVIEWING AND EXAMINATION OF PATIENTS WITH RESPIRATORY

DISEASES. PALPATION OF THE CHEST

COMPARATIVE AND TOPOGRAPHICAL PERCUSSION AS A METHOD OF

EXAMINATION. DIAGNOSTIC VALUE


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.

9.

Topographic regions and lines of the chest.

10.

The physiological principles of the percussion.

11.

The intensity of the percussion.

12.

The task and technique of the comparative percussion.

13.

The basic qualities of the percuss sound: intensity, pitch and duration.

14.

The task and technique of the topographic percussion.

15.

The upper borders of the lung. The lower borders of the lung. Respiratory excursion.

12

I.


1.

What are the main complaints of the patients with disease of the respiratory system?

2.

Please describe the concept of dyspnea. Add a possible causes for physiological and pathological dyspnea. Define a term as subjective and objective dyspnea. Define a term such as inspiratory, expiratory and mixed dyspnea.

3.

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? List the diseases that cause periodic and permanent cough.

4.

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.

5.

Specify the parts of the lungs that are sensitive to pain. List pulmonary diseases that can cause chest pain .

6.

Describe the scheme that you have to comply during the inspection of the chest.

Indicate signs that we define during static inspection. Indicate signs that we define during dynamic inspection.

7.

Please indicate normal shapes of the chest. Please indicate pathological shapes of the chest. What main causes of pathological shapes of the chest you know?

8.

What respiration types are known to you? Describe the method for determining the respiratory rate. Specify standards of respiratory rate for adult and newborn. What respiratory rate is typical for tachypnea and bradypnea? Specify causes of tachypnea and bradypnea. What types of respiration depth are known to you? Indicate their main characteristics and causes.What are the signs that characterized respiratory rhythm in norm? List known to you periodic types of respiration.

9.

What are the main points we need to define during palpation of the chest?

Describe the basic method for identification of the tender areas. Describe the basic method for assessment of elasticity of the chest.

10.

What types of percussion of the lungs you know? What is the main task of comparative percussion of the lungs? Describe the main points of technique of comparative percussion.

13

11.

Describe the technique of comparative percussion on anterior view. Describe the technique of comparative percussion on axillary regions. Describe the technique of comparative percussion on posterior view.

12.

What basic qualities of percussion sound you need to distinguish? What characteristics of intensity, pitch, and duration of percussion sound are known to you?

13.

Provide main causes of sound changes during percussion. Physiological changes of the percussion sounds over the lungs. Define the concept of intermediate sound. Specify main causes of the intermediate sound. Define the concept of dullness. Specify main causes of the dullness.

14.

Indicate the main purpose of topographic percussion. Indicate basic technique in determination of the upper borders of the lungs. Indicate basic technique in determination of the lower borders of the lungs.

15.

Indicate types of displacement of the lower borders of the lungs. Indicate causes for bilateral lowering of the lower borders of the lungs. Indicate causes for unilateral lowering of the lower borders of the lungs. Indicate causes for bilateral elevation of the lower borders of the lungs. Indicate causes for unilateral elevation of the lower borders of the lungs.

16.

For what purpose and with what technique determined respiratory excursion of the lungs.

II.



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.

14

5.

Comparative percussion of the lungs. Indicate main tasks of this method and show the technique of its performance.

6.

Topographic percussion of the lungs. Indicate main tasks of this method and show the technique of its performance.

7.

Determine the active mobility of the lower edge of the lungs, evaluate diagnostic value of symptoms.

III.


1.

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.

2.

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.

3.

“Cobbler chest” also called: a) emphysematous; b) paralytic; c) rachitic; d) funnel.

4.

Patients with grave diseases should be percussed in: a) standing position; b) sitting position; c) lying position;

15

d) does not matter.

5.

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.

6.

Lower border of the right lung by parasternal line localized: a) 5 th interspace; b) 6 th interspace; c) 7 th interspace; d) 8 th interspace.

7.

What kind of blood is typical for hemoptysis? a) bright red; b) dark brown; c) black; d) with the content of food.

8.

Pigeon chest is typical for: a) emphysema of the lungs; b) rheumatoid arthritis; c) pneumosclerosis; d) rachitis.




16

Topic 4

AUSCULTATION OF THE LUNGS

THE MAIN AND ADDITIONAL BREATH SOUNDS. DIAGNOSTIC VALUE

LABORATORY AND INSTRUMENTAL METHODS OF EXAMINATION

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.

11.

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.

12.

Examination of biological specimens: collection of the sputum, thoracocentesis, bronchoscopy.

13.

Sputum analisis: macroscopic, microscopic and bacterioscopic studies.

14.

Study of the pleural fluid. Transudates and exudates.

15.

Methods of functional studies. Tests of ventilatory function.

I.


1.

Types of auscultation and their characteristic. General rules for auscultation of lungs.

What areas should be listened? What main respiratory sounds do you know?

17

2.

Please describe vesicular breathing. 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?

3.

What is the physiology of the formation of bronchial breathing? What is the pathophysiology of formation of pathological bronchial breathing? What is amphoric respiration? What is bronchovesicular or mixed breathing?

4.

What types of added respiratory sounds do you know? What is mechanism and site of dry rales generation? On which types are divided dry wheezing?

5.

What is mechanism and site of moist rales generation? What types of moist rales do you know? What is mechanism of crepitation generation? What is mechanism of pleural friction sound generation? What is different between crepitation and pleural friction sound?

6.

Wheezes (sibilant rales), characteristics, mechanism of their appearance. Diagnostic meaning of wheezes.

7.

Rhonchi (sonorous rales), characteristics, mechanism of their appearance. Diagnostic meaning of rhonchi.

8.

Crackles (moist rales), characteristics, and mechanism of their appearance. Diagnostic meaning of crackles.

9.

Pleural rubs, characteristics, mechanism of their appearance. Diagnostic meaning of pleural rub.

10.

What method is routine for assessing the patients with disorders of the respiratory system?

11.

What method is more sensitive to distinguish small focuses?

12.

What is the physics basement of computer tomography?

13.

What is principle of the pulmonary angiography?

14.

In what cases ultrasound can be helpful for evaluation of pulmonary system disorders?

II.



18

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.


1.

Where appears crepitation: a) in the small bronchi: b) in the large bronchiin; c) in the alveoli; d) in the pleural cavity.

2.

What lung pathology is characterized by coarse bubbling rales: a) dry pleurisy; b) emphysema; c) bronchitis; d) pneumonia; e) cavern.

3.

"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.

19

4.

The routine method for assessing the patients with disorders of the respiratory system is: a) computer tomography; b) ultrasound examination; c) bronchoscopy; d) radiography.

5.

To distinguish small focuses in pulmonary tissue more sensitive is: a) magnetic resonance imaging; b) radiography; c) computer tomography; d) pulmonary angiography.

6.

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.

7.

Single erythrocytes in sputum can be visible in: a) inflammatory process in bronchi; b) lung infarction; c) any sputum; d) tumor endobronchially.

8.

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.

20

9.

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.

10.

How also called vesicular breathing: a) bronchial; b) amphoric; c) alveolar; d) laryngotracheal; e) metallic.

11.

What lung pathology is characterized by dry rales: a) dry pleurisy; b) emphysema; c) bronchitis; d) pneumonia; e) the attack of bronchial asthma.




21

Topic 5

INTERVIEWING AND EXAMINATION OF PATIENTS WITH DISEASES OF THE

CARDIOVASCULAR SYSTEM

PALPATION AND PERCUSSION OF THE HEART. HEART CONFIGURATION



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.

14.

Percussion of the heart. Relative and absolute cardiac dullness. Configuration of the heart.

I.


1.

What are specific and nonspecific complaints in the cardiovascular disease? What is typical to the heart pain?

2.

What are specific sings of the edema in cardiovascular disease? What causes of the syncope do you know?

22

3.

What forced postures in patients with cardiovascular disease are distinguished?

4.

What changes of skin and visible mucosa color in patients with cardiovascular pathology are distinguished? What special features can be found in the inspection of the face in patients with cardiovascular pathology?

5.

What are mechanisms of edema formation in patients with cardiovascular pathology?

6.

Dyspnea in patients with disorders of the cardiovascular system. Palpitation in patients with disorders of the cardiovascular system. Cough in patients with disorders of the cardiovascular system. Hemoptysis in patients with disorders of the cardiovascular system. Edema in patients with disorders of the cardiovascular system. Headache in patients with disorders of the cardiovascular system.

7.

What position is occupied by patients with exudative pericarditis? Why they hold such position? Patients with what pathological condition occupy a sitting position with legs drooping down? What is the name of this position?

8.

Cyanosis, what is it? What are the conditions under which arises cyanosis? Anasarca, what is it? What are the conditions under which arises cyanosis?

9.

What signs can be detected during the inspection area of the heart?

10.

Please describe technique of palpation of heart region. Where is found a normal apex beat? What are causes of the apex beat displacement? What are apex beat properties?

11.

Apex beat. Where is located in norm? Name pathological changes that lead to a change of localization of the apex beat. Symptom of systolic and diastolic trembling.

Where is defined? What pathological changes cause this symptoms?

12.

Configuration of the heart, what is it? Name the pathological conditions when the heart has mitral configuration, and when there is aortic configuration?

13.

What is examination plan of percussion of the heart? How to determine relative and absolute cardiac dullness, configuration of the heart?

14.

What types of heart configuration do you know? How to determine transverse length of the heart and borders of the vascular bundle?

15.

Increase of borders of relative cardiac dullness. Name the pathological conditions that cause it? Decrease of borders of relative cardiac dullness. Name the pathological conditions that cause it?

23

16.

Displacement of the right border of relative cardiac dullness. Name the pathological conditions that cause it? Displacement of the left border of relative cardiac dullness.

Name the pathological conditions that cause it? Displacement of the upper border of relative cardiac dullness. Name the pathological conditions that cause it? Decrease and increase of the area of absolute cardiac dullness. Name the pathological conditions that cause it?

II.



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.

5.

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.

6.

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.

7.

Determine by percussion the vascular bundle, evaluate findings.

8.

Determine by percussion configuration of the heart. Identify normal configuration of the heart.

24

III.


1.

What is the cardialgia: a) pain in the liver; b) pain in the heart; c) feeling of "disruptions" in the heart; d) muscle pain; e) heartbeat.

2.

Anasarca - is: a) edema on the legs; b) edema on the lower back; c) edema on the neck; d) abdominal hydrops; e) edema of the all body.

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.

Edema in patients with cardiovascular failure occurs on:

25

a) lower extremities; b) the face; c) back; d) the eyelids; e) the upper extremities.

6.

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.

7.

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.

8.

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.

9.

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;

26

d) hypertrophy and dilatation of left ventricular; e) mitral valve stenosis.

10.

Increasing area of absolute cardiac dullness observed in case of: a) left-sided pneumothorax; b) emphysema; c) attack of bronchial asthma; d) pneumopericarditis; e) hydropericarditis.




27

Topic 6

AUSCULTATION OF THE HEART. POINTS OF AUSCULTATION

NORMAL HEART SOUNDS, MECHANISM OF THEIR FORMATION


Type of a lesson


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.

I.


1.

What is plan of auscultation of the heart?

2.

Projection of the heart valves on the chest wall. Standard listening point of the heart.

3.

How many and what components have S1? How many and what components have S2?

4.

Third and fourth heart sounds (S3, S4), where we can heard them and under what conditions they appears?

5.

Please describe characteristics of two heart sounds and two pauses between them.

6.

Please describe changes of heart sounds in physiological and pathological conditions.

7.

Increase and decrease of heart sounds (causes).

8.

Both heart sounds increased. Both heart sounds decreased.

9.

At the heart apex a.

increased loudness of the first heart sound

28

b.

decreased loudness of the first heart sound

10.

Over aorta c.

accentuated second heart sound d.

decreased second heart sound

11.

Over pulmonary artery e.

accentuated second heart sound f.

decreased second heart sound

12.

At the base of the sternum g.

decreased loudness of the first heart sound

13.

What is a cause of reduplication and splitting of the heart sounds?

14.

In what conditions we can observe physiological splitting of the heart sounds?

15.

First heart sound a.

physiological splitting b.

pathological splitting

16.

Second heart sound a.

physiological splitting b.

pathological splitting

17.

What additional sounds can be auscultated over heart? Describe three-sound rhythms and systolic clicks.

18.

Three-sound rhythm (indicate the characteristics of following additional soud) a.

Triple rhythm b.

Gallop rhythm c.

Systolic clicks

II.



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.

29

III.


1.

S

1

occurs during: a) ventricular systole; b) ventricular diastole; c) auricular systole; d) auricular diastole; e) dilatation of the left ventricle.

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).

2.

S

2 consists of: 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) S

1

; b) S

2

; c) sound of mitral valve opening; d) S

3

; e) S

4

.

4.

Listening point of left atrioventricular valve located in: a) heart apex; b) 2 nd intercostal space to the right of the sternum; c) to the left of the sternum at the 3 rd costosternal articulation;

30

d) 2 nd 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 S

2

at the aortic valve typical for: a) atherosclerosis of the aorta; b) aortic defects; c) syphilitic mezoartryt; d) hypertension; e) hyperthyroidism.




31

Topic 7

CARDIAC MURMURS. FORMATION AND MECHANISM OF MURMURS


ECHOCARDIOGRAPHY



Contents:

1.

The plan of examination.

2.

Cardiac murmurs. Organic cardiac murmurs. Systolic and diastolic murmurs.

3.

Functional and organic murmurs.

4.

Systolic and diastolic murmurs.

5.

A configuration of the cardiac murmurs.

6.

The duration of the cardiac murmurs.

7.

The location and radiation of the cardiac murmurs. Best auscultator areas of cardiac murmurs.

I.


1.

Cardiac murmurs.

2.

Please describe systolic murmur which occurs with appearance of aortic stenosis.

3.

Please describe systolic murmur which occurs with appearance of pulmonary stenosis.

4.

Please describe diastolic murmur which occurs with appearance of aortic regurgitation.

5.

Please describe diastolic murmur which occurs with appearance of pulmonary regurgitation.

6.

How can you explain the mechanisms of cardiac mutmurs?

7.

What is difference between decrescendo murmur, crescendo murmur, diamond-shaped and plateau murmur?

8.

What is systolic and diastolic murmur? Which types of duration of murmurs do you know?

9.

Please describe the specificity of duration and radiation of cardiac murmurs.

32

10.

Which valves disorders can cause the systolic and diastolic murmurs?

11.

Which positions of the transducer can be useful to examine the heart?

12.

What is ejection fraction of the left ventricle? What methods of the assessment of the ejection fraction of the left ventricle do you know?

13.

How do you understand diastolic function of the left ventricle?

14.

Specify which parameters determined by echocardiography.

15.

Which you know ways of performing echocardiography, what their values.

16.

Where sensors are installed during echocardiography.

II.



Auscultation of the heart: specify examination plan of auscultation. Show the

III.

Control Test of theoretical knowledge. technique of auscultation (five standard listening points of the heart). Tell about the heart murmurs.

1.

Listening point of pulmonary valve located in: a) in the 2 nd intercostal space 1-1,5cm to the left of the sternum; b) heart apex; c) 2 nd intercostal space to the right of the sternum; d) 2 nd intercostal space to the left of the sternum; e) base of the xiphoid process.

2.

Increased both heart sounds typical for: a) pulmonary emphysema; b) pleural effusion on the left; c) excess of subcutaneous fat; d) anemia; e) myocardial infarction.

33

3.

Decrease S

1

at the apex of the heart typical for: a) myocarditis; b) insufficiency of the left atrioventricular valve; c) thyrotoxicosis; d) emphysema; e) hard physical exertion.

4.

Decrease S

2

at the aortic valve typical for: a) atherosclerosis of the aorta; b) aortic defects; c) syphilitic mezoartryt; d) hypertension; e) hyperthyroidism.

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.

34

Topic 8

EXAMINATION OF PERIPHERAL PULSE. DIAGNOSTIC VALUE

EXAMINATION OF BLOOD PRESSURE. DIAGNOSTIC VALUE

ELECTROCARDIOGRAPHY (ECG) AS A METHOD OF EXAMINATION OF

CARDIOVASCULAR SYSTEM


Contents:

1.

Study of arterial pulse: palpation, symmetry, rhythm, rate, tension, volume.

2.

Blood pressure measurement. Classification of hypertension by blood pressure level.

3.

Echocardiography: modalities, standard positions. Clinical application of the echocardiography.

4.

Basic physiological principles of ECG.

5.

Physiology of cardiac conduction system, cardiac automaticity, Cardiac conductivity function.

6.

Graduation of the ECG paper. Speed of ECG paper.

7.

The ECG leads.

8.

The triangle of Einthoven. The electrical axis of the heart.

9.

The waves and intervals on ECG.

10.

The algorithm of reading of normal ECG.

11.

Diagnostic ECG sings of atrial and ventricular hypertrophy.

I.


1.

On which arteries pulse can be assessed? Demonstrate the technique of pulse examination.

2.

Describe the characteristics of the pulse: symmetry, rhythm, rate, correlation of the pulse and heart rate, tension, filling, size, speed and pulse wave shapes.

3.

What causes of an irregular pulse do you know? What can you estimate indirectly according to the pulse tension? What can be causes of tachycardia and bradycardia?

4.

What method of using for measuring of blood pressure?

35

5.

What reading is systolic and what is diastolic BP? What is optimal and high normal

BP?

6.

Specify in which normal conditions (no pathological changes of the body) possible changes in the level of blood pressure (may increase or decrease).

7.

Indicate pathological changes in the body that lead to the appearance of hypotension.

Indicate pathological changes in the body that lead to the appearance of hypertension.

8.

What vessels are used for the study of pulse? Which are the cause of various of pulse during the measurement it in both hands

9.

Indicate normal pulse rate. Under what normal conditions pulse rate may be increased or reduced

10.

Indicate pathological causes leading to increased arterial pulse.

11.

Indicate pathological causes leading to decreased arterial pulse.

12.

Cardiac conduction system, please list the structural elements that it includes.

Sinoatrial (SA) node, please list its function and location. Atrioventricular (AV) node please lists its function and location. Bundle of His please list its function and location.

13.

Cardiac automaticity function. Please indicate the main accents of this function of the heart.

14.

Please indicate the main accents of this function of the heart. Depolarization. What this means? Repolarization. What this means? Refractoriness. What this means?

15.

What you know about ECG paper? On what speeds can be made ECG recording?

16.

What (bipolar) Standard leads you know? Please list. What (unipolar) Augmented leads you know? Please list. What (unipolar) Chest leads you know? Please list.

17.

Please indicate placement of electrode in Standard Limb lead. Please indicate placement of electrode in Standard Chest lead.

18.

Please indicate normal position of the heart direction. What values of R wave amplitude in normal position of the heart?

19.

Please indicate horizontal position of the heart direction. What values of R wave amplitude in horizontal position of the heart?

20.

Please indicate vertical position of the heart direction. What values of R wave amplitude in vertical position of the heart?

36

21.

What reflects P wave, indicate its main characteristics?

22.

What reflects P-Q interval, indicate its main characteristics?

23.

What reflects QRST complex, indicate its main characteristics?

24.

What reflects Q wave, indicate its main characteristics?

25.

What reflects R wave, indicate its main characteristics?

26.

What reflects S wave, indicate its main characteristics?

27.

What reflects QRS interval, indicate its main characteristics?

28.

What reflects ST segment, indicate its main characteristics?

29.

What reflects T wave, indicate its main characteristics?

30.

What reflects Q-T interval, indicate its main characteristics?

31.

What reflects T-P interval, indicate its main characteristics?

32.

What included interpretation of the ECG? Please list.

II.



1.

Palpation of the pulse. Show the technique of palpation. Identify the main characteristics of pulse and their normal manifestations.

2.

Blood pressure measurements. Specify examination plan of blood pressure measurement. Identify normal findings of blood pressure.

3.

Blood pressure measurements. Specify examination plan of blood pressure measurement. Identify common abnormalities of blood pressure.

4.

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

37

e) Presence of the four ECG syndromes: arrhythmias, conduction disturbances, atrial or ventricular hypertrophy, myocardial injury (ischemia, injury, necrosis, scar).

III.


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.

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;

38

e) AVF.

5.

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.

6.

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; c) 2-3 times in different days during 1 week; d) 2-3 times in one day.

7.

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).




39

Topic 9

EXAMINATION OF PATIENTS WITH DISEASES OF THE DIGESTIVE SYSTEM

DIAGNOSTIC VALUE OF QUESTIONING AND EXAMINATION OF PATIENTS,

PALPATION AND PERCUSSION OF THE ABDOMEN

INSPECTION, PALPATION AND PERCUSSION OF THE LIVER

MAIN LABORATORY AND INSTRUMENTAL METHODS OF EXAMINATION IN

GASTROENTEROLOGICAL PRACTICE



I.


1.

Diarrhea. Describe the symptom, indicate reasons of appearance? Acute diarrhea.

Describe the symptom, indicate reasons of appearance? Chronic diarrhea. Describe the symptom, indicate reasons of appearance? Inflammatory diarrhea. Describe the symptom, indicate reasons of appearance? Osmotic diarrhea – describe the symptom, indicate reasons of appearance? Secretory diarrhea. Describe the symptom, indicate reasons of appearance?

2.

Constipation. Describe the symptom, indicate reasons of appearance? What Drugs may lead to constipation?

3.

Causes of weight gain? Causes of weight loss?

4.

What it is melena? When occurs? Indicate causes o f upper gastrointestinal bleeding.

Indicate causes o f lower gastrointestinal bleeding.

5.

On what signs we pay attention during the abdominal inspection?

6.

Indicate the most common causes of protuberant abdomen? Provide main symptoms of gas in the abdomen. Provide main symptoms of tumor in the abdomen. Provide main symptoms of fat in the abdomen. Provide main symptoms of pregnancy. Provide main symptoms of ascitic fluid in the abdomen.

7.

Indicate main features of localized bulges in the abdominal cavity such as umbilical hernia. Indicate main features of localized bulges in the abdominal cavity such as incisional hernia. Indicate main features of localized bulges in the abdominal cavity

40

such as epigastric hernia. Indicate main features of localized bulges in the abdominal cavity such as lipoma.

8.

What pathological changes can be found thanks to Radionuclide studies? What bodys of digestive system we can inspect using Radionuclide studies?

9.

What pathological changes can be found thanks to Angiography? What bodys of digestive system we can inspect using Angiography?

10.

What pathological changes can be found thanks to Computed tomography? What bodys of digestive system we can inspect using Computed tomography?

11.

What pathological changes can be found thanks to Magnetic resonance imaging? What bodys of digestive system we can inspect using Magnetic resonance imaging?

12.

What pathological changes can be found thanks to Ultrasonography? What bodys of digestive system we can inspect using Ultrasonography?

13.

What pathological changes can be found thanks to Cholecyctography? What bodys of digestive system we can inspect using Cholecyctography?

14.

What you know about bilirubin, about what indicates change of its levels in the blood?

15.

What you know about protein (total protein and its fraction), about what indicates change of its levels in the blood?

16.

What liver enzymes are examined in the blood?

II.



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.

41

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.

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.

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.


1.

Specify the basic characteristic signs of damage the esophagus:

42

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.

3.

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.

4.

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?

5.

From what of the intestines segment begins deep palpation by Obraztsov-Strazhesko: a) cecum; b) the transverse colon; c) appendix cecum; d) the sigmoid colon;

43

e) ascending colon?

6.

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.

7.

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?

8.

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.




44

Topic 10

EXAMINATION OF PATIENTS WITH DISEASES OF THE BLOOD

INSPECTION, PALPATION AND PERCUSSION OF THE SPLEEN

CLINICAL ANALYSIS OF BLOOD. DIAGNOSTIC VALUE

THE MANIFESTATIONS OF BLOOD DISEASES


I.


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.

9.

Erythrocytes. What it is? Describe their meaning? Indicate normal values of this index.

10.

Erythrocytosis and erythrocytopenia. What it is? Under what conditions these pathological states arise?

11.

Hemoglobin. What it is? Describe its meaning? Indicate normal values of this index.

12.

Color index. What it is? Describe its meaning? Indicate normal values of this index.

13.

Leukocytes. What it is? Describe its meaning? Indicate normal values of this index.

14.

Leukocyte formula. Describe its meaning? Indicate normal values of this index.

15.

Indicate clinical significance o f leukocyte formula changes?

16.

Neutrophilia. Please indicate pathological factors that cause it? Leukemoid reactions.

What it is and what pathological factors cause it? Neutropenia. What it is? Please

45

indicate pathological factors that cause it? Eosinophilia and Eosinopenia. What it is?

Please indicate pathological factors that cause it? Basophilia. What it is? Please indicate pathological factors that cause it? Monocytosis. What it is? Please indicate pathological factors that cause it? Lymphocytosis and Lymphopenia. What it is?

Please indicate pathological factors that cause it?

17.

Indicate clinical significance o f thrombocytes changes? Indicate normal values of this index.

18.

Erythrocyte sedimentation rate (ESR). Indicate clinical significance of the Erythrocyte

Sedimentation Rate. Indicate normal values of this index.

19.

Please indicate clinical significance o f hemoglobin changes.

20.

Hyperchromia, Hypochromia and Normochromia. What it is? Please indicate pathological factors that cause it?

21.

Leukocytosis and Leukopenia. Please indicate pathological and physiological factors that can cause them?

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.

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.

Normal values of erythrocytes count in women: a)

3.8±1.0 x 10 12 /1; b) 4.8±1.0 x 10 12 /1; c) 6.8±1.0 x 10 12 /1; d)

8.8±1.0 x 10 12 /1.

46

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; d)

15.5±2.5 g/dl.

3.

Normal value of Eosinophils: a) 0.02-0.3 x 10 9 /1(0.5-5 %); b) 0-0.065 x 10 9 /1 (0-1 %); c) 1.2-3.0 x 10 9 /1(19-37%); d) 0.09-0.60 x 10 9 /1 (3-11 %).

4.

Normal number of thrombocytes (platelets) is: a) 100.0-220.0 x 10 9 /l ( 180000-320000 per 1 µl); b) 120.0-320.0 x 10 9 /l ( 180000-320000 per 1 µl); c) 180.0-320.0 x 10 9 /l ( 180000-320000 per 1 µl); d) 200.0-420.0 x 10 9 /l ( 180000-320000 per 1 µl).

5.

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.


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:


47

Topic 11

QUESTIONING AND EXAMINATION OF PATIENTS WITH DISEASES OF THE

URINARY SYSTEM. PALPATION OF THE KIDNEYS.

PASTERNATSKY’S SYMPTOM. DIAGNOSTIC VALUE.



I.


1.

The main complaint of the urinary system.

2.

Specify character and location of pain if the patient has pyelonephritis.

3.

Indicate character and location of pain if the patient has cystitis.

4.

Indicate known to you signs and causes of polyuria

5.

Indicate known to you the basic signs of edema in patients with disorders of the urinary system.

6.

Specify character and location of pain if the patient has glomerulonephritis.

7.

Indicate character and location of pain if the patient has urethritis

8.

Indicate known to you signs and causes of anuria.

9.

Indicate known to you secondary complaints that may occur in patients with disorders of the urinary system.

10.

Inspection of the patient.

11.

Pasternatsky symptom: specify technique and purpose of this method.

12.

Palpation accordingly to S. Botkin: indicate technique and the main purpose of this method.

II.



1.

Conduct questioning of patients with disorders of urinary system. Identify the main complaints.

48

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.


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; 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;

49

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?




50

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

100……….85

84…….…70

69…….…50

49…….….0

Evaluation of a four-system

"Excellent" – 5

"Good" – 4

"Satisfactory" – 3

"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.

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Metoduchka_II_kyrs._stomat._Modul_1

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