Methodological Instructions to Lesson № 6 for Students
(practical lesson-5 hours)
Themes:
1. Inquiry and general inspection of patients with diseases of digestive tract. Inspection and superficial palpation of an abdomen, percussion and auscultation of an abdomen. Methods of recognition of ascites.
2. Deep sliding methodical palpation of parts of intestine and a stomach, a liver, a spleen and kidneys.
3. Examination of patients with digestive tract disorders.
Place of training: educational rooms, hospital wards.
Aim: To possess methods of inquiry and inspection of patients with gastrointestinal problems. To be able to perform superficial palpation, percussion and auscultation of an abdomen, to analize obtained results. To possess methods of detection of ascites. To be able to reveal symptoms typical for gastrointestinal pathology and to group them into syndromes.
To acquaint students with the method of deep sliding methodical palpation by Obraztsov and Strajesko: parts of intestine, a stomach, a liver, a spleen and kidneys. To be able to analyse data obtained. To be able to make interpretation of data of instrumental and laboratiry examination (of stomach secretion, duodenal content, feces)to know their meaning for diagnostics of diseases of digestive system
Professional Motivation:
Inquiry of a patient and inspection of patient’s abdomen posess a significant place in diagnostics of digestive system disorders. The correct correlation of data obtained by patient’s inquiry, inspection of his abdomen, its palpation, percussion and auscultation lets us to reveal main syndromes of the pathology. It is very important also to render in-time and correct emergency care in the case of pain in abdominal region, vomiting, stomach bleeding and other acute conditions.
A student must lay hands on the technique of deep sliding methodical palpation of liver, spleen and buds, by percussional determination of scopes of liver after Obraztsov and Kurlov. The diseases of organs of digestion often appear for the people of capable of working age and are reason of temporal or permanent loss of capacity. It is determined, from one side, by chronic motion of many diseases, from the second – the diseases of the gepatobiliary system are accompanied the row of changes of exchange of matters, violation of the functional state of other systems which influence on an organism sick of vtsilomu.
Considerable successes with gastroenterologies predefined of implementation of new instrumental methods inspections which promote exactness of diagnostics.
І. Practical work – 900-1200
Visual Aids and Material Tools: Tables, slides, compact-disk
Methodics of Student s Practical Activitiy:
І. Inquiry and general inspection of patients with diseases of digestive organs
Work `1. Students carry out inquiry of patients with diseases of digestive system, the reveal main complaints and actty out general inspection.
Work 2. Students record obtained data as a part of case history.
ІІ Inspection and superficial palpation of an abdomen, percussion and auscultation of an abdomen. Methods of detection of ascites
Work 1. Students perform inspection of an abdomen in both upright and horisontal position of the patient to determine abdominal configuration, presence of venous collaterals, pigmentation, scars, visible peristalsis and antiperistalsis, they measure abdominal girgle.
Work 2. After inspection students carry out percussion of the abdomen and try to reveal zones of dull sound. Students carry aout auscultation of the abdomen.
Physical examination of a patient
“percussion of a liver ”
The list of necessary skills
1.Friendly facial expression and smile.
2.Gentle tone of speech.
3.Greeting and introducing
4.Physical examination of a patient
· Taking patient’s concent for examination
· Prepare for the examination (natural sufficiernt lighting in the room, warm clean hands, cut nales, dermograph, ruler)
· Execution of patient’s examination and report of obtained results (determine liver lower border on the right enterior axillary line, midclavicular line, median mile. Determine sizes of the liver by Kulov’s method)
5.Explain to the patient results of his/her examination correctly and accessibly
6.Conversation accomplisment.
Next stage of ecxamination is superficial palpation of an abdomen. Pay atantion on condition of scin and subcutaneous fat tissue, possible hernia and rectus abdominis muscles divergention, presence of zones of skin hypersesnitivity, pain in abdominal muscles, muscular resistance, muscular defance and symptoms of peritoneal irritation.
Obtained data are to be recorded as a part of case history.
IIІ. Deep sliding methodical palpation of parts of intestine and a stomach. The Instrumental and laboratory methods of research of gastro-intestinal tract.
Work 1. To conduct sliding methodical palpation of intestine, stomach and a liver.
To define the sizes of a liver after Obraztsov and after Kurlov.
Physical examination of a patient
“palpation of intestine by Vasylenko-Strajesko method”
The list of necessary skills
1.Friendly facial expression and smile.
2.Gentle tone of speech.
3.Greeting and introducing
4.Physical examination of a patient
· Taking patient’s concent for examination
· Prepare for the examination (natural sufficiernt lighting in the room, warm clean hands, cut nales)
· Execution of patient’s examination and report of results obtained during palpation of the abdomen (execute palpation of sygmoid intestine, cecum, ascending and descending colon, trancverse colon)
5.Explain to the patient results of his/her examination correctly and accessibly
6.Conversation accomplisment.
Work 2. Interpretation of the results of laboratory and instrumental examinations.
Students are given results of laboratory examination of stomach and duodenal content, X-ray and ultrasound examinations of digestive tract and give interpretations.
Students¢ Independent Study Program
І Inquiry and general inspection of patients with diseases of digestive organs
1. Method of inquiry of patients with gastrointestinal problems.
2. How to reveal main complains and to perform general inspection
ІІ Inspection and superficial palpation of an abdomen, percussion and auscultation of an abdomen. Methods of detection of ascites
1. The method of inspection of an abdomen amd its diagnostic value.
2. Пpercussion and auscultation of abdominal wall, methods of ascites recognition..
Superficial palpation of abdominal wall (condition of skin, subcutaneous fat, presence of hernia and rectus abdominis muscles divergention, presence of painful zones, determination of muscular resistance and muscular guard.
IIІ. Deep sliding methodical palpation of departments of intestine and stomach and aliver. The Instrumental and laboratory methods of research of shlunkovo-kishkovogo highway.
1. A method of deep sliding palpation after the method of V. Obraztsov and N.Strazhesko.
2. Sequence of palpation of organs of abdominal region;
3. Palpational description of different departments of intestine (location, mobility, consistency, sizes, state of surface, grumbling).
4. Methods of determination of low bound of stomach;
5. Description of large and small curvature of stomach, palpation of pylorus.
6. Method of palpation of liver, description of its edge.
7. A method of percussion of liver is after Obraztsov and Kurlov.
8. To learn the features of anamnesis for patients with pathology of the gepatobiliary system.
9. To learn the signs of symptoms and syndromes of diseases of liver and biliary ways, which it can find out at the review of patient.
10. To learn the diagnostic value of laboratory and instrumental methods of inspection of organs of the gepatobiliary system.
11. To learn the changes of macroscopic properties of gastric juice, duodenal maintenance, excrement.
12. To learn a conducting method and shows to the instrumental methods of inspection
ІІ. Seminar Discussion of pracrical work – 1230-1400 (2 hours)
Examples of real-life situations.
1. Patient A. admitted to the hospital with the complains of a vomiting with admixted of blood, tarry stool. What can you say about diagnosis ?
2. Patient R. admitted to the hospital with the complains of a night pain in the epigastric region, heartburn, regurgitation. He is ill several years. The exacerbations of disease at vernal and autumnal season. Last aggravation tie together with long-term dry meals. What questions necessary more accurate? What can you say about diagnosis?
- At research in a patient the enlarged abdomen was revealed with amplate venous vessels on the frontal abdominal wall. What cause of enlarged of abdomen?
- The abdomen is of the board-like form. At superficial palpation the sharp strain of an abdominal wall muscles is revealed. What pathology can be suspected in the patient?
5. At palpation of sigmoid bowel the got results: width close 1см, very dense, hilly dense education. What does this testify about?
- Patient C., 47 years old, complains of pain during palpation of all parts of large intestine. What do these findings testify about?
7. At palpation of sigmoid bowel at a patient., 25 years, it is exposed that a sigmoid bowel wide
8. In a patient a smooth dense painless formation was found in left hypochondrium. What may it be?
9. Patient D., 35 years old. When his kidneys were palpated in vertical position the lower pole of right kidney was possible to palpate. The kidney surface is smooth, painless, dense. Left kidney is not palpated. What do this symptoms indicate on?
- Patient M., 24 years old, complains on periodic pain in right hypochondrium with an irradiation in a right shoulder. An abdomen is soft, sickly in right hypochondrium, De Mussy–Georgievsky, Ortner‘s, Obraztsov–Murphy, and Vasilenko‘s symptoms are positive.The Blumberg symptom is negative. Previous diagnosis? What additional methods must be appointed for confirmation of diagnosis?
- Sick I, 20 years old, is ill chronic cholecystitis. At the duodenal probing is not the В- portion. What this testifies about? Tactic?unsickly
Answers to real-life situations:
- Gastric hemorrhage.
- Relieving factor (food intake, vomiting).Can suspected duodenal ulcer.
- Ascites.
- Perforated gastric ulcer. Peritonitis.
- Tumor of sigmoid bowel.
- About a diffuse colitis.
- Norm.
- Spleen or left kidney
- Nephroptosis of right kidney of the I stage.
- Сhronic cholecystitis. General analysis of blood, urines. Biochemical blood analysis. Duodenal probing.Cholecystography, ultrasonic examination
- About a pathological process of bile ducts.
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§ Discussion of theoretical questions
Final level of knowledges and skills
Students must know:
1. Main complaints of patients with digestive organs diseases.
2. Main signs of diseases of gastriontestilal tract are possible to reeveal by inspection of a patient.
3. Rules of conducting of palpation of abdomen, moments of deep methodical palpation;
4. sequence of palpation of abdomen.
5. Method of palpation of intestine, a stomach; сharacteristic of different departments of intestine.
6. Method of deep palpation of liver.
7. Воrders of liver.of healthy man
8. Metods of percussive determination of liver edges according to Obraztsov and Kurlov.
9. Method of taking away of gastric content for research. Stimulators of gastric secretion.
10. method of carry out of the duodenal probing.
11. preparation and carry out of gastroscopy, colonoscopy, rectoromanoscopy.
12. Roentgenologic methods of inspection of organs of digestive system.
13.
Students should be able to:
1. Carry out inquiry of patients with gastrointestinal disorders.
2. To reveal main symptoms typical for diseases of gastrointestinal tract..
3. Carry out general inspection of patients with gastrointestinal disorders.
4. To determine diagnostical value of obtained results.
5. to perform palpation of large intestine and stomach;
6. to take characteristic of different departments of intestine.
7. to perform palpation of liver.
8. to determine by percussion of liver edges according to Obraztsov and Kurlov.
9. to assess orally data obtained by inspection.
10. to perform a patient for laboratory and instrumental methods of research.
11. make interpretation data of laboratory and instrumental methods of research.
12.
ІІІ. Test control of students’ knowledges – 1400-1500 (1 hour).
Referenses:
1. Propedeutics to internal diseases. – Vinnytsya : Nova knyha publ., 2011 .P. 1 : Diagnostics / O. N. Kovalyova, T. V. Ashcheulova. – 2nd ed. – 2011. – 424 p. : fig., tab.
2. Propedeutics of internal medicine in questions and answers : educational textbook / O.V. Pishak, O. V. Glubochenko, N. M. Malkovych. – Вижниця : Черемош, 2011. – 448 с.
3. Barbara Bates. A Guide to Physical Examination and History Taking. 11th Edition, 2012.J.B.Lippincott Company. Philadelphia – PP. 329-344, 346-357.
4. Douglas G., Nicol F., Robertson C. Macleod’s Clinical Examination.12th edition , 2007. PP. 154-180.
5. Vasylenko V. Propaedeutics of internal diseases. Mosow, 1987.- PP. 332-385, 394-438, 436-464.
6. Practical classes materials.
Additional:
1. Thompson J., Willson S. Health assessment iursing practice. 4th edition, 2008. – PP. 437-467.
2. Short Textbook of Medical Diagnosis and Management (Third Edition). Mohammad Inam Danish. – Pakistan, 2002. PP. 11-16, 89-101..
3. Bogolubov I. Internal diseases. Moskow, 1987.- PP. 206-238.
Prepared by N. Bilkevych
Is addopted at the chair sitting 07. 06. 2013., Minutes № 11
