Methodological Instructions to Lesson № 2 for Students

(practical lesson-6 hours)

 

Themes: 1. Complaints, anamnesis and general inspection of patients with pathology of respiratory system. Physical methods of examination: percussion and auscultation of lungs. Physical methods of examinaion. Percussion and auscultation of lungs. Laboratory and instrumental methods of examination of respiratory system.

2. Inquiry and general inspection of patients with digestive system disorders. Physical methods of examination of gastrointestinal organs: palpation of an abdomen. Supplementary methods of examination of digestive organs. Main syndromes in diseases of respiratory and digestive system.

Place of training: educational rooms, hospital wards.

          Aim:  To be able to reveal signs of pathology of respiratory and digestive systems at inquiry of a patient, to use general inspection for recognition  of a disease. To render emergency care measures in asphyxia, hemopthysis, lung and gastrointestinal bleeding, acute abdomen.

  

            Professional Motivation:

Systemic examination of a patient with disease of respiratory organs lets us to determine syndromal and nozologic diagnosis. In this process inspection, palpation and percussion are of great diagnostic value. It is not enough only to perform their technique but in is necessary to make correct interpretation of findings. In practical activity of a doctor percussion is a very informative method of diagnostics. Inculcation of the method had begun with works of V.Obrastsov and F. Yanovsky.

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 – 9⁰⁰-13⁰⁰ (4 hours)

Visual Aids and Material Tools: Tables, slides, compact-disk

  Methodics of Student s Practical Activitiy:

І. Inquiry, general inspection of patient with pathology of cardiovascular system. Physical methods of examination: percussion and auscultation of a heart. Heart sounds and murmurs. Laboratory and instrumental methods of examination of cardiovascular system. Main cardiological syndromes. Emergency care in sudden heart arrest, collaps, acute pain in heart region.

Work 1. Students perform inquiry of a patient independently according to the Scheme of Case History. They determine main and secondary complaints. After that students perform static and dynamic inspection, palpation of patient’s chest under the teacher’s control.

Work 2. Under the teacher’s control students perform inspection, palpation of patient’s chest, comparative and topographic  percussion of the patient’s chest, auscultation of lungs  and make interpretation of obtained data

Work 3. Students prescribe obtained results as a part of a case history.

ІІ. Inquiry and general inspection of gastroenterological patients. Physical methods of examination of gastrointestinal organs: palpation of an abdomen. Supplementary methods of examination of digestive organs. Main syndromes in gastroenterology Changes in oral cavity in diseases of digestive organs. Tactics of a doctor-dentist in acute pain in abdominal region.

Work `4. Students carry out inquiry of patients with diseases of digestive system, the reveal main complaints and  actty out general inspection.

Work 5. 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 6. 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 7. After inspection students carry out percussion of the abdomen and try to reveal zones of dull sound. Students carry aout auscultation of the abdomen.

 

Students¢ Independent Study Program

І. Inquiry, general inspection of patient with pathology of cardiovascular system. Physical methods of examination: percussion and auscultation of a heart. Heart sounds and murmurs. Laboratory and instrumental methods of examination of cardiovascular system. Main cardiological syndromes. Emergency care in sudden heart arrest, collaps, acute pain in heart region.

1. Complaints of a patient with diseases of bronchi or lungs. Peculiarities of the history of present illness.

2.     Signs revealed by general inspection of patients with diseases of bronchi or lungs.

3.     Sequence and method of static and dynamic inspection of a chest. Determination of the type and shape of a chest, type, rhythm of breathing and respiratory rate. Diagnostic meaning

4.     Sequence and method of palpation of a chest. Investigation of chest elasticity and vocal fremitus. Diagnostic meaning.

5. Physical fundamentals of percussion. Rules, method and technique of percussion. Types of mediate and immediate percussion.

6.  Mechanism of creation of dull, tympanic and resonant sounds.

7.  Rules of performance of comparative percussion.  Diagnostic meaning of comparative percussion

8. Rules of performance of topographic percussion.  Determination of height of lungs apexes, diagnostic value.  Method of determination of Kroenig’s area, diagnostic value.
9.   Determination of lower lung border position, its mobility, diagnostic value.
10.   Physical basis of auscultation. Types of auscultation, their prevalence and faults. Rules, technique and devices for auscultation.
11.   Mechanism of creation of vesicular and bronchial breathing in a healthy individual.
12.   Change of intensity (wakening and intensification) of vesicular breathing in physiological and pathological conditions.
13.   Harsh breathing, its origin, diagnostic value.
14.   Conditions necessary for creation of pathological bronchial breathing and its diagnostic value.
15. Types of dry rales and mechanism of their origination. Diagnostical value.
16. Types of moist rales and mechanism of their origination. Diagnostical value.
17. What is crepitation? Which pathological conditions crepitation is typical for?
18. Auscultatory peculiarities of pleural friction sound.
19. What is bronchophony?
20.  Instrumental methods of examination in pulmonology, Their diagnostic value.
21.  Laboratory methods of examination in pulmonology, Their diagnostic value.

ІІ  ІІ. Inquiry and general inspection of gastroenterological patients. Physical methods of examination of gastrointestinal organs: palpation of an abdomen. Supplementary methods of examination of digestive organs. Main syndromes in gastroenterology Changes in oral cavity in diseases of digestive organs. Tactics of a doctor-dentist in acute pain in abdominal region.

1. Method of inquiry of patients with gastrointestinal problems.
2. How to reveal main complains and to perform general inspection

3.     The method of inspection of an abdomen amd its diagnostic value.

4.     Пpercussion and auscultation of abdominal wall, methods of ascites recognition..

5. A method of deep sliding palpation after the method of V. Obraztsov and N.Strazhesko.
6. Sequence of palpation of organs of abdominal region;
7. Palpational description of different departments of intestine (location, mobility, consistency, sizes, state of surface, grumbling).
8. Methods of determination of low bound of stomach;
9. Description of large and small curvature of stomach, palpation of pylorus.
10. Method of palpation of liver, description of its edge.
11. A method of percussion of liver is after Obraztsov and Kurlov.
12. To learn the features of anamnesis for patients with pathology of the gepatobiliary system.
13. 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.
14. To learn the diagnostic value of laboratory and instrumental methods of inspection of organs of the gepatobiliary system.
15. To learn the changes of macroscopic properties of gastric juice, duodenal maintenance, excrement.

16.  To learn a conducting method and shows to the instrumental methods of inspection

 

ІІ. Seminar Discussion of pracrical work – 13⁰⁰-14⁰⁰ (2 hours)

Examples of real-life situations.

1.     Data of examination of a patient: anterio-posterior and transverse diameters of a chest are nearly equal. How this type of the chest is called?

2.     Patient K. complains of acute pain in the right part of the cheat which intensifies in coughing and deep breathing. What is the mechanism of creation of this pain?

3.     It was revealed by inspection of a patient that the right part of his chest is narrower than the left one. The chest is flat at the anterior axillary line. It is known that the patient has the history of right-sided pleurisy in the past. What is possible cause for changes of chest symmetry?

4.     During the auscultation of the patient are heard moist small-bubble rales lower the shoulder-blade. What are the reasons of the rise of this rales?

5.          During the auscultation of 60-years patient female are heard dry whistling rales on the background of increasing vesicular breathing. What is the mechanism of the rales in this patient?

6.   Patient A. admitted to the hospital with the complains of a vomiting with admixted of blood, tarry stool. What can you say about diagnosis ?

7.      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?

8.       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?

 

Answers on real-life situations:

1.     Emphysematous (barrel-shaped).

2.     Pleural affection. Friction of pleural layers due to their uneveness (fibrin deposits, cancer metastases etc) causes pain.

3.     Shrivering of the lung due to pneumossclerosis, atelectasis or pulmonectomy.

4. Accumulation of the liquid secret in the broncial gap.
5. Accumulation of the viscuos secret in the broncial gap.
6. Gastric hemorrhage.
7. Relieving factor (food intake, vomiting).Can suspected duodenal ulcer.
8. Ascites.

 

§       Discussion  of theoretical questions

 

Final level of knowledges and skills

Students must know:

1.     Complaints of a patient which indicate on respiratory pathology.

2.     Signs of respiratory pathology possible to reveal by general inspection.

3.     Sequence of statical and dynamical inspection of a chest. Types and shapes of a chest. Characteristics of respiratory rate, type and rhythm of breathing. Pathological types of breathing.

4.     Sequence and method of palpation of a chest. Method of investigation of chest elasticity and vocal fremitus. Normal indices.

5. Elements of care of patients with respiratory diseases.  

6.     Method of percussion and its physical basis. History of elaboration and development of percussion.

7.     Types of percussion, general rules of its performance.

8.     Rules, method and technique of comparative percussion of lungs.

9.     Mechanism of creation and characteristics of resonant, dull and thympatic sounds.

10.  10.Rules of performance of topographic percussion of lungs.

11.  Method of determination of height  of lungs apexes, width of Kroenig’s area; data of a healthy individual.

12. Method of determination

                                                    i.     Physical basis of auscultation.

13.  2.Types of auscultation, their prevalence and faults.

14.  3.Rules, technique and devices for auscultation.

15.  4.Mechanism of creation of vesicular and bronchial breathing in a healthy individual.

16.  5.Change of intensity (wakening and intensification) of vesicular breathing in physiological and pathological conditions.

17.  6.Harsh breathing, its origin, diagnostic value.

18.  7.Conditions necessary for creation of pathological bronchial breathing and its diagnostic value.

19. Types of dry rales and mechanism of their creation
20. Types of moist rales and mechanism of their creation?
21. Diagnostical value of rales
22. What is crepitation
23. Which pathological conditions crepitation is typical for?
24. Auscultatory peculiarities of pleural friction sound?
25. What is bronchophony?
26. Method and technique of  pneumotachymetry, its diagnostic value.
27. Method and technique of  spyrography, its diagnostic value.
28. Method and technique of  bronchoscopy, bronchygraphy, their diagnostic value.
29. Indicies obtained by pneumotachymetry and spyrography.
30. Inidcations and contraindications for bronchoscopy.
31. Laboratory examination of sputum, bronchial washings and pleural content, their diagnostic value.
32. Main complaints of patients with digestive organs diseases.
33. Main signs of diseases of gastriontestilal tract are possible to reeveal by inspection of a patient.
34. Rules of conducting of palpation of abdomen, moments of deep methodical palpation;
35. sequence of palpation of abdomen.
36. Method of palpation of intestine, a stomach; сharacteristic of different departments of intestine.
37. Method of deep palpation of liver.

38.  Воrders of liver.of healthy man

39.  Metods of percussive determination of liver edges according to Obraztsov and Kurlov.

40.  Method of taking away of gastric content for research. Stimulators of gastric secretion.

41.  method of carry out of the duodenal probing.

42.  preparation and carry out of gastroscopy, colonoscopy, rectoromanoscopy.

43.  Roentgenologic methods of inspection of organs of digestive system.

 

Students should be able to:

1.     Separate complaints of a patient with respiratory pathology and data of his anamnesis being performing inquiry of the patient.

2.     Perform general inspection of patients with respiratory disease.  To evaluate correspondence of obtained data to norm.

3.     Perform statical and dynamical inspection of a chest. Determine type and shape of a chest, type, depth and rhythm of breathing. To evaluate correspondence of obtained data to norm.

4.     Perform palpation of a chest. To investigate chest elasticity and vocal fremitus. To evaluate correspondence of obtained data to norm.

5.     Perform comparative percussion of lungs anteriorly and posteriorly. To evaluate correspondance of obtained data to norm.

6.     Determine height of lungs apexes anteriorly and posteriorly. To evaluate correspondance of obtained data to norm.

7.     Determine width of Kroenig’s area.  To evaluate correspondance of obtained data to norm.

8.     Determine position of lower lungs borders and their mobility. To evaluate correspondance of obtained data to norm.

9. Make interpretation of data by physical examination of a patient.

10.  Perform of auscultation of lungs.

11.  Determine character of main respiratory sounds.

12.  Reveal changes of intensity (wakening and intensification) of vesicular breathing in physiological and pathological conditions.

13.  Reveal harsh breathing ant to make diagnostic evaluation.

14.  Catch pathological bronchial breathing.

15.  Reveal by auscultation of adventitious respiratory sounds and to make diagnostic evaluation.

16.  Perform bronchophony and to make diagnostic evaluation.

17.  Perform pneumotachymetry and to make diagnostic evaluation.

18.  Perform spyrography and to make diagnostic evaluation.

19.  Evaluate results of bronchoscopy, bronchygraphy.

20. Evaluate results of Laboratory examination of sputum, bronchial washings and pleural content.
21. Carry out inquiry of patients with gastrointestinal disorders.
22. To reveal main symptoms typical for diseases of gastrointestinal tract..
23. Carry out general inspection of patients with gastrointestinal disorders.
24. To determine diagnostical value of obtained results.

25.  to perform palpation of large intestine and stomach;

26. to take characteristic of different departments of intestine.
27. to perform palpation of liver.

28.  to determine by percussion of liver edges according to Obraztsov and Kurlov.

29. to assess orally data obtained by inspection.

30.  to perform a patient for laboratory and instrumental methods of research.

31. make interpretation data of laboratory and instrumental methods of research.

 

ІІ. Test control of students’ knowledges – 14⁰⁰-15⁰⁰ (1 hour).

 

Referenses:

1.     Ivashkin V.T., Okhlobystin A.V. Internal diseases propedeutics. – M., GEOTAR-Media, 2005. – PP. 8-42, 82-122.

2.     Barbara Bates M.D. A Guide to Physical Examination. 12th Edition., 1012 . –  J.B.Lippincott Company. Philadelphia – PP. 115-130, 135-142, 168, 186-189, 194.

3.     Bogolubov I. Internal diseases. Moskow, 1987.- PP. 133-140.

4.     Vasylenko V. Propaedeutics of internal diseases. Mosow, 1989.- PP. 41-53.

5.     Practical classes materials.

6.     Lecture materials.

 

 

Prepared by  N. Bilkevych

Is addopted at the chair sitting  07. 06. 2013р Minutes № 11

Revised