Methodological Instruction to Lesson No 2 (PRACTICAL – 6 Hourse).
THEME:
1. Acute purulent diseases of soft tissues and brush (2 hours).
2. Acute specific surgical infection (2 hours).
3. Necrosis. Gangrene. Ulcers. Fistulas. Extraneous bodies (2 hours).
AIM: To determine the basic local and general clinical symptomes of an acute purulent nonspecific infection (APNI) on its kind, to acquire algorithm of diagnostic search, modern approaches to surgical and conservative treatment, a way of prophylaxis of acute purulent diseases of soft tissues.
To learn a symptomatology of different forms of panaritiums and phlegmons of a hand, to seize their diagnostics. To acquire questions of prophylaxis and modern principles of treatment. To learn to distinguish a symptomatology of osteomyelitis. To acquire modern methods of diagnostics, principles of treatment and prophylaxis of occurrence of purulent diseases of bones and joints.
To learn to distinguish and estimate value of syndromes in early diagnostics of a tetanus, to carry out complex prophylaxis and treatment. To acquaint students with clinical displays of anthrax, a diphtheria of wounds, to methods of prophylaxis and treatment.
To determine the basic clinical, laboratory, roentgenological, endoscopic attributes of disease; to acquire algorithm and principles of diagnostics, treatment of necrosis and ways of their prophylaxis.
PROFESSIONAL MOTIVATION: The surgical infection occupies one of the main places in frame of surgical illnesses. Frequency of wound’s infectious complications achieves 14-20 %. About 40 % of lethal outcomes after operative measures are predetermined by purulent – septic complications. The quantity of patients with extensive purulent processes which result in development of septic conditions has increased.
Hand – the basic organ of work, organ of influence of the person on an environment. Values of a brush in human life induces physicians to concern with special attention to prophylaxis and treatment of its diseases and traumas.
Almost 2 % of the population is sick on acute purulent diseases of a hand and fingers which in polyclinic surgical practice occupy one of the first places. That is all 1/3 patients on different purulent diseases which for the first time have addressed in a polyclinic, make persons with purulent-inflammatory diseases of a hand and fingers.
Purulent diseases of a hand are the important social problem in connection with high frequency of occurrence, a plenty lost operating time, the material inputs connected to payment of a temporary disability, and by adverse results. They demand of the doctor of a profound knowledge and skills in questions of diagnostics and medical tactics.
Necessity of illumination of problem of osteomyelitis caused by insufficient studying of a pathogeny, difficulty of diagnostics, late hospitalization, absence of unity of views on a choice of methods of diagnostics, rational volume of operation, conducting the postoperative period.
The tetanus continues to remain one of 10 main reasons of mors of the population. Extremely long conservation of spores of the originator of anthrax in ground will cause of constant vigilance and knowledge of all aspects of this illness dangerous to the person. Important value gets also the professional factor. At cattlemen, shepherds, workers of the leather industry possible antrax, and at diggers, workers of an agriculture – a tetanus.
The doctrine about necrosis leaves far for borders of surgery and finds the display in everyone without exception to clinical discipline. In an organism of the person constantly there are processes of extinction of cells and their neogenesis: peeling of skin’ cells, an epithelium of the upper respiratory ways, destruction of blood cells. Their place occupy new cells, and function of bodies is not broken. Therefore the deep and correct comprehension of an etiology, a pathogeny, questions of diagnostics and treatment of necrosises is a key to successful struggle against many difficult diseases and allows in certain to carry out a measure their prophylaxis.
BASIC LEVEL:
STUDENTS’ INDEPENDENT STUDY PROGRAM
I. Objectives for Students’ Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
Theme 1.
1. To determine the basic local and general symptomes of an inflammation;
2. To make algorithm of individual diagnostic search;
3. To establish a role of additional methods of research for statement of the diagnosis.
4. To teach anatomico-physiological features of a structure of a hand.
5. Classification, features of clinic and treatment of a panaritium.
6. Classification, surgical approach and treatment of phlegmons of a hand.
Theme 2.
1. The etiology, a pathogeny, clinic, diagnostics and treatments of a tetanus.
2. The reasons of occurrence of feature of clinic and treatment of a wound’s diphtheria.
3. The anthrax. An etiology, a pathogeny, clinic, diagnostics and treatments.
Theme 3.
1. To learn an etiology, a pathogeny and kinds of necrosis
2. A clinical picture, principles of diagnostics and treatment of necrosis.
3. An etiology, a pathogeny of separate kinds of necrosises. Clinic, diagnostics and treatments of gangrenes, ulcers, fistulas.
II. Tests and Assignments for Self – assessment
Multiple Choices.
Choose the correct answer/statement:
1. Patient A., 22 years old, has addressed for medical aid with complaints to a pain of constant character in a site of the right palm which amplifies at movements by fingers, the general delicacy, subfebrile temperature. Objectively: at the basis of the third finger of the right hand on a palmar surface it is marked callosity skins around of which the edema and hyperemia of skin are observed. Through epidermis the purulent exudation is visible. A palpation of a place of defeat morbid, violation of function of fingers and brushes. It is possible to think of what pathology?
A. A hypodermic panaritium of the basic phalanx IIIrd finger of the right hand.
B. A dermal panaritium of the basic phalanx IIIrd finger of the right hand.
C. A phlegmon of median checkered space of the right hand.
D. Subcallosal abscess.
E. Articular panaritium of the IIIrd finger of the right palm.
2. Patient G., 28 years old, has addressed for medical aid with complaints to a pain of constant character in a region of IInd finger of the left hand, infringement of function of a finger. Objectively: on a dorsum of the basic phalanx of the IInd a finger of the left brush the inflammatory infiltrate 1,5×2 сm with a necrotic hinge in center is determined . What disease takes place in the patient?
A. A skin panaritium.
B. A subskin panaritium.
C. A carbuncle.
D. A furuncle.
3. Patient A., 26 years old has received a microtrauma (puncture) of a nail phalanx of the IInd finger of the left hand. 5 days later has addressed in a polyclinic where the diagnosis was exposed: a hypodermic panaritium of nail phalanx of the IInd finger of the left hand. Under what anesthesia it is expedient to execute disclosing of a panaritium?
A. Local infiltrative anaesthesia.
B. An intravenous narcosis.
C. Intraosseous anaesthesia.
D. A conduction anaesthesia by Oberst-Lukachevitch.
E. Intubatioarcosis.
4. Patient M., 60 years old, admit in surgical department 10 days later from the beginning of disease with complaints to pains in a region of the IInd finger of the left hand, infringement of function of a finger, the general delicacy, a fervescence up to 38°С. Objectively: a condition of the patient satisfactory, pulse 90 per 1 minutes, arterial pressure – 120/80 mm Hg., a body temperature 38°С, IInd finger of the left hand dwarfed, deformed, a skin hydropic, cyanotic. In the field of an average phalanx on a palmar surface – is a fistula up to 0,3 sm with purulent discharges. Flexion contracture of finger. Active movements are absent. On a roentgenogram a destruction of a bone of middlephalanx is determined.
What disease at the patient?
A. A bone panaritium.
B. A pandactylitis.
C. Tendovaginitis.
D. A subskin panaritium as “cuff link”.
E. A thecal whitlow.
Real-life situations to be solved:
5. The indication to urgent surgical treatment of an acute thrombophlebitis of superficial veins is:
A. Varicose disease.
B. Posttrombophlebitic syndrome.
C. Young age of patients.
D. Necrotic changes.
E. An acute ascending thrombophlebitis.
6. Trophic ulcers of a medial surface of the lower third of shin arise as complication:
A. Obliterating atherosclerosis.
B. Obliterating endarteriitis.
C. Elephantiasises.
D. An acute thrombophlebitis.
E. Varicose disease.
7. Symptoms of a transmissible ischemia is characteristic for:
A. Posttrombophlebitic syndrome.
B. An obliterating aterosclerosis.
C. An osteomyelitis of a femur.
D. Varicose disease.
E. Embolism of a femoral artery.
8. Violation of blood flow, damage of an intima and a hypercoagulation is a triad of:
A. Bazedov.
B. Pirogov.
C. Virhov.
D. Rokitansky.
Real-life situations to be solved:
9. Patient E., 35 years old, was treated during 3 days concerning a thecal whitlow of the fifth finger of the left hand. On given time of the complaint for a pain in a hand, infringements of a flexion of the Ist and Vth fingers. Objectively: expressed edema and morbidity in the field of the Ist and Vth fingers, rise in temperature up to
10. Patient K., 18 years old, has addressed in surgical department with complaints to a throbbing pain in the field of the thumb of the right hand. From an anamnesis it is known, that 2 days later has received insignificant wound in time of nails paring. Objectively: nails platen is swollen in lateral side, hyperemia is observed. From under it is allocated insignificant quantity of white pus.
Diagnose. Your tactics.
11. Patient E., 56 years old, was operated concerning a fibromyoma of a uterus. On the fourth day after operation there was a acute pain in a site of the right lower extremity, a body temperature is 39° С. During examination the expressed edema of foot, anticnemions and hips. The skin is intense, morbidity on a course of deep veins.
Your diagnosis?
12. Patient N., 64 years, complains of a pain in gastrocnemius muscles at walking through everyone of
How this sign refers to as?
III. Answers to the Self-Assessment:
1. D;
2. D;
3. D;
4. B;
5. E;
6. E;
7. B;
8. С;
9. U-like phlegmon of the left hand.
10. Diagnosis: paronychia of the thumb of the right hand. Tactics: to raise with the help of a scalpel the nail platen for pus discharge.
11. Acute right-side ileofemural thrombosis.
12. Symptom of a transmissible lameness.
IV. References:
Essential reading:
1. Gostishchev V.K. General surgery /The manual. – M.: GEOTAR-MED, 2003. – 220p.
2. Lectures prof. B.I. Dmitriev from
3. Surgery: Text-book for English medium medical students / S.I. Shevchenko, O.A. Tonkoglas, I.M. Lodyana, R.S. Shevchenko. – Kharkiv: KSMU, 2001. – 344p.
4. Kushnir R. Ya. General surgery /Lectures.- Ternopil, Ukrmedknyha, 2005.- 308 p.
5. Butyrsky A. General surgery /The manual.- Simpheropol: publishers CGMU, 2004.- 478 p.
L.Ya. Kovalchuk et al. Doctor (student) – patient models of communication. Ternopil, TSMU, “Ukrmedknyha 2009, 39 p.
6. Materials for practical classes preparing.
7. Materials for lectures preparing.
Further reading:
1. Oxford handbook of clinical surgery / Edited by G.R. Mc Latchie, D.J. Leaper, 2002.- 930 p.
V. Students’ Practical Activities – 9.00 – 12.00
Theme 1.
· Work 1. To distinguish the basic clinical attributes of acute purulent diseases of fingers and hands;
· Work 2. To leaddiagnostics of an acute purulent pathology of fingers and hands on its kind and localization;
· Work 3. To prove the plan of individual treatment (conservative and surgical);
Theme 2.
· Work 3. To distinguish the basic clinical attributes of a tetanus, antrax and diphtheria of wounds;
· Work 4. Methods of specific prophylaxis and treatment of an acute specific surgical infection;
· Work 5. – to prove the plan of individual treatment (conservative and surgical) an acute specific surgical infection;
Theme 3.
– Work 6. To make the individual circuit of diagnostic search, to analyse results of objective research. To determine a role and a place of laboratory and instrumental diagnostics in formation of the diagnosis.
· Work 7. To plan and prove the plan of individual treatment;
· Work 8. To offer the basic methods of prophylaxis of occurrence of necrosis.
Communicative skills: a. Surgical patients have collection of complaints and anamnesis; b. Physical methods of surgical patients examination; c. Report of examination results; d. A receipt of patient is on operative interference consent.
VI. Seminar Discussion Of Theoretical Questions And Practical Work – 12.30 – 14.00
VII. Student’s individual works – 14.15 – 15.00. Students who did not pass the test on the eve of the system Moodl are required to remain on independent work
Students must know:
· Definition, classification of a panaritium, a phlegmon of hand;
· A clinical picture of a panaritium, a phlegmon of a hand;
· Diagnostics and treatment of a panaritium, a phlegmon of a hand.
· An etiology, a pathogeny acute hematogenous osteomyelitis;
· Diagnostics and medical tactics of purulent diseases of bones;
· Kinds of operative treatment;-
· Chronic forms of osteomyelitis, their treatments;
· An etiology, a pathogenesis, methods of diagnostics, the basic clinical attributes of a tetanus, antrax, diphtherias of wounds;
· Methods of specific prophylaxis and treatment of an acute specific surgical infection.
· Concept about fistula.
· Concept about stoma.
· Concept about exzogenic decubitus.
· Concept about necrosis.
· Kind of necrosis.
· Concept about lymphostasis.
Students should be able to:
· to collect an anamnesis;
· to lead objective inspection of the patient;
· to distinguish the basic clinical attributes of purulent diseases of fingers and hands;
· to lead diagnostics of an acute purulent pathology of fingers and hands on their kind and localization;
· to prove the plan of individual treatment (conservative and surgical);
· to give the reference on an aftertreatment of patients.
· to make the individual circuit of diagnostic search;
· to analyse results of objective research;
· to determine a role and a place of laboratory-instrumental diagnostics in formation of the diagnosis;
· to plan and prove the plan of individual treatment;
· to offer the basic methods of prophylaxis of occurrence of necrosises.
