Physical research methods include: Physical examination methods. Rules for determining the boundaries of the vascular bundle

The condition of the prostate gland is assessed using a digital rectal examination. The most characteristic symptom is pain of varying intensity. In acute prostatitis, the gland is significantly enlarged, sharply painful, often dense and homogeneous. When abscess formation occurs, a focally convex area is noted, and after an abscess ruptures, on the contrary, a recession occurs. Chronic inflammation without exacerbation or CPPS is characterized by little or no pain. The consistency is homogeneous or heterogeneous, elastic or somewhat compacted, sometimes atonic.

Microscopic examination of prostate secretion allows you to confirm the inflammatory process in the prostate gland, as well as judge its functional state. Using microscopes of prostate secretion, the main indicators are recorded:

White blood cell count

Number of lecithin grains;

Presence and type of microflora.

Before starting the procedure, the patient urinates partially to remove the contents of the urethra. Then a prostate massage is performed. If it is not possible to obtain prostate secretion, then examine the urine sediment obtained immediately after prostate massage (no later than 30 minutes).

The most objective information about the condition of the lower urinary tract is provided by 4-glass sample, described E. M. Meares And T. A. Stamey in 1968. It is one of the main research methods, allowing not only to establish a diagnosis, but also to determine treatment tactics. The test consists of a microscopic and bacteriological examination of urine samples obtained from different parts of the genitourinary tract and prostate secretions, which makes it possible to determine the source of inflammation.

Patient preparation:

Full bladder;

Before the examination, it is advisable for the patient to abstain from sexual intercourse for 24 hours to easily obtain prostate secretions.

The rod head must be clean and treated with a 70% alcohol solution.

Obtaining samples for research is carried out in 4 stages:

1. After preparing the patient, collect the first 10 ml of urine into a sterile container (I - urethral portion).

2. After partial emptying of the bladder in a volume of 150-200 ml, 10 ml of urine is also collected in the same way (II - bladder portion).

3. The next step is to massage the prostate gland to obtain prostate secretions (III - prostate portion).

4. Collect the first 10 ml of urine after prostate massage (II / - massage portion). Interpretation of results:

The first portion of urine (I) reflects the condition of the urethra. Urethritis is characterized by an increase in the number of leukocytes and bacteria in 1 ml compared to the vesical portion (II).

The presence of leukocytes in the first and second portions of urine (II) makes it possible to diagnose cystitis or pyelonephritis. Detection of leukocytes and uropathogenic bacteria in the secretion of the prostate (III) or in a portion of urine (IV) obtained after a prostate massage allows us to establish a diagnosis of bacterial prostatitis if the bacteria are not present (or are detected in lower concentrations) in the first (I) and second portions urine (II).

The absence or isolation of non-pathogenic bacteria, the presence of more than 10 leukocytes in the prostate secretion (III) or urine obtained after prostate massage (IV) means that these patients have inflammatory CPPS (non-bacterial prostatitis).

The absence of inflammatory changes during microscopy of all portions of urine and prostate secretion, as well as the sterility of prostate excreta, is the basis for establishing a diagnosis of non-inflammatory CPPS (prostatodynia).

The study of ejaculate allows

In some cases, make a differential diagnosis between inflammatory and non-inflammatory CPPS;

Determine the inclusion of reproductive system organs in the inflammatory process (vesiculitis).

TRUSY significantly expanded the diagnostic capabilities of the urologist. Indications for its use:

Acute bacterial prostatitis - exclusion of prostate abscess in the absence of positive dynamics against the background of antibacterial therapy;

Identification of pathological changes in the prostate gland that can affect treatment tactics (cysts, stones)

Suspicion of prostate cancer during a digital rectal examination or after a PSA test;

In the presence of pain associated with ejaculation, to exclude obstruction or cyst of the ejaculatory duct and pathogenic changes in the seminal vesicle.

If clinically significant diseases are suspected (prostate abscess, prostate and bladder cancer, benign prostatic hyperplasia, lesions of the musculoskeletal system, simulating symptoms of prostatitis, etc.), CT and MRI are used.

Treatment of prostatitis. Antibacterial therapy today is a generally accepted method of treating chronic prostatitis. One of the factors that significantly complicates the choice of antibiotics for the treatment of chronic prostatitis is the limited number of drugs that can penetrate the blood-prostatic barrier and accumulate in the prostate gland in concentrations sufficient to eradicate the pathogen. The highest priority in this regard are drugs from the fluoroquinolone group.

Treatment of acute prostatitis. In acute prostatitis, in contrast to the chronic inflammatory process, beta-lactam antibiotics and aminoglycosides are able to accumulate in prostate tissue in concentrations sufficient to suppress most pathogens, due to increased perfusion of the prostate and increased permeability of the blood-prostatic barrier. It should be remembered that the ability of antibacterial drugs of these groups to penetrate the prostate gland decreases as the inflammatory process subsides. Therefore, when a clinical effect is achieved, one should switch to oral fluoroquinolones.

Treatment of chronic bacterial prostatitis. Today, fluoroquinolones (norfloxacin, levofloxacin, ciprofloxacin) are the drugs of choice. In patients allergic to fluoroquinolones, doxycycline is recommended. It is generally accepted among urologists in Europe and the USA that antibacterial therapy for chronic prostatitis requires a long time, and, in contrast to the prevailing practice in our country, therapy is carried out, as a rule, with one drug. The tradition of changing antibiotics every 7-10 days has no scientific basis and is unacceptable in most clinical situations. A 2-4 week course of treatment is now considered optimal. Therefore, drugs that are prescribed once daily, such as fluoroquinolones such as levofloxacin, deserve special attention.

Treatment of chronic nonbacterial prostatitis. Despite the absence of cultured bacteria, antibiotic therapy for inflammatory CPPS is the most commonly recommended treatment.

The basis for prescribing antibacterial drugs is

The probable role of cryptogenic (highly cultivated) microorganisms in the etiology of chronic nonbacterial prostatitis and the high frequency of their detection in this category of patients;

Antibacterial therapy brings relief to patients with CPPS.

Antibacterial therapy for chronic nonbacterial prostatitis (inflammatory CPPS) is prescribed according to the following scheme:

Antibacterial therapy with fluoroquinolones, doxycycline for 2 weeks

Then a re-examination is carried out and if the dynamics are positive (reduction of pain), antibiotics are continued for a total duration of up to 4 weeks.

Non-inflammatory CPPS. There is still no consensus on the role of antibacterial therapy in the treatment of patients with this form of prostatitis.

Asymptomatic prostatitis. Such patients do not require treatment, despite laboratory, cytological or histological signs of inflammation.

Treatment of patients in this category is carried out according to certain indications:

Infertility

Identification of pathogenic microorganisms during microbiological examination;

With an elevated PSA level and positive results of microbiological examination (before determining the indications for prostate biopsy)

Before surgical treatment on the prostate gland.

For this, the same antibacterial drugs are used for the treatment of chronic bacterial prostatitis. In addition to antibiotics, drugs from other groups are also used to treat patients with prostatitis of any origin. Moreover, in the case of abacterial forms of prostatitis, these drugs are of paramount importance compared to antibiotics.

Technological advances in medicine have brought breakthroughs in the diagnostic process. However, a medical history and a thorough physical examination are still a physician's most important tools and respected methods of the art of medicine.

The physical examination of the patient is the primary clinical competency of the physician, along with the medical history, information about the symptoms experienced by the patient. The history and physical examination form the basis for making a diagnosis, planning further diagnostic steps, and developing treatment for the patient. The most important tools for a specialist are his inquisitiveness, patience, delicacy, but also mastery of physical examination methods - inspection, palpation, percussion and auscultation, with the help of which anatomical results are assessed. The data is entered into the medical record.

A relatively complete physical examination should be performed on every patient, regardless of the reason for the visit. It happens that a physical examination reveals unexpected findings that are not related to the patient's main complaint. In some cases, limited or inadequate physical examination of organs may miss a serious illness or potentially life-threatening condition. Although specialists have different approaches in sequence, a systematic physical examination usually begins with the head and ends with the extremities.

Physical methods of examining children differ from examining adult patients, and are adapted depending on the age category: 0-6 months; 6-24 months; 2 years +. Thus, percussion for a child under 2 years of age is difficult to perform and most likely will not bring significant results.

Methods for performing the procedure on a patient

The general appearance of the patient can already provide a diagnostic clue to the disease or severity of the disease. The astute clinician begins to gather information the first time he or she meets a patient during a physical examination, observing gait, facial features and expression, handshake, voice quality, and identifying unique features and potential problems.

Physical examination methods rely on the doctor's senses (vision, hearing, touch, sometimes smell, such as for infection) and are based on four steps:

• examination of the patient;
• palpation (feeling);
• percussion (tapping to determine resonance characteristics);
• auscultation (listening).

A general physical examination can take different forms depending on the circumstances. But more often than not, the doctor will evaluate areas of the body as a whole and look for abnormalities. Information obtained from the anamnesis indicates the need for a more accurate and detailed study of a specific organ system. Observations are recorded in the medical record in a standard format. This makes it easier for other subject matter experts to read the notes.

Examination of the patient

The first part of the physical examination is the examination of the patient. The patient can sit, stand or lie down, with direct/side lighting.

The inspection is coordinated according to the following scheme:

• patient's age;
• measurement of pulse, blood pressure;
• general appearance (habitus): the most informative part of the clinical examination: body features, symmetry;
• general state;
• weight, changes in metabolic processes;
• condition of subcutaneous tissue;
• The lymph nodes;
• muscular system;
• nails, skin and mucous membranes;
• head, hair distribution;
• torso (movement of the abdomen and chest on each side during breathing);
• limbs.

Examination of the cardiovascular or respiratory system during a physical examination does not begin with a stethoscope. The specialist can obtain valuable information by observing the patient (appearance, skin pigmentation, gait, handshake, items of clothing reflecting the physical and psychological state). He checks the patient's skin for characteristic signs that provide information about body disorders or anatomical changes in organs. Red eyes may be noted; pigmentation such as cyanosis, jaundice, pallor or freckles on the lips. Many violations are immediately noticeable.

Analysis of consciousness

The normal state of consciousness is a daily, repetitive state of the brain, awake, when a person consciously engages in consistent cognitive and behavioral responses to the external world (while awake, or one of the stages of sleep from which he can easily awaken).

An abnormal state of consciousness is more difficult to define and characterize, as evidenced by the many terms that are applied to altered states by different specialists. Among them are clouding of consciousness, delirium, lethargy, stupor, dementia, hypersomnia, vegetative state, akinetic mutism, locked-in syndrome, coma. Many of these terms mean different things to different professionals and may not be accurate in conveying information about a patient's state of mind. Therefore, it is more appropriate to define several terms that analyze the patient’s consciousness as closely as possible:

1. Cloudiness: a mild form of altered mental status in which the patient is inattentive (decreased wakefulness)
2. Confused state: deeper deficit including disorientation, misunderstanding
3. Lethargy: severe drowsiness from which the patient can be roused by mild stimuli but then return back to a sleepy state.
4. Obstruction: a lethargic-like state in which the patient shows less interest in the environment, with a delayed response to stimulation;
5. Stupor means that only vigorous and repeated stimuli can affect the patient, but if left unaided he immediately returns to an unresponsive state.
6. Coma is a state of insurmountable unresponsiveness.

1. determine the level of consciousness.
2. examine the patient to look for the cause of clouding of consciousness.
3. the presence or absence of focality of the disease: in terms of the level of dysfunction in the central nervous system, and specific lesions of the cortical or stem structures.

The level of impairment of consciousness is assessed based on the degree of response to stimulation.

Facial expression

One useful physical examination technique is to observe the patient's facial expressions during the physical examination. Problems may be indicated by drooping eyebrows, raised cheeks, drooping eyelids, a raised upper lip or open mouth, flared nostrils, a wrinkled nose, or twitching lips.

Inspection and analysis of the outer dermis and mucous membranes

Careful examination of the skin during the physical examination is considered best practice. Many clues regarding systemic disease are noteworthy. For skin abnormalities, morphological descriptive terms are used: macula, papule, plaque, node, tumor, vesicle, bulla, pustule, blister, telangiectasia, comedon, cyst. Secondary changes: scales, crust, crack, erosion, ulcer, ulceration, atrophy. Morphological changes are characteristic of the pathological process and form the basis of diagnostic categories of dermatological diseases. Descriptions of color and consistency may be added to evoke an accurate image for those reading during physical examinations of specific organ systems. "Accurate image" does not imply diagnosis, only descriptive terminology. When evaluating skin disorders, objective findings from physical examination and diagnostic tests are given more weight than the patient's subjective history.

Edema

The term "edema" refers to a noticeable excess of interstitial fluid. He will be examined:

• for pitting (leaves pits when pressed in the edematous area) - acute edema: interstitial fluid has a low concentration of protein, which is associated with a decrease in plasma oncotic pressure and a disorder caused by an increase in capillary pressure;
• resistance – muscular swelling (does not leave pits);
• soreness;
• temperature changes, colors, skin textures.

Recognizing edema on physical examination is often the first step in complex clinical problems. In most cases, optimal care for a patient with edema depends on identifying the cause (eg, vascular platelet or primary hemostasis).

The lymph nodes

Lymph nodes are distributed throughout the body; the main groups are located along the anterior and posterior sections of the neck and on the underside of the jaw. Palpation assessment is carried out as part of physical examinations of the head and neck, chest and axillae, upper and lower extremities, and external genitalia. If the nodes are enlarged, they may be seen to bulge under the skin, especially if the expansion is asymmetrical.

Using the pads of the three middle fingers (the most sensitive parts of the hands), apply steady pressure with small circular movements to note the size, shape, flexibility, texture, mobility of the knots. They constantly interact with extracellular fluid from adjacent tissues, and examination can provide information about the presence of infections or malignancies in the area. Detection of even one abnormal node leads to inspection of all nodes.

Joints

A detailed examination of the joints is not usually included in the general physical examination. However, associated complaints are quite common, and understanding the anatomy and physiology of both normal function and pathological conditions is critical when assessing the symptomatic patient.

Thyroid

Physical examination of the thyroid gland is based on physiological analysis and tradition, and not on a study that meets the accuracy of the prognosis:

• inspection;
• palpation;
• combining methods.

The patient is examined in a sitting or standing position. To find the isthmus of the thyroid gland, the doctor probes between the cricoid cartilage and in the area of ​​the jugular fossa. With one hand, slightly abduct the sternocleidomastoid muscle. The patient is asked to take a sip of water before palpating, feeling an upward movement from the thyroid gland. The outline of the thyroid gland is often observed as projections on either side of the trachea, but 2 cm below the thyroid cartilage. The physician looks for abnormal enlargement, nodularity, or asymmetry while the patient continues to swallow water. Not only the thyroid, the neck should also be checked for abnormal masses and noticeable pulsations.

Anthropometry and thermometry

Anthropometric data are used in many contexts of physical examination and disease monitoring. Anthropometry is a simple and reliable method of quantifying: body size and proportions by measuring body length, width, circumference, organ size and skinfold thickness.

Thermometry, or temperature measurement, along with other vital signs, is performed at every physical examination and on a fixed schedule during hospitalization. Most often, a glass thermometer placed in the armpit or groin folds is used. Modern electric digital thermometers are more convenient in terms of response time and measurement accuracy. Oral temperature is measured with a thermometer placed under the tongue (lips closed around the instrument). Three minutes is the time usually quoted for accurately measuring temperature, but it is wise to wait at least 5 minutes. Rectal measurement is indicated for children or critically ill patients. Temperature is measured using a lubricated glass thermometer with a blunt end, inserted to a depth of 4-5 cm into the anal canal at an angle of 20°. Waiting time – 3 minutes.

Normal body temperature is 37°C; however, there is wide variation. Among ordinary people, the average daily temperature can vary by 0.5°C, and daily changes can reach 0.25-0.5°C. The lowest level is usually observed at 4:00, the peak at 18:00. This circadian rhythm is fairly constant for the individual and is not disrupted by periods of fever or hypothermia.

Auscultation is listening to the internal sounds of the body, usually using a stethoscope. A method of physical examination that requires skill and clinical experience. Specialists listen to three main organ systems: circulatory, respiratory, and gastrointestinal systems. Unusual sounds may be associated with certain pathological changes (heart murmurs, wheezing in the lungs, bowel sounds).

Anamnesis

History - information obtained by the doctor asking specific questions is important for substantiating the diagnosis and prescribing appropriate treatment. The complaints reported by the patient are called symptoms. Clinical signs are determined by the doctor during the examination. Following medical histories is different. For example, an ambulance paramedic limits the case to only the basic details (name, complaint, allergic reactions, etc.), while specialized specialists, for example, a vascular surgeon or orthopedic surgeons, provide an in-depth and detailed analysis, allowing for an accurate treatment plan.

Percussion

A diagnostic procedure (physical examination technique) using finger tapping (less commonly with a hammer) to assess the condition of the chest or abdomen: using the middle finger of one hand tapping the middle finger of the other hand, attached to the body. Sounds help determine the size and position of internal organs and identify the presence of fluid or air in the lungs.

Palpation

Another method of physical examination is a diagnostic manual palpation procedure to detect internal abnormalities. The doctor can determine an enlarged organ, excess fluid in the tissues, a tumor mass, a bone fracture and the presence of inflammation (as with appendicitis), irregular heartbeat, and vibrations in the chest.

Features of a physical examination in a child

Although some of the principles of the physical examination of children are similar to the examination of adults, there are fundamental differences, both in the algorithm and in the details. In addition, it is important to distinguish between a general physical examination of the child (mainly to identify abnormalities of growth and development) and an examination of sick children, which establishes the nature, cause of the disease or injury.

The baby or toddler is usually fussy during the examination. Doctors use some tricks to distract the child, make him less restless and make the examination easier. Physical examination is determined by the age and understanding of the child. It is important to approach the child at his level and, if necessary, kneel down. It is difficult not to provoke crying in irritable children and first of all they need to be carefully examined before proceeding with other examination methods.

Objective examination of the patient: algorithm and significance of the technique

A well-performed physical examination provides 20% of the information needed for diagnosis and treatment. The clinician is like a detective, looking for evidence of disease in the history and physical examination. This is a unique situation where the patient and doctor understand that interaction is necessary for diagnosis and treatment. The patient should have confidence in the competence of his physician and feel that he can trust him during the physical examination. History, X-ray results, subjective complaints, and an accurate physical examination are essential components for a proper treatment plan. It is the physician's responsibility to find out what is wrong with each individual patient.

Physical examination algorithm (introduction):

• wash your hands (try to keep your hands warm); introduce himself; confirm the patient’s passport details;
• Explain the purpose of the physical examination and inform the patient that any discomfort may be caused;
• obtain consent; arrange the patient for examination, noting body position and assessing the degree of comfort (lying, sitting, standing).

Thyroid gland

A physical examination of the thyroid gland includes:

1. Inspection: for masses, scars, lesions, signs of previous surgery or trauma. Swelling/enlargement (ask patient to swallow water). Eyes (Graves' ophthalmopathy, exophthalmos). Skin (wet/dry). Hair (signs of baldness). Tremor. Tibial myxedema. Behavior (anxiety).
2. Palpation (cricoid cartilage as a reference): lobes and isthmus (patient swallows water)
3. Auscultation: listening for noises (the patient must hold his breath)
4. Additionally: reflexes (hyperactive/hypoactive); features - tachycardia, rhythm disturbance (for example, atrial fibrillation).

Mammary glands

Please note that any physical examination of an intimate nature (including examination of the mammary glands) can be carried out in the presence of an accompanying person, especially if the doctor is a man (specialty - mammologist). Any actions of a specialist must be explained.

Examination: asymmetry in size and contour (in healthy women, one breast is larger than the other); skin changes (lumps and associated changes, including signs of inflammation, ulceration and skin retraction, may be caused by cancer), an “orange peel” appearance may be visible (caused by lymph node obstruction); discoloration may be a sign of imminent ulceration; scarring.

Various maneuvers are performed to accentuate any thin masses (the patient raises his arms above his head or presses them against his thighs).

Palpation begins with the upper inner quadrant, gradually moving to the outer upper quadrant, and then covers the lower quadrants and the paranasal area. Pay attention to whether there is any discharge from the mammary glands (color, consistency, quantity), which represents valuable biological and diagnostic material. Every suspicious symptom should be carefully examined.

Chest organs

The physical examination begins with an anamnesis, which determines the format: volume, intensity of the chest examination. When the history raises suspicion of a problem, the physical examination of the chest should be expanded to determine the nature of the pathology and establish a diagnosis. The examination includes all methods. The physician asks about the symptoms that prompted the visit and begins a physical examination, checking and feeling the patient's hands and noting grip strength.

Palpation, confirmed by percussion, assesses the degree of expansion of the chest. Auscultation, a more sensitive process, confirms early findings and may allow identification of specific pathological processes that were not previously recognized. By the time the physical examination is completed, even before laboratory tests begin, the diagnosis should be sufficiently substantiated.

Bronchial asthma

Characteristic physical signs of bronchial asthma are loud, prolonged polyphonic expiratory wheezes and random sounds. During an asthma physical exam, your doctor will examine your ears, nose, throat, eyes, skin, chest, and lungs.

Heart and cardiovascular system

The physical examination includes inspection, palpation, and auscultation of the heart, arteries, and veins.

With surgical pathologies

Surgical pathology is the study of tissue taken from patients during surgery to help diagnose disease and determine treatment plans. Includes both physical examination of the tissue with the naked eye and examination under a microscope.

The Objective Structured Clinical Examination is a new form of testing that is used to assess the clinical competency of physical examination candidates. They are assessed as they progress through a series of stations in which they interview, study and treat standardized patients (individuals trained to identify signs and symptoms of various diseases and conditions), demonstrate communication skills, and the ability to deal with unpredictable patient behavior during physical examinations.

Each station is focused and typically short in duration, 3-20 minutes; Candidates are given clear instructions. There are many stations, they can include several testing methods, demonstration of clinical signs, anamnesis, interpretation of clinical data (diagnosis), practical skills, psychological counseling skills, and so on - tasks of different types and levels of complexity.

Physical methods of examining patients are an integral and essential part of diagnosing vascular diseases both at the prehospital stage and in the hospital. A physical examination is a comprehensive medical examination of a patient with varicose veins. Despite technical progress and the active introduction of modern instrumental examination methods, questioning and physical examination of patients continue to occupy a crucial place in the diagnosis, including varicose veins. For many years now, not a single modern doctor can do without an examination. Each person has their own characteristics of physical and instrumental examination, but in clinical practice they are equally important for making the correct diagnosis and should complement each other.

What is the point of a medical examination?

When visiting a doctor for an initial or repeat visit regarding venous vessel disease, the patient, in addition to communication and a thorough study of complaints and medical history, undergoes a thorough examination. This kind of work is called a physical examination. Physical examination methods include:

• Inspection.
• Palpation.
• Percussion.
• Auscultation.

Based on an analysis of complaints, anamnesis and examination, palpation, percussion and auscultation, a preliminary diagnosis is usually made, which is subsequently confirmed or refuted using laboratory and instrumental diagnostic methods. In case of varicose veins, an additional examination method most often becomes ultrasound of the vessels of the lower extremities.

In medicine there is a consonant expression - physical therapy. Otherwise it is also called physiotherapy. Such treatment involves influencing the patient to physical factors in order to relieve a particular disease. For example, currents and magnetic fields of various strengths are widely used. That is, there is no direct connection between such a concept as physiotherapy and the examination (examination) of the patient that is consonant with it. These words have a similar sound, but completely different meanings.

Appearance assessment

The first thing the doctor does after talking with the patient and finding out his complaints and medical history is an examination. This is an important part of the physical examination. In this way, you can obtain a large amount of information both about the general condition of the patient and about local changes in his body. During the examination, the patient’s condition is first assessed (satisfactory, moderate, severe). In people with varicose veins, the condition is often satisfactory, but it can also be severe with the development of complications such as pulmonary embolism. Varicose veins, complicated by deep vein thrombophlebitis, can also cause a significant deterioration in the general condition due to pain and hyperthermia.

A patient examination always begins with a questioning.

Next, during examination, the appearance of the skin is assessed. The patient is examined completely, from head to toe, the presence of any damage to the skin is noted (rash, hemorrhages, petechiae, hematomas, wounds, dermatitis, any other pathological changes). Skin color is assessed - general and local changes, the presence of visible subcutaneous formations, postoperative or other scars on the skin.

In a patient with varicose veins of the lower extremities, special attention is paid to examining the legs. The following symptoms are possible:

• The presence of vascular (venous) networks.
• Visual changes in the saphenous veins in the legs – their thickening, tortuosity, symmetry of changes, the presence of nodes and bumps.
• In later stages of the disease, during examination, the presence of trophic ulcers can be noted as a complication of varicose veins.

During the physical examination, the level of consciousness is determined. The facial expression is noted, whether it is calm, whether there are signs of suffering and pain on the face, whether facial expressions are disturbed, whether there is swelling of the face, cyanosis of the nasolabial triangle (acrocyanosis) and other signs. You should definitely pay attention to forced posture, changing which causes pain or deterioration of the patient’s condition.

Palpation

If the examination is largely carried out visually, then palpation implies physical contact between the doctor and the patient - the doctor feels the organs, joints, and damaged areas accessible for palpation.

With the help of palpation, you can obtain information about the condition of the skin, its moisture, turgor, and estimate the temperature. Using palpation, the pulse in the main arteries is determined.

Much information about the skin can be obtained through palpation.

A physical examination of the musculoskeletal system also involves palpation, which determines the integrity of the skeleton, the presence of damage to the bones or joints, as well as pain upon palpation. After an injury, the damaged bone, joint or muscle is palpated. The doctor, having conducted a physical examination of the patient and his musculoskeletal system at the prehospital stage, can establish a preliminary diagnosis without the use of instrumental diagnostic methods.

Palpation of the abdomen makes it possible to determine changes in the internal organs, an increase in their size, a change in position relative to each other, pain when pressed, and sometimes space-occupying formations can be identified by palpation.

For varicose veins, the doctor palpates the affected areas on the lower extremities. Assess the presence of pain, inflammatory changes, and, if possible, determine the presence of blood clots and nodes. Palpation also determines the presence of edema and changes in local temperature. Thrombophlebitis of superficial venous vessels is accompanied by their hardening, pain, and sometimes hyperemia of the skin. The doctor can easily determine all these signs of vascular disease by palpation.

Percussion

During a physical examination, without the use of any instruments or equipment, the doctor performs percussion. This method is based on differences in organ density, which determines their ability to acoustically conduct sound. It is performed by tapping with one finger (acting as a hammer) on another finger tightly applied to an area of ​​the patient’s body (role of a plessimeter). The result of tapping is a dull (liver) sound or a clear (pulmonary) sound. With the help of percussion, you can determine the boundaries of internal organs, an increase in their size, the presence of pathological formations, and suspect various diseases.

Physical examination may suggest the presence of poorly perfused areas.

With such a complication of varicose veins as pulmonary embolism, percussion of the lungs helps to suggest the presence of poorly supplied areas. These disorders occur due to blockage of the pulmonary vessels. Sometimes infarction-pneumonia develops, causing hardening of the organ area and dulling of the pulmonary sound upon percussion.

Auscultation

Auscultation is one of the physical methods of examining a patient, carried out using a stethophonendoscope and consisting in the doctor listening to the sounds produced by the work of internal organs (heart, lungs, gastrointestinal tract). Auscultation helps determine whether internal organs are functioning normally and whether there are additional pathological noises.

For a patient who has applied for varicose veins, the doctor will necessarily listen to the lungs and heart. This will help identify concomitant diseases of the heart, blood vessels and lungs, as well as systemic complications of varicose veins.

Such important swelling

By doing a physical examination, the presence of edema is separately assessed. Swelling can be located on the face, upper limbs, in the area of ​​injury or fracture. People often experience swelling of the lower extremities associated with varicose veins.

The presence of edema, in addition to visual assessment, is determined by pressing a finger on a certain area of ​​the skin close to the bone. With varicose veins, this is the front surface of the lower leg. In the presence of edematous syndrome, a notch or depression will remain on the skin at the site of pressure.

Small, barely noticeable swelling is called pastosity. One of the causes of swelling in the legs is varicose veins of the lower extremities. Such vascular edema usually occurs in the evening and is accompanied by heaviness and fatigue in the legs. In the morning, symptoms usually disappear. However, in later stages of varicose veins, swelling can persist constantly, regardless of the time of day.

Varicose veins of the lower extremities can lead to swelling in the legs.

A physical examination of the patient is of great importance for making a primary diagnosis and assessing the dynamics of varicose veins of the lower extremities. Some people underestimate such an examination, believing that laboratory and instrumental methods provide more accurate information about the state of health. A professional physical examination helps the doctor get an idea of ​​the course of varicose veins and the condition of the blood vessels in the legs. Regular visits and examinations allow the specialist to assess the dynamics of the condition of the veins of the lower extremities, the progression of vasodilation and the occurrence of complications. This is the basis of successful quick relief from varicose veins.

A physical examination is carried out taking into account the history and complaints of the pregnant woman. At the same time, attention is paid to those organs whose diseases were observed previously. During the first stage of labor, the examination is carried out between contractions.

General inspection

Basic physiological indicators. The pulse rate is measured, blood pressure is measured in pauses between contractions. If necessary, the measurement is carried out several times.

A sign of chorioamnionitis may be an increase in body temperature, especially after the rupture of amniotic fluid. Tachycardia and tachypnea during labor are normal in the absence of changes in other physiological parameters.

An ophthalmoscopy is necessary to exclude retinal hemorrhage, vasospasm, or retinal edema, which may be present in diabetes mellitus and arterial hypertension. Pale conjunctivae or nail beds may be a sign of anemia. Swelling of the face, hands and feet is observed with preeclampsia. Palpation of the thyroid gland is mandatory.

A rare but serious complication during childbirth - venous stagnation is manifested by swelling of the neck veins and requires mandatory treatment. If a woman has a history of bronchial asthma, auscultation of the lungs is performed to detect shortness of breath and wheezing and auscultation of the heart, paying attention to the presence of systolic murmur. It must be remembered that mesosystolic murmur is observed during pregnancy normally.

The abdomen is palpated to exclude pain and the presence of space-occupying formations. Pain on palpation of the epigastric region may be a sign of preeclampsia. During full-term pregnancy, palpation of the abdomen is difficult.

During full-term pregnancy, minor swelling of the legs is normal. A neurological examination is carried out if severe swelling of the legs or hands is detected (signs of preeclampsia). Increased tendon reflexes and clonus indicate increased seizure readiness.

External obstetric examination

Dimensions of the uterus. By the end of the 1st obstetric month (4th week), the uterus reaches the size of a chicken egg. It is usually not possible to determine pregnancy with a vaginal examination. By the end of the 2nd month (8th week), the uterus increases to the size of a goose egg. By the end of the 3rd month (12th week), asymmetry of the uterus (Piskachek’s sign) is noted; it increases to the size of a man’s fist, its bottom reaches the upper edge of the symphysis. By the end of the 4th month (16th week), the uterine fundus is determined at the middle of the distance between the symphysis and the navel or 6 cm above the navel. By the end of the 5th month (20th week), the fundus of the uterus is located 11-12 cm above the womb or 4 cm below the navel. By the end of the 6th month (24th week), the fundus of the uterus is at the level of the navel or 22-24 cm above the womb. By the end of the 7th month (28th week), the uterine fundus is determined two transverse fingers above the navel or 25-28 cm above the womb. By the end of the 8th month (32nd week), the fundus of the uterus is located in the middle of the distance between the navel and the xiphoid process, 30-32 cm above the pubis. By the end of the 9th month (36th week), the fundus of the uterus reaches the xiphoid process and costal arches. By the end of the 10th month (40th week), the fundus of the uterus drops to the level of 32 weeks of pregnancy. By palpation of the uterus, the approximate size of the fetus and the amount of amniotic fluid are determined. It is also important to determine the thickness of the anterior abdominal wall of the woman in labor and the degree of insertion of the presenting part of the fetus into the pelvic area. It is necessary to exclude malformations of the uterus or fetus or multiple pregnancies if the size of the uterus exceeds the expected gestational age. For this purpose, an ultrasound is performed.

External obstetric examination includes four Leopold maneuvers.

The first technique allows you to determine the height of the uterine fundus and that part of the fetus that is located in the uterine fundus. The head is more rounded and dense compared to the buttocks. The head moves, and the pelvic part moves only along with the fetal body.

The second technique is used to determine the position of the fetus and its type. Consists of palpation of the lateral surfaces of the uterus. It allows you to determine on which side the small parts of the fetus (arms, legs) are located, and on which side the back is located, as well as its movement, the tone of the uterus.

The third technique is used to determine the presenting part and its relationship to the entrance to the pelvis. The head must be distinguished from the pelvic end of the fetus. It is round and dense. When the head moves, the symptom of balloting is noted. In case of breech presentation, a bulky part of the fetus with a softish consistency without clear contours is determined above the entrance to the pelvis, which does not give the symptom of balloting. By shifting the presenting part from side to side, its position is determined in relation to the entrance to the pelvis. If displacement is difficult, it means that it is fixed at the entrance to the pelvis.

The fourth technique allows you to clarify the presentation of the fetus. To perform the maneuver, the obstetrician turns to face the woman in labor and palpates the presenting part with both hands. With an occipital presentation, the occipital curvature is determined on the same side as the small parts of the fetus, while the head is bent and the occiput is presented. With a facial presentation, the occipital curvature is determined on the opposite side of the small parts of the fetus, the head is extended.

The location of the fetus in the uterus. According to the basic research methods, it is possible to easily determine the position of the fetus in the uterus, its position, position and type of fetus.

Fetal position is the ratio of the longitudinal axis of the fetal body to the longitudinal axis of the mother's body. The position of the fetus can be longitudinal (with pelvic or cephalic presentation), transverse and oblique, when the axes of the fetal and maternal bodies intersect.

The articulation of the fetus is the relationship of the fetal limbs and head to its body. A favorable articulation is the flexion type, in which the fetus resembles an ovoid in appearance.

Fetal presentation. This is the relationship of the large part of the fetus to the entrance to the pelvis. The presenting part is the part of the fetal body that is located above the entrance to the pelvis. The fetal head, pelvis or shoulder may be present. The most common and physiological is considered to be cephalic presentation. When the fetal head is flexed, the presentation will be considered occipital. When the head is in an extension position, a frontal or facial presentation is formed. If the pelvic part of the fetus is located above the entrance to the pelvis, the presentation is called breech. Breech presentation can be purely breech (the legs of the fetus are extended along the body, and the buttocks are facing the entrance to the pelvis), mixed breech (the buttocks and feet of the fetus are presented), complete leg (both legs are presented) and incomplete (one leg is presented). With foot presentation, a complication often occurs in the form of umbilical cord prolapse. In the transverse position, the fetal shoulder is located above the entrance to the pelvis. In a normal full-term pregnancy, it is very rare that several parts of the fetal body (head and small parts) may present simultaneously.

Fetal position is the relationship of the fetal back to the left or right wall of the uterus. There are first (left) and second (right) positions of the fetus.

The appearance of the fetus is the relationship of its back to the anterior wall of the uterus.

The first position is often combined with a front view, the second - with a rear view.

Auscultation of the fetal heart has recently been increasingly replaced by CTG. This method helps to more accurately record heart rate and heart rate variability (acceleration and deceleration).

Conducting a vaginal examination

It begins with inspection and palpation of the perineal and pelvic area. In the presence of bleeding from the vagina and premature discharge of amniotic fluid, a vaginal examination is carried out only after an ultrasound.

Examination of the perineum consists of identifying herpetic eruptions, varicose veins of the external genitalia, the presence of condylomas, and scars. In cases of suspected labia herpes, a thorough examination of the cervix and vagina is necessary. Also, during the examination, attention is paid to the integrity of the pelvic bones and amniotic sac, the opening and smoothing of the cervix, as well as the position of the presenting part.

Diagnosis of the discharge of amniotic fluid is almost never in doubt, but if necessary, examine the cervix and vaginal vault in the speculum. When amniotic fluid ruptures, a vaginal examination may reveal the fetal buttocks, or the head or loops of the umbilical cord. In this case, amniotic fluid is present in the posterior vaginal fornix. If the fluid present in the posterior fornix contains amniotic fluid, then a microscopic examination of the dried smear reveals a fern phenomenon. Amniotic fluid turns the test strip dark blue if the result is positive, as it has an alkaline reaction. The test may be false positive if there is blood or urine in the posterior fornix. The possible admixture of meconium is also taken into account. Meconium is the primary fecal content of the fetal intestine, which increases in late pregnancy. The presence of meconium in the amniotic fluid is a sign of fetal hypoxia. The presence of blood in the amniotic fluid may be a sign of placental abruption. If premature birth occurs and chorioamnionitis is suspected, a culture of discharge from the posterior vaginal fornix is ​​performed. In case of premature rupture of amniotic fluid, it is necessary to determine the degree of maturity of the fetal pulmonary system using a foam test.

Cervix

The degree of cervical dilation is measured in centimeters: from 0 (the cervix is ​​closed) to 10 cm (fully dilated).

Smoothing of the cervix is ​​one of the indicators of its maturity and readiness for childbirth. The size of the immature cervix is ​​3 cm (degree of effacement 0%). Smoothing occurs gradually and becomes maximum at the beginning of labor (100% degree of effacement). In primiparous women, the cervix first undergoes effacement and then dilatation. During repeated births, effacement and dilatation of the cervix occur almost simultaneously.

Palpation of the presenting part of the fetus

Fetal presentation is determined by palpation. With an occipital presentation, you can palpate the sutures and fontanelles on the fetal head, with a pelvic presentation, you can identify the buttocks and feet, with a facial presentation, you can palpate the front part of the fetal head, but ultrasound provides more accurate data on the presentation.

The degree of insertion of the presenting part into the pelvis.

In order to determine the position of the presenting part, the line that connects the woman’s ischial spines is taken as the starting point. If, during an occipital presentation, the fetal head has reached this line, it means that it has entered the small pelvis with biparietal size (degree of insertion “0”).

If the presenting part is 1 cm above the ischial spines, the degree of its insertion is determined as “–1”, if 2 cm below the ischial spines - as “+2”. If the degree of insertion of the presenting part is more than “-3”, then this means its mobility above the entrance to the pelvis. If the degree of insertion is “+3”, then the presenting part is located at the bottom of the pelvis and is visible in the genital slit during pushing.

The position of the fetus is the location of certain points of the presenting part of the fetus in relation to the anatomical structures of the pelvis. In the anterior position, the presenting part faces the pubic symphysis, and in the posterior position, it faces the sacrum. Transverse (right or left) position - the presenting part faces the right or left wall of the pelvis.

The position for occipital presentation can be determined by the point of intersection of the lambdoid and sagittal sutures.

In case of pelvic presentation - along the sacrum of the fetus, in case of facial presentation - according to the location of the chin. In the anterior position of the occipital presentation, the back of the head is turned towards the pubic symphysis. In the right transverse position of the occipital presentation - to the right vaginal wall.

Examination of the pelvic bones. The size and shape of the small pelvis are determined by the size of the large pelvis. A narrow pelvis has such features that when a full-term fetus passes through it, mechanical obstacles are formed. External measurement of the pelvis does not always make it possible to identify the shape and degree of narrowing of the pelvis. In some cases, the discrepancy between the sizes of the pelvis and the fetal head can only be determined during childbirth. The size of the pelvis is one of the three main factors that determine the physiological course of childbirth. Other important factors are the size of the fetus and normal labor activity.

The entrance to the small pelvis is formed from the front by the upper edge of the pubic articulation of the symphysis, from the back by the apex of the promontorium, and the lateral borders by the arcuate lines of the ilium. The direct size of the small pelvis is determined by the size of the diagonal conjugate - the distance between the promontory and the lower edge of the pubic symphysis, which is normally 12 cm or more.

The pelvic cavity is formed in front by the posterior surface of the pubic symphysis, in the back by the anterior surface of the sacral vertebrae, and the side walls by the ischial bones. The transverse size of the pelvic cavity is normally more than 9 cm. This distance between the ischial spines is determined during a vaginal examination.

The exit from the small pelvis in front is located in the area of ​​the lower edge of the pubic arch, in the back - in the area of ​​the apex of the coccyx, on the sides - between the ischial tuberosities. The transverse size of the small pelvis is the distance between the ischial tuberosities of at least 8 cm at normal sizes.

You can indirectly judge the size of the outlet from the small pelvis by the size of the subpubic angle and the protrusion of the apex of the coccyx.

An acute subpubic angle most often indicates a narrow pelvis. Usually there is a combined decrease in all sizes of the small pelvis.

A physical examination is a set of medical diagnostic measures performed by a doctor to make a diagnosis. All methods related to physical examination are carried out directly by the doctor using his senses.

Physical examination includes inspection, palpation, percussion of the chest and auscultation of the lungs. However, along with an examination of the chest and lungs, a general examination is also required, paying special attention to changes in other organs characteristic of pulmonary diseases.

For what?

To establish the nature of the bacterial flora and sensitivity to antibacterial drugs for rhinitis, tonsillitis and pharyngitis, remove mucus or plaque from the throat with a sterile cotton swab.

How?

A physical examination of the patient is based on palpation, listening to the respiratory system, and a full examination.

What diseases is it used to determine?

To determine diseases of an infectious nature, respiratory organs, etc.

At the Pulmonology Center, highly qualified specialists and modern high-tech equipment will help you identify the disease at the earliest stages.

For your information:

A mistake often made is an incomplete examination of the patient, limited to the most striking complaints. For example, a patient with complaints of a sore throat in some cases is examined only by the oropharynx and the cervical group of lymph nodes, which usually allows a diagnosis of “angina” or “ARVI” to be made. At the same time, a large number of various infectious and non-infectious diseases may be accompanied by changes in the oropharynx, and examination of other organs makes the diagnostic search much more complete (for example, a combination of sore throat with polylymphadenopathy and hepatolienal syndrome is possible with infectious mononucleosis, adenoviral infection, stage of primary manifestations of HIV infection and etc.). In all cases, regardless of complaints, the patient must be examined from head to toe, not leaving any organ system unattended and not forgetting to carefully examine the skin after undressing the patient.