Examination methods in the clinic of internal diseases

1. General plan for examining the patient.

2. Subjective examination and its role.

3. Assessment of the patient’s general condition.

4. Objective examination: inspection, palpation, percussion, auscultation.

5. Additional examination methods.

Examination methods patients are divided into 2 large groups: subjective And objective.

At subjective examination, all information comes from the patient during his interview, i.e. collecting anamnesis.

Objective survey is obtaining information using basic and additional research methods.

The main methods are general and local (local) examination, feeling (palpation), tapping (percussion), listening (auscultation).

Additional (auxiliary) methods include: laboratory and instrumental methods.

Questioning method - history taking:

1/ passport part;

2/ complaints;

3/ medical history;

4/ life story.

Passport part: Full name, age, gender, education, profession, position, place of work, home address, date of admission, name of the institution that referred the patient.

Complaints: highlight the main and related ones. The correct first question to ask is: “What worries you most?” or “What worried you most when entering the hospital?” Then: detailing complaints (for example, “cough”). Next question: “What else worries you?”

One of mandatory requirements When collecting anamnesis, active identification of complaints is carried out, when clarifying questions and prompts are asked in relation to other organs.

Medical history (medical history) reflects the onset of the disease and its further development to the present time. The right question is appropriate: “When was the first time in your life and under what circumstances did you experience attacks of chest pain?” - if in front of you is a patient with manifestations of angina pectoris. Then, by asking questions, it is necessary to force the patient to remember the entire chronology of the disease: the treatment, exacerbation, hospitalization, the next deterioration in health, etc.

Life story (anamnesis of life): factors need to be established environment(domestic, social, economic, hereditary) that could contribute to the occurrence and development of the disease. Childhood, youth; working conditions, living conditions, living conditions, nutrition, family history, heredity, past accompanying illnesses, bad habits.

Allergy and drug history.

Objective examination patients includes main methods and auxiliary (additional) methods.

Basic methods of objective examination of patients: inspection, palpation, percussion, auscultation.

1. Inspection: distinguish between general and local (local).

Subsequence general examination :

1/ general condition;

2/ state of consciousness;

3/ patient’s position, gait, posture;

4/ physique and constitution;

5/facial expression, examination of the head and neck;

6/ examination of the skin and visible mucous membranes;

7/ character of hair, nails;

8/ development of the subcutaneous fat layer; presence of edema;

9/state of lymph nodes;

10/ assessment of the condition of muscles, bones, joints.

1/ General state May be:

Extremely heavy;

Heavy;

Moderate;

Satisfactory.

A complete understanding of the patient’s condition arises after assessing consciousness, the patient’s position in bed, a detailed examination of the systems and determining the degree of dysfunction internal organs

2/ Consciousness may be clear, stunned, stupor, coma:

Clear – responds adequately to the environment;

Stunning - responses are slow but correct;

Stupor – absence of verbal contact, but vital functions and reflexes are preserved, responds to pain with defensive movements;

Coma is a complete loss of consciousness, lack of response to any external stimuli.

3/ Patient position:

a/ active – he changes his position in bed;

b/ passive – cannot independently change position;

c/ forced – in which suffering is alleviated (for example, with heart failure, the patient sits with his legs down, his head thrown back;

d/ active in bed – in patients with fractures of the lower extremities with skeletal traction.

The gait is normally firm, confident, and movements are free.

The posture is correct: the patient holds his head straight, sits and stands straight, the sizes of individual parts of the body (head, torso, limbs) are proportional. There is no spinal deformity, chest and other parts of the body.

4/ Body type: height, weight, body shape, muscle development, degree of fatness, skeletal structure, proportionality or harmony physical development.

Height over 190 cm is gigantism.

Height less than 100 cm – dwarfism.

Assessment of physical development using special assessment tables (low, below average, average, above average, high).

Constitution– 3 types:

Asthenic type (longitudinal dimensions predominate);

Hypersthenic type (transverse dimensions predominate);

Normosthenic type (average value).

5/ Facial expression- This is a mirror of mental and physical state. In some diseases, facial expression is an important diagnostic sign. For example, with Graves' disease (for diseases thyroid gland, increasing its function) - pronounced bulging eyes (exophthalmos). In case of kidney disease, the face is pale, puffy, “bags under the eyes.”

6/ Examination of the skin and mucous membranes– color, presence of rash, scars, scratching, peeling, ulcers.

Varieties of skin color: pallor, redness (hyperemia), cyanosis (cyanosis), jaundice, sallow tone, vitigo (or white spots).

A skin rash may be a sign of an infectious or allergic disease.

7/ Nails– normally smooth, pink.

8/ Development subcutaneous fat layer may be normal, increased or decreased (the thickness of the skin fold along the outer edge of the straight line of the abdomen at the level of the navel = 2 cm is normal).

Body mass index = body weight (kg): height squared (m2). N=18.5-24.9. The normal waist circumference is 94 cm for men and 80 cm for women.

Edema: pathological accumulation of fluid in soft tissues, organs and cavities. For example: a swollen limb is increased in volume, its contours are smoothed, the skin is stretched and shiny; When pressed with your thumb, a hole is formed.

9/ Lymph nodes normally not palpable. Enlargement of lymph nodes can be systemic (generalized) or limited (regional). Generalized enlargement of lymph nodes occurs with blood diseases, regional enlargement occurs with local (local) inflammatory processes.

Palpation of the lymph nodes is carried out with the fingers of the entire hand, pressing them to the bones. It is carried out in a certain sequence: submandibular, chin, anterior and posterior parotid, occipital, anterior and posterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal.

10/ Muscle s – tone (atrophy, hypertrophy).

Spine has 4 physiological bends:

Cervical lordosis is a forward bulge;

Thoracic kyphosis– convexity back;

Lumbar lordosis– convexity forward;

In the area of ​​the sacrum and coccyx there is a convexity backwards.

Hump- This is pathological kyphosis.

Scoliosis– curvature of the spine to the side.

Kyphoscoliosis– combined lesion (back and to the side).

When examining the skeletal system, it is necessary to pay attention to their shape (curvature, deformation), surface, and pain.

When examining joints: shape (configuration) of joints; the volume of active and passive movements, the presence of effusion in them, the color of the skin over them, the temperature of the skin over the joint.

Normal body temperature is 36-36.9 o C.

The temperature is measured with a mercury thermometer in the armpit for 10 minutes (sometimes in the rectum - rectally, where it is 1 o C higher than normal).

An increase in temperature is called a fever.

By degree of increase temperatures are distinguished:

Subfebrile – 37-38 o C;

Moderately elevated – 38.1-39 o C;

High – 39.1-40 o C;

Excessively high - 40.1-41 o C;

Hyperpyretic – above 41 o C.

After a general examination, palpation begins.

Palpation– research method using touch, i.e. palpation, as a result of pressure and sliding of the fingertips along the surface of the palpated organs.

Palpation rules:

The position of the palpater is to the right of the patient;

Hands should be warm, without sharp nails;

Palpation should be done gently, not harshly;

Palpate organs abdominal cavity in connection with breathing.

Distinguish superficial, deep, sliding, bimanual(with both hands) and jerky palpation.

The technique of palpation of individual organs and systems will be considered when studying specific diseases.

Superficial palpation: palpation of the skin to determine the subcutaneous fat layer, elasticity, taking it into the fold. Palpation of edema in the lower extremities is performed by pressing with a finger. The presence of a hole indicates edema.

By palpation, lightly squeezing the skin over the passage of the artery (radial, temporal, carotid) with your fingers, the pulse is examined.

Lymph nodes are normally not palpable. With pathology they increase. During palpation, their size, pain, mobility, consistency, and adhesion to the skin are determined. More often the submandibular, cervical, supraclavicular, axillary, and inguinal lymph nodes become enlarged. The lymph nodes should be palpated from top to bottom, standing in front and to the right of the patient, with both hands in the following sequence: occipital, parotid, submandibular, sublingual, cervical, supra- and subclavian, axillary, elbow, inguinal, popliteal.

When palpating the bones, it is important to identify painful areas, deformation, and crepitus.

The apical impulse is palpated on the chest. When palpating the apex beat, the palm right hand placed on the heart area in a transverse direction (the base of the palm is towards the sternum, and the fingers are in the IV, V, VI intercostal spaces).

Palpation of the chest in order to identify pain points is carried out with fingertips in symmetrical areas, pressing on the chest in a certain sequence from top to bottom.

Palpation of the abdomen begins with superficial palpation. The right hand with slightly bent fingers is placed flat on the stomach and the entire stomach is carefully felt, starting from left to right or from the healthy area to the sick one. Normally, the abdomen is soft and painless.

Deep palpation carried out in the following sequence: sigmoid colon, cecum, ascending, descending colon, stomach, transverse colon, liver, spleen, kidneys. Deep sliding palpation is used to palpate the stomach and intestines. The stomach, liver, and kidneys are felt in a horizontal and vertical position. Palpation of the liver, spleen, and kidneys is carried out with both hands - bimanually.

The guideline for palpation of the thyroid gland is cricoid cartilage. To palpate the lateral lobes of the thyroid gland, push the sternocleidomastoid muscle to the side with your thumb, and then, moving from top to bottom on the lateral surface of the larynx, determine the lateral lobe of the thyroid gland.

Percussion- tapping method.

When tapping, the underlying tissues and organs begin to vibrate, which are transmitted to surrounding tissues, air, and are perceived by the ear as specific sounds. They vary in volume (strength), frequency (pitch), hue, and duration.

When percussing dense, airless organs (heart, liver, spleen, kidneys, bones, muscles), the percussion sound is high, quiet and short.

When percussing the “air” organs (lungs, stomach, intestines), the sounds will be low, loud and prolonged.

Basic sounds produced by percussion:

Pulmonary - over the entire surface of the lungs;

Dull - over all airless, dense organs and tissues (liver, spleen, muscles, bones, absolute cardiac dullness);

Blunt - where the edge of the lung overlaps the airless organs; relative cardiac and hepatic dullness;

Tympanic (tympanic) - above the cavity organs filled with air or gases (stomach, intestines).

Percussion classification.

According to the methodology percussion happens:

Direct, in which the finger directly hits the human body (rarely used);

Mediocre – finger-finger percussion, i.e. hitting the finger with a finger - is currently used all over the world.

According to the strength of percussion sound:

Loud (strong, deep);

Quiet (weak, superficial);

The quietest (ultimate, threshold).

According to the purpose of the event:

Topographic (to determine the boundaries of the organ);

Comparative (for comparing sounds over symmetrical areas of the body).

Rules for performing percussion:

The patient's position should be comfortable, relaxed, preferably sitting or standing;

The room should be warm and quiet;

The physician should be to the patient's right;

The third finger of the left hand (pessimeter finger) is pressed tightly, without compression, along its entire length to the percussed surface; adjacent fingers should be slightly apart and also pressed tightly to the skin;

The third finger of the right hand (the mallet finger) is slightly bent so that the nail phalanx strikes strictly perpendicular to the middle phalanx of the plessimeter finger. Make 2-3 hits on one place. During a strike, the hand with the hammer finger should move freely only in the wrist joint.

The strength of the percussion blow depends on the purpose of the percussion (deep, superficial, quiet).

During topographic percussion, the finger-pessimeter is installed parallel to the expected border of the organ. Percussion is directed from an organ with a clearer sound to an organ with a dull or dull sound. The boundaries are marked along the edge of the plessimeter facing the zone of clearer sound.

Comparative percussion is carried out strictly on symmetrical areas of the patient’s lungs.

Normally, a clear pulmonary sound is detected by percussion over all pulmonary fields.

Topographic percussion is used to determine the boundaries of the lungs.

With comparative percussion over symmetrical areas of the lungs on the right and left, the same clear lung sound is normally detected.

The purpose of cardiac percussion is to identify the boundaries of relative (covered by the lungs) and absolute (not covered by the lungs) cardiac dullness.

The liver produces a dull sound when percussed.

The liver boundaries are measured using the method of M.G. Kurlov. To do this, 5 Kurlov points are determined by percussion and the distance between them is measured.

We will consider percussion of organs and systems in more detail in the relevant topics.

Auscultation– listening to sound phenomena occurring in the body:

- direct auscultation - listening with the ear;

- mediocre auscultation using a stethoscope, invented by René Laennec in the 19th century.

Just a stethoscope - made of wood, biauricular stethoscopes, phonendoscopes (they have a resonance chamber membrane), a stethophonendoscope, which is currently used.

Auscultation is important for examining the lungs, heart and blood vessels; blood pressure measurements using the Korotkoff method; in obstetric practice, as well as in the study of the digestive organs (definitions bowel sounds etc.).

Auscultation rules:

The room should be quiet and warm;

The patient is naked to the waist;

Position of the patient standing or sitting on a chair, in bed; seriously ill person - lying down;

When auscultating the axillary areas, the patient raises both hands behind his head;

When auscultating from behind along the scapular lines, I raise both the patient’s arms “to the shoulder”;

If there is abundant hair, before auscultation it is moistened with water, lubricated with Vaseline, cream or, in as a last resort, shaved;

Depending on the situation, the patient is listened to in various situations (standing, lying on his side, after physical activity).

To measure blood pressure using the Korotkoff method, a sphygmomanometer is used. The cuff is applied to the shoulder area, 2-3 cm above the elbow. When the pressure in the cuff decreases, the appearance of the first tone indicates the value of systolic blood pressure. Complete disappearance of sounds is an indicator of diastolic blood pressure.

Optimal systolic blood pressure is 120 mm Hg.

Optimal diastolic blood pressure is 80 mm Hg.

We will analyze auscultation in more detail when considering relevant topics.

Additional research methods:

- laboratory :

General clinical;

Biochemical;

Microbiological;

Immunological;

- instrumental :

Thermometry;

Anthropometry;

Blood pressure measurement;

R-logical;

Endoscopic;

Ultrasonic;

Radioisotope;

Functional.

A subjective examination method is questioning the patient. The paramedic needs to thoroughly understand the methodology for carrying it out. This skill must be learned. If the patient is given the opportunity to talk about his illness and life himself, he may omit important information and dwell in detail on minor circumstances. Some patients find it difficult to talk about their bad habits or past sexually transmitted diseases. It is necessary to win over the patient, enter into a trusting relationship with him and begin questioning by sequentially asking questions according to a certain pattern.

Scheme this includes the following sections:

· general information about the patient;

· patient complaints;

anamnesis (history) of the disease;

· patient's life history.

General information about the patient. This part of the interview includes the following information about the patient:

· last name, first name and patronymic;

· age (date of birth and number of completed years). The advanced age of the patient, especially if the person looks older than his age, allows one to suspect the presence of atherosclerosis and arterial hypertension. Knowing the age is also necessary to calculate the dose of drugs during drug therapy.

· the patient’s place of residence (for example, living in polluted, environmentally unfavorable areas increases the risk of developing cancer; in areas with iodine deficiency - endemic goiter);

· education, profession, place of work and position. Knowing the patient’s profession and working conditions, it is possible to find out the causes and conditions contributing to the disease (for example, the possibility of intoxication, hypothermia);

· Family status.

Patient complaints . Find out the patient’s complaints at the time of contacting an outpatient facility or admission to a hospital. Analysis of complaints involves identifying main and additional ones.

First they find out basic complaints, carefully detailing them according to a scheme that includes its characteristics, localization and irradiation (for pain), time and reasons for its appearance, after which procedures it decreases or disappears. For example, if a patient complains of pain in the heart, it is necessary to find out the nature of the pain (pressing, stabbing, aching, etc.), its location (behind the sternum, at the apex of the heart, diffuse pain in the left half of the chest), possible irradiation ( pain can radiate to the left arm, shoulder, back, etc.), conditions for the occurrence of pain (at rest or during physical activity), how the pain is relieved (goes away on its own after rest or you need to take nitroglycerin under the tongue). If the patient complains of abdominal pain, it is necessary to find out the nature of the pain (acute paroxysmal or constant dull, aching), localization (in the epigastric region, right hypochondrium, lower abdomen), whether it occurs on an empty stomach or after a meal (if after a meal, then after what time), is relieved by eating or, conversely, intensifies after eating.

Details of main complaints helps to associate their presence with damage to certain organs and systems of the body. There are complaints that are characteristic of many diseases: cough, headache, weakness, fever, loss of appetite and others, and there are specific complaints that allow you to immediately suspect a specific disease.

After the patient describes in detail the main complaints, it becomes clear additional. These complaints are identified by systems. This is due to the fact that some patients, having chronic diseases, get used to certain complaints (for example, cough when chronic bronchitis) and do not point to them. Knowing the list of symptoms that occur when each body system is affected, ask the patient about them. Judge the condition respiratory system can be determined by the presence or absence of cough, hemoptysis, chest pain when breathing, shortness of breath. State of cardio-vascular system characterizes the presence or absence of pain in the heart, palpitations, swelling of the legs, dizziness. If the digestive system is damaged, appetite may change, swallowing may be impaired, nausea, vomiting, abdominal pain, bowel movements, etc. may occur. When talking with a patient, one must take into account his educational level and try to avoid using medical terms that are incomprehensible to him.

Complaints	What to clarify	Description
THE CARDIOVASCULAR SYSTEM
Pain in the heart area	Localization	Behind the sternum, in the area of ​​the apex of the heart, in the left half of the chest without clear localization.
	Cause and conditions of appearance	At rest, during physical under load, with excitement.
	Character	Stitching, burning, pressing, aching, sharp, dull, squeezing.
	Duration	Constant, paroxysmal, for angina in minutes
	Irradiation	In the left shoulder, shoulder blade, jaw, arm
	How are they stopped?	Go away on their own, after taking nitroglycerin, validol
Heartbeat	Character	A feeling of interruptions in the work of the heart, a feeling of rapid heartbeat.
Dyspnea	Constant or paroxysmal	At rest or during physical activity.
Edema	On the legs, ascites, anasarca	Swelling in the legs may appear in the evening or be permanent. With ascites, patients will complain of an increase in the size of the abdomen and heaviness in the abdomen. With anasarca, swelling spreads to subcutaneous tissue the patient's entire body.
RESPIRATORY SYSTEM
Cough	Duration	Constant or paroxysmal. Over what period of time.
	Character	Dry or wet (with phlegm), rough, barking, quiet.
Sputum	Consistency	Liquid, viscous, thick.
	Quantity per day	From a small amount to a mouthful of sputum.
	Character	Mucous, serous, purulent, bloody.
	Color	Yellow or greenish with purulent sputum.
	Smell	With gangrene of the lung - fetid, putrefactive.
Chest pain	Localization	In the right or left half of the chest.
	Character	Aching, dull, stabbing.
	Duration	Constant or paroxysmal.
	Conditions of appearance	When coughing, when breathing deeply.
Dyspnea	Conditions of appearance	At rest, during physical activity.
	Character	Difficulty in inhaling (inspiratory) or exhaling (expiratory), mixed.
DIGESTIVE SYSTEM
Appetite disturbance		Decreased or increased appetite. Aversion to meat food (may be due to stomach cancer). Aversion to fatty, fried foods - for liver diseases.
Heartburn	Intensity	Weak or pronounced.
	Occurrence frequency	Frequent or rare.
	Connection with food intake	After meals or without connection with meals.
Belching	Frequency	Frequent or rare.
	Character	Belching of air, eaten food, rotten.
Nausea, vomiting	Connection with food intake	Yes or no.
	Frequency	It may be periodically or after each meal, or it may be artificially induced.
	Relieves the condition	Not really
Stomach ache	Localization	In the epigastric (epigastric) region, in the right or left hypochondrium, lower abdomen, iliac region, right and left.
	Irradiation	In the back, encircling or without irradiation.
	Character	Colicky, cutting, aching.
	Duration	Paroxysmal, constant, periodic.
	Availability of seasonality	Spring or autumn
	Relationship between pain and food intake	Hungry, at night, early (immediately after eating), late (1.5-2 hours after eating).
Feeling of fullness and heaviness in the abdomen	Localization	Widespread or limited abdominal bloating (flatulence).
Changing the stool	Stool frequency	Constipation (less than once every 1-2 days), diarrhea (frequent loose stools)
	Consistency of stool	Formed (dense) or unformed (liquid, semi-liquid, mushy).
	Impurities	Mucus, pus, worms
URINARY SYSTEM
Pain	Localization	Lumbar region, sacral region, above the pubis.
	Irradiation	In the leg, in the back area, in the genitals.
	Character	Sharp, dull, aching
	Duration	Constant, paroxysmal, periodic.
	Conditions of appearance	When walking, shaking, may be accompanied by dysuric phenomena.
	What makes it easier	Warmth, hot bath, antispasmodics
Urinary disorder (dysuria).	Pattern of urination	Arbitrary, not arbitrary.
	Is urination accompanied by pain or burning?	At the beginning, at the end of urination or painlessly.
	Frequency of urination and approximate amount of urine per day in ml	Frequent (more than 5-7 times a day), rare (less than 3-5 times a day).
NERVOUS SYSTEM
Headaches, noise in the head, dizziness	Frequency, duration.	Constant, paroxysmal. Frequent or rare.
BONE-ARTICULAR-MUSCULAR SYSTEM
Pain in bones, joints, spine	Localization	In large or small joints, parts of the spine.
	Character	Sharp, dull, aching, shooting
	Irradiation	Up, down, along the nerve
	Duration	Permanent, "volatile", periodic. Over what period of time: days, weeks, months, years.
	When do they arise?	At rest, during movement, during physical activity.
	What makes it easier	Warmth, peace
Swelling, joint deformation, stiffness.	Localization	Large or small joints.

Anamnesis (history) of the disease. This an important part questioning, since it is associated with an idea of ​​​​all stages of the development of the disease.

When collecting anamnesis of the disease, it is necessary to obtain answers to the following questions

· when did the disease begin(considers himself sick with...)

· how it started(what is associated with the onset of the disease, what was the onset - acute or gradual, what were the symptoms, what was done then)

· how did the disease progress?(worsened, no change, new signs of illness appeared, etc.)

· whether the patient sought medical help(where, when)

· what examination and treatment was carried out, what is the effectiveness of treatment

· about the latest deterioration(with a long course of the disease), for which the patient sought help. I am interested in the time of the deterioration, how it manifested itself, what I tried to help myself with, and the reason for my appeal.

The history of the present disease should reflect the development of the disease from its onset to the present. It is necessary to find out the general state of health of the patient before the onset of the disease and try to establish the reasons that caused it.

Patient's life history is a medical biography of the patient for the main periods of his life.

1) General biographical information

Place of birth - this may suggest a disease common in the area (endemic goiter)

What kind of child was the subject in the family?

· feeding conditions in infancy(more relevant to collecting an anamnesis of the child’s life - information must be obtained from the parents

· when he began to walk and talk, general health and development

· time of onset of puberty, beginning of menses in women

· find out from men about military service, and if you did not serve, what disease was the cause

· in women, the number of pregnancies, births, their course

· Where did you study, the beginning of your working career?

2) living conditions

· separate apartment or dormitory, wooden house, living conditions (presence of dampness, etc.)

· marital status (how many people are in the family, their health status, financial security)

3) previous diseases

· be sure to specifically clarify whether you have had tuberculosis, Botkin’s disease, or sexually transmitted diseases

· clarify the features of the flow past diseases, presence of complications

· have you had contact with infectious patients or feverish patients, have you traveled abroad?

· were there any operations, when and what, were there any blood transfusions (risk of infection with viral hepatitis)

4) bad habits

· smoking (from what age, number of cigarettes per day). This is a risk factor in the development of diseases of the respiratory system and cardiovascular system

· drinking alcohol (how often, what drinks, in what quantity).

· use of drugs, toxic substances

· excessive passion for coffee and other stimulating drinks

5) expert labor history

· who and where he works

· nature and working conditions

· Availability occupational hazards(dust - bronchial asthma, pneumoconiosis, vibration - vibration disease), physical stress, long business trips, night shifts, stressful and conflict situations

· number of days of temporary disability and number of cases per year

6) family history

information about the health status of parents and immediate relatives.

This is important, since some diseases occur in close relatives (for example, diabetes mellitus, arterial hypertension, bronchial asthma, etc.) and a predisposition to them can be inherited.

7) allergy history

Receive information about intolerances medicines, food (nausea, vomiting, itchy rash, loss of consciousness), dust, plant odors (tearing, sneezing, runny nose). Clarify what substances were used allergic reaction, and how it manifested itself. They ask if there was exudative diathesis in childhood.

Objective methods of examining a patient.

The second stage of collecting information about the patient is objective examination, which, like questioning, is the main method of research. An objective examination of the patient allows you to get an idea of ​​the general condition of his body and internal organs. Information is obtained through the senses: vision, hearing, smell, touch. The examination is carried out according to a specific plan:

General examination of the patient, measurement of body temperature, patient height, weight,

Palpation (feeling),

Percussion (tapping),

Auscultation (listening) sequentially: respiratory organs, circulatory system, digestion, urination, thyroid gland, lymph nodes, musculoskeletal system, as well as clinical, laboratory and instrumental studies.

INSPECTION.

Inspection is a method diagnostic examination the patient, based on the visual perception of the medical worker. To obtain valuable and reliable results during an inspection, certain rules must be followed.

It is better to carry out the inspection in daylight or with diffused artificial lighting. A completely or partially naked patient should be sequentially examined in direct and lateral lighting. The latter is especially convenient for determining the relief and contours of various parts of the body and identifying pulsations on its surface.

The examination begins from the moment of meeting the patient. During the conversation, the patient’s appearance, demeanor, posture, gait, facial expression, consciousness, etc. are assessed.

There are general and local examinations. The first concerns the entire patient as a whole, and is carried out at the beginning of any study. Local examination involves examining individual parts of the body, organs and systems.

GENERAL INSPECTION

A general examination allows us to establish the state of consciousness, the position of the patient, his general form(habitus) and the condition of the external integument.

Consciousness the patient may be clear , disturbed or missing . There are several degrees of impairment of consciousness.

1) Stuporous consciousness(sturog) - states of stun. The patient is poorly oriented in the surrounding environment and answers questions late. It is observed with contusions and some diseases.

2) Soporous state(sorog) - hibernation, from which the patient emerges only after a loud cry or braking for a short time. Reflexes are preserved. May be observed in infectious diseases.

3) Coma(soma) - complete absence of consciousness with absence of reflexes, reaction to external stimuli and dysfunction of vital organs. In this case, information about the patient is obtained from relatives. Causes comatose states varied (may be with cerebral hemorrhage, may be alcoholic coma, hyperglycemic with lack of insulin, hepatic, uremic with renal failure and etc.). Coma can develop acutely or gradually with a precomatous period (state).

_Position the patient may be active, passive and forced .

The position is defined as active, if the patient can easily and quickly change it voluntarily, it is observed in mild diseases or in the initial stages of more severe ones, and is not, as a rule, accompanied by disturbances of consciousness (with the exception of mental illnesses).

Passive is a position observed in an unconscious state or in cases of extreme weakness, when the patient is unable to independently change the position.

Forced the patient takes the position to alleviate the existing discomfort. Sometimes the forced position is so characteristic that it can serve as the basis for a diagnostic conclusion already at the stage of a general examination. Such provisions include orthopnea- semi-sitting or sitting position, reducing the severity of shortness of breath due to circulatory failure; sitting position with a forward bend, characteristic of patients with effusion pericarditis., lying on your sore side with dry pleurisy, lung abscess (the pleura rubs less with dry pleurisy, and with an abscess the cough decreases, position on the side with the head thrown back and bent to the stomach legs with meningitis; 4) during an attack of bronchial asthma the patient sits, resting his hands on the edge of a chair or table, leaning slightly forward (auxiliary respiratory muscles are mobilized).

_General view assessment The patient begins with determining the constitutional type of physique: asthenic, normosthenic or hypersthenic .

For asthenic type is characterized by a predominance of longitudinal dimensions over transverse ones, the chest is narrow and elongated in length, the supra- and subclavian fossae are pronounced, the intercostal spaces are contoured, the shoulder blades are spaced from the chest, the epigastric angle is acute.

In persons hypersthenic type, the transverse dimensions of the chest prevail over the longitudinal ones, short neck and limbs, well-developed muscles, obtuse epigastric angle.

Normosthenic the type is characterized by proportionality to the main dimensions of the body, a conical shape of the chest, a tight fit of the shoulder blades to the chest, and a right epigastric angle.

The constitutional body type is hereditary and can be a marker of certain diseases. Thus, patients with an asthenic physique have lower blood pressure and cholesterol levels. They are more likely to suffer from peptic ulcers and tuberculosis. Hypersthenics are characterized by a tendency to increase blood pressure, hyperlipidemia and the development of hypertension, coronary disease, diabetes, obesity.

The condition is to a certain extent associated with the body type fatness (nutrition) sick. Various indicators are used to assess body weight.

More often than others, the formula is used for this purpose Broca: body weight in kg is equal to height in cm minus 100, with fluctuations of 10%.

Quetelet index BMI = weight kg/height m2 norm 18.5-24.9

In addition, it is necessary to determine the thickness of the skin fold, grasped with two fingers at the level of the navel or under the scapula. This fold, together with the underlying tissue, is normally 1 cm.

Reduced nutrition is observed during fasting, dehydration, and digestive disorders. Extreme degree of weight loss - kachexia - occurs with malignant neoplasms and some endocrine diseases.

Increased body weight - obesity (adipositas) can be nutritional, or occur due to diseases of the endocrine glands.

There are four degrees of obesity: I - body weight exceeds normal by 10-30%, II - by 31-50%, III - by 51-100%, and IV - more than twice.

Gait assessment. In many cases, by the patient’s posture and demeanor, one can judge his general tone, degree of muscle development. Straight posture, cheerful gait, free movements indicate good condition body. Most physically seriously ill and mentally depressed and depressed subjects tend to be hunched over. A specific gait occurs in some diseases nervous system(radiculitis, sciatica, hemiplegia, etc.). "Duck" gait occurs with congenital dislocation of the hip joints.

At the time of questioning and examining the patient, it is important to draw up characteristics of his mental state. When observing appearance, manner of speaking and other parameters, the norm of behavior or its deviations is interpreted.

For example, pose: forced, tense, relaxed;

posture: straight, lordosis, kyphosis, scoliosis, hunched, lowered head;

appearance: angry - violation of the need for communication (mental illness, defects of character and education); frightened - fear, phobias, neurosis, suspiciousness; balanced is the norm of behavior.

At detailed inspection First of all, it is necessary to fix attention on the open parts of the patient’s body - head, face, neck.

Examination of the head. We perform a visual assessment of the size and shape of the patient’s head. An excessive increase in the size of the skull occurs with hydrocephalus. Excessive reduction in head size (microcephaly) is often combined with mental retardation. With cervical spondyloarthrosis, myositis, the characteristic position of the head is (sedentary). Involuntary head movement (shaking) occurs with parkinsonism.

Feminine facial features in men and masculine ones in women also play a diagnostic role, which may indicate the presence of endocrine disorders.

Other facial changes. 1) Puffy face: kidney disease, local venous stasis, mediastinal tumor, etc. 2) Feverish face: flushed skin, shiny eyes, excited expression (infectious diseases); with typhus “rabbit eyes” - the sclera of the eyes is injected; 3) Moon-shaped face with Itsenko-Cushing's disease; 4) the face of Hippocrates - sunken eyes, pointed nose, pallor with cyanosis, drops of cold sweat - with serious illnesses abdominal cavity (peritonitis), 5) Corvisar's face in heart failure.

Examination of eyes and eyelids allows you to identify a number of symptoms. Violation of fat metabolism leads to the formation of “xanthoma” in the thickness of the eyelids. Icterus (yellowness) of the sclera - in liver diseases. Swelling of the eyelids (“bags” under the eyes) may be a sign of kidney disease, anemia, appear after sleepless nights, with frequent coughing attacks. Dark coloration of the eyelids - with Addison's disease. Omission upper eyelid(ptosis) is a sign of certain lesions of the nervous system. The shape, uniformity, reaction to light, and pulsation of the pupils are of great diagnostic importance. Constriction of the pupils is characteristic of brain tumors due to morphine poisoning. Pupil dilation - for comatose states, in case of atropine poisoning.

Oral examination carried out using a sterile spatula. Inspected first vestibule of the mouth, then oral cavity. Attention is paid to the condition of the mucous membrane, excretory ducts of the salivary glands, and teeth. Filatov-Koplik spots are found on the mucous membrane in measles, and aphtha in stomatitis. Changes in the gums can occur with a number of diseases: scurvy, acute leukemia. Carious teeth are a source of infection. Has the meaning tongue examination. In some diseases, the appearance of the tongue has its own characteristics: crimson with smoothed papillae - with B 12 deficiency anemia; dry with cracks and a dark, brown coating - with severe intoxication and infections; “varnished” tongue - for stomach cancer.

The pharynx is examined: uvula, pharynx, tonsils.

Looking around ears and external auditory openings (possible rash and weeping behind the ears or purulent, bloody discharge from the ears).

Examination of the scalp. On the scalp, attention is paid to the condition of the hair: brittle, dull, split ends - with anemia, myxedema; intensively falling out - with endocrine pathology; local baldness - due to fungal diseases (microsporia); the presence or absence of pediculosis, seborrhea, skin lesions.

Neck examination. Pay attention to the pulsation of the carotid arteries, swelling and pulsation of the external jugular veins (right ventricular heart failure or compression syndrome of the superior vena cava), enlargement of the lymph glands (tuberculosis, leukemia, cancer metastases); enlargement of the thyroid gland (goiter, malignant tumor).

Skin examination It is advisable to carry out in natural light. The color of the skin depends on the degree of blood supply to the skin vessels, the quantity and quality of pigment, the thickness and transparency of the skin.

Hyperemia(redness) skin is explained by the dilation of peripheral blood vessels, which can occur with fever, excitement, or after drinking alcohol. Transient hyperemia occurs with the introduction or ingestion of nicotinic acid. Persistent hyperemia is caused by excessive formation and presence of red blood cells in the vessels (erythremia). With lobar pneumonia, hyperemia of the cheek is observed on the side where the pneumonia is localized.

Pale skin More often it occurs due to blood loss, low hemoglobin content (anemia), spasm of skin vessels (collapse, shock).

Cyanosis(cyanosis) skin occurs due to the accumulation of a large amount of reduced hemoglobin in the blood, hypoxia due to circulatory disorders, chronic diseases lungs. Cyanosis may be:

Central – for pulmonary diseases;

Peripheral (acrocyanosis) – with heart failure. In heart failure, blood flow in the periphery slows down (blood stagnation), oxygen delivery to tissues increases, and reduced hemoglobin accumulates in the blood.

Yellowness (icterus) of the skin and mucous membranes occurs when there is excessive accumulation of bile pigments (bilirubin) in the blood. The cause is liver disease (hepatitis, cirrhosis, cholelithiasis, cancer of the head of the pancreas). Rarely, yellowness may appear when carotene or carrots are consumed in large quantities, but then the mucous membranes do not become stained.

Skin pigmentation. With chronic adrenal insufficiency, the skin color becomes bronze. There may be areas of skin depigmentation (vitiligo) or complete loss of skin pigmentation (albinism).

The skin may have different rashes:

Petechiae are pinpoint hemorrhages in the skin; - Purpura – large hemorrhages; - Urticaria (blister rash) - itchy pink spots; - Erythema - a slightly raised hyperemic area of ​​skin; - Herpetic rash - blisters (vesicles) with a diameter of 0.5-1 cm.

The rash often leaves behind peeling skin.

Physical condition of the skin. When examining, you need to pay attention to the moisture or dryness of the skin, its atrophy, turgor, and swelling. The condition of the subcutaneous fat layer is determined. Overdevelopment subcutaneous fat layer (obesity) can be caused by endogenous and exogenous factors. Thinning of the subcutaneous fat layer (weight loss) occurs during fasting, diseases of the digestive system, cancer, etc. An extreme degree of emaciation is called cachexia.

Can see swelling. Edema is caused by the release of fluid from the vascular bed through the walls of the capillaries and its accumulation in the tissues. Edema fluid can be stagnant (transudate) or inflammatory (exudate). Cavity edema: ascites(fluid in the abdominal cavity ), hydrothorax(in the pleural cavity), hydropericardium(in the pericardial cavity). General swelling is characterized by distribution throughout the body or in symmetrical areas, but mainly in lower parts of the body and is called anasarca. Local swelling depends on some local circulatory or lymph circulation disorder. It is observed when a vein is blocked by a blood clot, compressed by a tumor or an enlarged lymph node.

Examination of the limbs. Pay attention to the degree of development of the muscular system, which depends on the person’s profession and sports activities. Muscle strength and local atrophy of the limb muscles are determined. Defects, curvatures, deformations of joints and bones are identified, the range of movements in the joints, and the condition of the skin over them are determined. The detection of varicose veins (nodes) is of diagnostic importance. The nail phalanges are examined, which may be thickened (symptom “ drumsticks") with emphysema. Nails may take the shape of “hour glasses” (evenly convex) in bronchiectasis. Brittle nails are characteristic of anemia.

Examination of the chest. The shape of the chest, the state of the intercostal spaces during breathing, and the nature of breathing are assessed.

Inspection of the front abdominal wall. The shape, size of the abdomen, and its participation in breathing are assessed.

At the end of the general examination, after determining the value of blood pressure and pulse characteristics, a severity rating general condition patient.

Criteria for determining the general condition of the patient: consciousness, position in bed, facial expression, skin color, body temperature, breathing pattern, blood pressure, pulse pattern, symptoms of the disease.

It can be: - satisfactory, - moderate severity, - heavy, - extremely heavy,

At satisfactory the state of consciousness is clear, the position in bed is active, the skin color is normal, the body temperature is normal or subfebrile. The patient takes care of himself.

State moderate severity accompanied by significant complaints, consciousness is clear, the patient spends most of the time in bed, fever, pronounced dysfunctions of the internal organs are objectively detected.

Severe or extremely serious condition it is stated if there is a disturbance of consciousness (coma), high fever, a passive position in bed, pale skin (shock), the face expresses suffering, significant disturbances in the internal organs.

PALPATION

Palpation (palpatio) - a clinical method of directly examining a patient using touch to study the physical properties of tissues and organs, the topographic relationships between them, and their pain.

This research method has been known since the time of Hippocrates, but until the 19th century, its use was limited to studying the condition of the skin, joints, bones and the properties of the pulse. From the middle of the 19th century to clinical practice included the study of vocal tremor and apex beat of the heart, and systematic palpation of the abdominal cavity became mandatory only from the end of the last and beginning of the present century.

Depending on the goals pursued, two types of palpation are used: superficial and deep.

Superficial palpation skin, joints, chest, abdomen is used as a general, indicative study. Superficial– used to identify pathological formations in the skin and underlying tissues, pain, muscle protection, pulsations, trembling (voice, “cat purring”), etc.

Deep palpation serves for the purpose of detailed study and more precise localization of pathological changes. Deep palpation allows you to determine the location, size and shape of the organ being examined, the nature of its surface, consistency, mobility, the presence of pain, pulsations, “rumbling”, relationships with surrounding organs and tissues. Deep palpation is used mainly to examine the abdominal organs and kidneys.

A variety of deep is penetrating palpation , used to determine pain at certain points (appendicular, gallbladder, etc.).

Palpation rules:

The room where palpation is performed should be warm.

The position of the palpater is to the right of the patient.

The patient should be in a position that is comfortable for him and the doctor. The muscles should be relaxed as much as possible.

Hands should be warm and nails should be cut short.

Palpation should be done gently, not harshly. Feeling movements should be smooth and careful.

The abdominal organs are palpated in connection with breathing.

During palpation

The skin or muscles are felt by taking them in a fold to determine elasticity, firmness, thickness, etc. Humidity, dryness, and skin temperature are assessed by placing your palms flat on symmetrical areas of the skin and joints. Palpation of edema in the lower extremities is performed by pressing a finger against the bone on the front surface of the leg. The presence of a pit at the site of pressure indicates the presence of edema, which is not visible upon examination and is called pastosity. By palpation, lightly squeezing the skin with your fingers over the passage of the artery (radial, temporal, carotid artery) pulse is examined. Lymph nodes are normally not palpable or palpable in the form of peas. They are soft, mobile, and not fused to the skin. Palpation determines their size, pain, consistency, mobility, and adhesion to the skin. The lymph nodes should be palpated from top to bottom, standing in front and to the right of the patient, with both hands in the following sequence: occipital, parotid, submandibular, sublingual, cervical, supra- and subclavian, axillary, inguinal, popliteal. An apex beat and tremors of the chest wall are palpated on the chest in some heart defects.

Palpation of the abdomen begins from the superficial (from left to right, but from the healthy area to the patient). Then systematic deep palpation is carried out in the following sequence: sigmoid colon, cecum, ascending and descending colon, stomach, transverse colon, liver, spleen, kidneys.

PERCUSSION

Percussion(percussio) - an objective method of examining a patient, consisting of percussing areas of the body and determining, by the nature of the resulting sound, the physical properties of the organs and tissues located under the percussed area (mainly their different density, airiness, elasticity). Hippocrates used tapping to identify the accumulation of liquid or gas in the abdomen.

The scientific basis for the method of systematic percussion was developed by the Viennese physician L. Auenbrugger, who in 1761

Currently, the most widespread method throughout the world is direct finger percussion, proposed by the Russian scientist I. Sokolsky in 1835. The middle finger of the left hand is used as a plessimeter, and blows are applied with the middle finger of the right hand. This percussion method allows you to evaluate changes in percussion sound not only by hearing, but also by touching with a pessimeter finger.

With the same force of percussion blows, the nature of the vibrations of the underlying organs and tissues, and, accordingly, the properties of the resulting sound, depend on the amount of air contained in them. If there is no air in the tissues located under the percussed area, dull (femoral) or dull percussion sound. If the size of the airless tissue is small, a dull sound is heard, and if it is large, a dull sound is heard. With a large amount of air - tympanic (tympanic). Above normal lung tissue - clear lung sound. With increased airiness (emphysema) of the lungs - boxed percussion sound. If dullness is detected above the area of ​​the lung where pulmonary sound is usually produced, one must think about compaction of the area of ​​the lung (focal pneumonia) or a cavity filled with fluid.

Percussion can be:

- direct(when blows are applied directly to the surface of the patient’s body)

Indirect (when a metal plate or the doctor’s finger is placed).

To study the symmetrical parts of the lungs, use comparative percussion, with the help of which pathological changes in the lung tissue (presence of compaction, increased airiness, cavity) and pleura (pleural overlays, accumulation of fluid or air) are detected. Comparative percussion is carried out over symmetrical areas of the lungs, taking into account topographic lines and along the intercostal spaces. To determine the boundaries of internal organs (heart, lungs, liver and spleen), the level of fluid in the pleural and abdominal cavities, they are used topographical percussion.

Basic rules of percussion:

The room should be warm and quiet.

The person percussing must be in comfortable position, his hands should be warm.

The patient's position should be comfortable. If possible, the patient should be seated on a chair facing the back of the chair, head slightly tilted forward, hands placed on knees.

The left palm is pressed tightly to the body, so that there is no air gap, with fingers slightly apart.

Bend the middle finger of the right hand at the terminal phalanx so that during percussion it falls on the middle phalanx of the left middle finger at a right angle.

The blow is not applied with the whole hand, but only by moving the hand at the wrist joint.

The percussion blow should be short and abrupt. The blows should be struck with the same force.

During topographic percussion, the finger of the left hand should be placed parallel to the expected border of the organ. Percussion is carried out from an organ producing a louder sound to an organ above which a quiet sound is determined. The border is marked along the edge of the left finger facing the side of the clear sound.

Comparative percussion must be carried out on strictly symmetrical areas of the body and with the same force of blows.

1. General information about percussion

Percussion (from Latin percussio - tapping) is based on tapping on the surface of the subject's body with an assessment of the nature of the sounds that arise.

When tapping, vibrations occur in the underlying tissues and organs, which are transmitted to the surrounding air and perceived by the ear as sound.

1.1. Percussion classification

I. By methods of execution:

1. indirect (by plessimeter);

2. direct (directly on the surface of the body).

II. By purpose:

1. comparative (compare the sound in symmetrical areas of the chest);

2. topographic (determination of the boundaries of organs, their size and shape).

III. According to the strength of percussion sound and the depth of propagation of sound vibrations:

1. loud (7 – 8 cm);

2. medium strength (5 – 6 cm);

3. quiet (3 – 4 cm);

4. quietest (threshold) (2 - 3 cm).

1.2. Properties of percussion sound

The properties of percussion sound depend on the amount of air in the organ, the elasticity and tone of the organ being examined (i.e., on the degree of density of the organ). The sounds produced by percussion are distinguished by strength (clarity), height and shade. The strength distinguishes between loud (clear) and quiet (dull) sound; in height - high and low; by hue - tympanic, non-tympanic and sound with a metallic tint.

Types of percussion sound:

Clear pulmonary - loud, long-lasting, relatively low-frequency (109 - 130 Hz), with rich timbre coloring. Determined over normal lung tissue. The standard is the sound determined by percussion of the axillary and subscapular areas of a healthy person.

Dull – low amplitude (loudness), duration and relatively high frequency (up to 400 Hz). Determined over dense airless organs (liver, spleen) and fluid. The sound is dull, barely perceptible to the ear. The standard of an absolutely dull sound is the sound determined by percussion of the thigh muscles (femoral sound).

Tympanic (from the Greek tympanon - drum) - loud, long-lasting, relatively low-frequency, without timbre coloring, with periodic fluctuations (approaches the properties of tone). Defined over hollow organs or a cavity containing air. The standard is the sound determined by percussion of the abdominal cavity and Traube's space.

Boxed - loud, low-frequency (70 - 80 Hz), almost without timbre coloring. It is determined by pulmonary emphysema (increased airiness and decreased elasticity of the lung tissue). The standard is the sound that appears when the box is percussed.

Dull-tympanic - combines the properties of dull and tympanic sounds. It is determined by maintaining some airiness of the alveoli while simultaneously significantly reducing the elasticity of the lung tissue.

Metallic – short, clear, with strong high overtones, reminiscent of the sound of hitting metal. Occurs as a result of resonance in a nearby large smooth-walled cavity containing air.

1.3. Changes in percussion sound in a healthy person

The change in percussion sound in a healthy person is due to:

1. weight and thickness of the pulmonary layer;

2. influence on percussion sound neighboring organs.

A quieter and shorter percussion sound is determined by:

Above the right apex (since it is located slightly lower than the left apex due to the shorter right upper bronchus and more pronounced development muscles of the shoulder girdle on the right);

In the II – III intercostal space on the left (close location of the heart);

Above the upper lobes of the lungs compared to the lower lobes (different thickness of lung tissue);

In the right axillary region compared to the left (proximity of the liver).

Louder, with a tympanic tint, the percussion sound is determined by:

In the lower sections on the left (neighborhood of the stomach – semilunar space of Traube: right – left lobe liver, on the left - the anterior edge of the spleen, above - the diaphragm, below - the edge of the costal arch).

1.4. Change in airiness of the lungs

A decrease in the amount of air is observed when:

1. pneumosclerosis, fibrous pulmonary tuberculosis;

2. the presence of pleural adhesions or fibrothorax (limited expansion of the lung);

3. focal (especially confluent) pneumonia;

4. pulmonary edema (especially in the inferolateral regions);

5. compression atelectasis (above the fluid level);

6. incomplete obstructive atelectasis (gradual resorption of air below the site of blockage).

Complete absence of air in the lobe or lung segment observed when:

1. lobar pneumonia (in the stage of compaction, hepatization);

2. the presence of a large cavity filled with liquid (pus, hydatid cyst, etc.);

3. presence of a tumor (complete obstructive atelectasis);

4. hydrothorax (exudate, transudate, blood, pus).

An increase in air content is observed when:

1. emphysema (increased airiness and decreased elastic tension of the lung tissue);

2. the formation of a large smooth-walled cavity filled with air and communicating with the bronchus (tuberculosis cavity, air cyst, emptied abscess).

1.5. Diagnostic value of changes in percussion sound

A clear pulmonary percussion sound over the lungs indicates the absence of pronounced changes in the pulmonary parenchyma and is determined over normal lung tissue. However, its presence does not exclude inflammatory changes in the bronchial mucosa, their narrowing and other changes in the bronchial tree.

Dullness or dull percussion sound over the lungs is determined by the presence of:

1) compaction of lung tissue (lobar or focal pneumonia, pulmonary infarction, obstructive atelectasis);

2) fluid in the pleural cavity (exudative pleurisy, hydrothorax, hemothorax);

3) a cavity in the lung filled with fluid;

4) obliteration of the pleural cavity (fibrothorax).

A boxy percussion sound indicates increased airiness of the lungs and a decrease in their elasticity (emphysema).

Tympanic sound is detected when:

1) pneumothorax;

2) the presence in the lung of a large cavity communicating with the bronchus (abscess, tuberculous cavity).

A dull tympanic sound is determined by:

1) in the initial stage of lobar pneumonia;

2) in the presence of a partially filled cavity in the lung, communicating with the bronchus;

3) with incomplete obstructive atelectasis;

4) over compression atelectasis.

A metallic percussion sound is detected over a very large (6–8 cm in diameter) smooth-walled cavity in the lung.

“The sound of a cracked pot” is a peculiar quiet rattling sound over a large superficial cavity communicating with the bronchus through a slit-like opening.

1.6. Topographic percussion data in healthy people

1. Height of the apex of the lungs on the right and left

Front: 3 – 4 cm above the collarbone;

Posterior: at the level of the spinous process of the VII cervical vertebra.

2. Width of Krenig's fields (areas of clear pulmonary sound between the clavicle and the spine of the scapula, divided into anterior and posterior parts by the upper edge of the trapezius muscle): 5 - 6 cm;

3. Lower borders of the lungs (Table 4.1.).

Table 4.1.

Position of the lower borders of the lung in a normosthenic

Topographic lines	Right lung	Left lung
Parasternal	Upper edge of the 6th rib	-
Midclavicular	Lower edge of the 6th rib	-
Anterior axillary	7th rib	7th rib
Middle axillary	8th rib	8th rib
Posterior axillary	9th rib	9th rib
Scapular	10th rib	10th rib
Paravertebral	At the level of the spinous process of the 11th thoracic vertebra

4. Mobility of the lower pulmonary edge (on the left is determined only by the middle axillary and scapular lines):

Along the midclavicular line: 4 – 6 cm;

Along the midaxillary line: 6 – 8 cm;

Along the scapular line: 4 – 6 cm.

5. Width of the roots of the lungs: 4 – 6 cm.

1.7. Diagnostic value of changes detected

with topographic percussion

The height of the apexes of the lungs and the width of the Krenig fields.

Enlargement: increased airiness of the lungs (emphysema), air cyst of the lung.

Decrease: decrease in airiness of the lungs (inflammatory infiltrate, presence of connective tissue, obstructive atelectasis).

The lower borders of the lungs.

Omission:

Bilateral (increased airiness of the lungs, sharp weakening of the tone of the abdominal muscles, splanchoptosis);

Unilateral (vicarious emphysema of one lung, unilateral paralysis of the diaphragm).

Offset up:

Bilateral (ascites, flatulence, air in the abdominal cavity);

Unilateral (pneumosclerosis, pneumofibrosis, obstructive atelectasis, hydrothorax, pneumothorax, sharp enlargement of the liver (cancer, echinococcus) or spleen).

Mobility of the lower pulmonary edge.

Increase: in well-physically trained individuals, athletes (swimming, rowing, cross-country skiing).

Decrease: impaired bronchial obstruction, obstructive atelectasis, inflammatory infiltration of lung tissue, pneumosclerosis, pneumofibrosis, hydrothorax, pneumothorax, pulmonary infarction, sharp enlargement of the liver (cancer, echinococcus) or spleen, ascites, flatulence, air in the abdominal cavity.

In obstructive conditions (impaired bronchial obstruction), the exhalation excursion is predominantly reduced.

In restrictive conditions (reduction of the respiratory surface), the inspiratory excursion is predominantly reduced.

In the presence of both obstruction and restriction, both components decrease.

Width of the roots of the lungs.

Increased: inflammation (bronchitis, pneumonia, tuberculosis, etc.), metastases, lymphoproliferative diseases, sarcoidosis.

Decreased: increased airiness of the lungs.

Percussion of the lungs

The purpose of lung percussion is to identify pathological changes in any part of the lung or pleura, determine the boundaries of the lungs and the mobility of the lower edge of the lungs.

Patient position. It is usually vertical - standing or sitting. In a standing position during percussion from the front, the patient stands with his arms down. During percussion from behind in the same position, the patient crosses his arms over his chest and slightly bends the spine in the cervical and lumbar regions.

In a sitting position, during percussion from the front, the patient puts his hands on his knees; when percussing from behind, he sits on a chair, bends slightly, bending the spine in the cervical and lumbar regions, the shoulder blades should be separated.

When percussing the lateral chest, the patient raises one or both hands and places them on the head.

Comparative percussion is percussion performed on strictly symmetrical areas of the chest, both in front and behind. In this case, the percussion sound obtained in this area is compared with that in a symmetrical area of ​​the other half of the chest.

Sequence of comparative percussion from the front. Comparative percussion of the lungs begins from the front in the supraclavicular fossae above the apices of the lungs. The pessimeter finger is placed parallel to the collarbone. Then directly along the collarbones. Further below the clavicles: in the 1st and 2nd intercostal spaces along the sternal and midclavicular lines. The pessimeter finger is placed in the intercostal spaces parallel to the ribs in strictly symmetrical areas of the right and left halves of the chest.

In the 3rd and lower intercostal spaces in front, comparative percussion is not performed, since from the 3rd intercostal space the dullness of the percussion sound from the adjacent heart begins. You can only percussion lower only along the parasternal line, comparing the sounds obtained by percussion in the 3rd to 5th intercostal spaces.

Side Comparative Percussion Sequence. In the lateral areas of the chest, percussion is performed in the axillary fossa and along the 4th and 5th intercostal spaces. The pessimeter finger in the axillary areas is placed in the intercostal spaces parallel to the rib. In the 6th intercostal space, comparative percussion along the axillary lines is not carried out, since on the right in this intercostal space the dullness of sound from the adjacent liver begins, and on the left the sound acquires a tympanic hue from the proximity of the gas bubble of the stomach.

Sequence of comparative rear percussion. From behind, comparative percussion is carried out in the suprascapular areas, upper, middle and lower parts interscapular spaces and under the shoulder blades - in the 8th and 9th intercostal spaces. The pessimeter finger is installed horizontally in the suprascapular region, vertically in the interscapular spaces, parallel to the spine, and horizontally, parallel to the ribs, under the shoulder blades.

Variants of pulmonary sound during comparative percussion of the chest:

1) clear pulmonary sound - clear (loud), full (long), low timbre. Occurs over areas with the same thickness of the pulmonary (mass of lung tissue) and muscle layers, not subject to reflected influence from neighboring organs;

2) a slightly shortened (dull) clear pulmonary sound - quieter and shorter. It is determined: 1) above the right apex - due to the shorter right upper bronchus, which reduces its airiness, and greater development of the muscles of the right shoulder girdle; 2) in the II and III intercostal spaces on the left due to the closer location of the heart; 3) above the upper lobes of the lungs compared to the lower lobes as a result of different thicknesses of air-containing lung tissue; 4) in the right axillary region compared to the left due to the proximity of the liver;

3) tympanic shade of clear pulmonary sound - louder and higher (sonorous). Determined in the lower parts of the lungs on the left along the anterior and middle axillary lines. This is due to the fact that the stomach, the bottom of which is filled with air, adjoins the diaphragm and lung on the left. Therefore, the percussion sound in the left axillary region, due to the resonance from the “air bubble” of the stomach, becomes louder and higher, with a tympanic tint.

Topographic percussion - this is percussion to determine the upper boundaries of the lungs or the height of the apexes and their width (the width of the Krenig fields); the lower borders of the lungs and the mobility of the pulmonary edge of the lungs.

Determination of the upper boundaries of the lungs or the height of the apexes in front. The pessimeter finger is installed in the greater supraclavicular fossa at the outer edge of the sternocleidomastoid muscle. Percussion is carried out in an oblique direction from the middle of the collarbone upward to a dull sound. The mark is placed on the side of the pessimeter finger that faces the clear pulmonary sound, the collarbone. Normally, the height of the apex is at a distance of 3-4 cm from the middle of the collarbone. The right apex is 1 cm lower than the left.

Determination of the upper boundaries of the lungs or the height of the apexes at the back. The patient tilts his head down slightly. The pessimeter finger is installed in the middle of the suprascapular fossa at the scapular crest, and then moved in the direction of the 7th cervical vertebra until a dull sound occurs. The mark is placed on the side of the clear pulmonary sound. Normally, the height of the apex on the back right and left corresponds to the level of the spinous process of the 7th cervical vertebra.

Determination of the width of the Kroenig field - a strip of clear pulmonary sound that spreads from the front of the clavicle back to the scapula. The pessimeter finger is installed in the middle of the upper edge of the trapezius muscle (Fig. 198). Then the middle of this muscle is percussed along its upper edge to the shoulder until a dull sound is produced. A mark is made on the side of the clear pulmonary sound. Next, percussion is carried out again from the middle of the trapezius muscle along its upper edge to the neck until a dull sound occurs. The mark is placed on the side of the clear pulmonary sound. The distance between two marks, expressed in centimeters, is the width of the Kroenig field. Normally it ranges from 5 to 8 cm.

Determination of the lower borders of the lungs on the right (hepatopulmonary border). Percussion is performed from top to bottom along the intercostal spaces along the parasternal line, midclavicular line , anterior, middle and posterior axillary lines, scapular line, paravertebral line. The border mark is placed along the edge of the finger facing the lung.

Determination of the lower borders of the lungs on the left. Percussion is performed from top to bottom, starting from the anterior axillary line. It is impossible to percussion along the parasternal and midclavicular lines because of the heart. Next, percussion is carried out along the anterior, middle and posterior axillary lines, scapular and paravertebral lines.

The border mark is placed along the edge of the finger facing the lung.

Determination of mobility of the lower edges of the lungs. To do this, determine the lower border of the lungs separately at the height of a deep inspiration and after a complete exhalation. The study is carried out along all lines, but in practice we can limit ourselves to determining mobility along three lines, where the excursion of the pulmonary edge is greatest: midclavicular, middle axillary and scapular.

Mobility of the pulmonary edge along the main lines:

The pessimeter finger is installed on the corresponding line parallel to the pulmonary edge. First, the border of the lung is determined along this line during quiet breathing. The mark is placed on the side of the pessimeter finger that faces the clear pulmonary sound. Without removing the pessimeter finger, ask the patient to take as deep a breath as possible and hold his breath. At this moment, they percussion downward until the sound becomes dull again. A mark is placed on the side of the plessimeter finger that faces the clear pulmonary sound. The distance between the obtained marks, measured in centimeters, reflects the mobility of the pulmonary edge downwards. To determine the mobility of the edge of the lung upward, the finger-pessimeter is again installed so that the mark corresponding to the lower border of the lung, during quiet breathing, passes on the side of the finger that faces the clear lung sound. After installing the finger-pessimeter, the patient is asked to first inhale, then exhale as much as possible and hold his breath. In the position of maximum exhalation, percussion is performed upward until there is a clear pulmonary sound. Since in this case the percussion was carried out from a dull sound to a clear one, a mark is placed on the side of the pessimeter finger that faces the direction of the dull sound, for example, towards the liver. The distance from the resulting mark to the border of the lung during quiet breathing will correspond to the mobility of the pulmonary edge upward. The distance between the marks corresponding to the positions of maximum inhalation and maximum exhalation reflects the general or maximum mobility (excursion) of the lower edge of the lung.

PERCUSSION OF THE HEART

The purpose of cardiac percussion is identification of relative (deep) and absolute (superficial) percussion dullness of the heart; determination of the size (dimensions), configuration of the heart and vascular bundle.

Orientation of the heart in the chest cavity in the frontal plane. The right atrium (RA) usually makes up the convex side of the heart's silhouette. The right ventricle (RV) is located anteriorly. A small portion of the left ventricle (LV) is identified as the left border. The superior vena cava (SVC), aorta, and pulmonary artery cluster above the heart in the superior mediastinum.

Orientation of the heart in the thoracic cavity in cross section. If you look from top to bottom, the heart is located obliquely in the chest cavity, with the right ventricle in contact with the anterior wall of the chest to the left of the midline. The left atrium forms the posterior wall of the heart.

Boundaries of percussion dullness of the heart. The area of ​​cardiac dullness upon percussion is always smaller than the actual size of the heart due to its rounded size. The percussion borders of the heart are usually 1-1.5 cm smaller than its silhouette observed on radiographs.

Relative percussion dullness of the heart (deep dullness of the heart). This is a section of the anterior surface of the heart, which is covered by the lungs and upon percussion gives a dull percussion sound. Lung tissue, covering the deep-lying parts of the heart, “conceals” its true boundaries. Therefore, percussion should be done along the intercostal spaces to avoid lateral propagation of vibrations along the ribs. The pessimeter finger should be pressed tightly against the chest wall, which achieves the wall, which ensures a greater spread of blows inward. Percussion is carried out with blows of medium force. Usually percussion is carried out from the lungs to the heart; the border of the heart is determined by the first noticeable muffling of the percussion sound. The identified boundary is marked along the outer edge of the pessimeter finger.

Projection of the boundaries of relative (deep) dullness of the heart on the anterior surface of the chest. The right border is located 1-1.5 cm outward from the right edge of the sternum in the IV intercostal space; it is formed by the right atrium. The left border is located 1-1.5 cm medially from the midclavicular line in the 5th intercostal space; it is formed by the left ventricle. The upper border is located along the upper edge of the third rib near the left edge of the sternum; it is formed by the conus pulmonary artery and the left atrial appendage.

Data from physical (physical) research methods

General examination of the patient

1. General condition: satisfactory, moderate, severe, extremely severe.

2. Consciousness: clear, disturbed (stupor, stupor, coma).

3. Position of the patient: active, passive, forced (which one).

4. Constitution: normosthenic, asthenic, hypersthenic.

5. Body type: correct, incorrect (which one).

6. Height in centimeters.

7. Quetelet index. Reflects the number of kilograms per 1 m 2 surface area of ​​the human body. The surface area of ​​the body is conventionally equal to the square of the patient's height (in meters).

8. Posture and gait.

8. Odor (in the presence of pathological odors).

9. Features revealed during examination of the head and neck.

Examination of the skin.

1. Color: flesh-colored, pale, pale pink, dark, red, cyanotic, earthy, brown, dark brown or bronze (indicating the location of this color).

2. The presence of pathological elements on the skin and their nature: erythema, roseola, papule, pustule. Scales, scabs, erosions, cracks, ulcers, spider veins (indicating their location), telangiectasias.

3. The presence of depigmented areas of the skin, their localization.

4. Hemorrhagic phenomena: localization, nature, severity.

5. Scars, their character and mobility.

6. Skin elasticity: normal, reduced.

7. Dry skin. Peeling.

8. External tumors (atheromas, angiomas, etc.).

9. Nails: shape (“watch glasses”), coloring, longitudinal striations, transverse striations (koilonychia), fragility, destruction of nails.

10. Hair: hair loss (specify where), eyebrows, scalp baldness. Graying of hair. Excessive hair development (specify where); in women - the presence of hirsutism.

11. For adolescents from 13 to 18 years old, indicate the form of sexual development.

Visible mucous membranes (eyes, nose, lips).

1. Color: pale pink, cyanotic, pale, icteric. Injection of scleral vessels, their icterus, subicterus.

2. Enanthema - rash on mucous membranes: area and nature of the rash.

Subcutaneous tissue.

1. Subcutaneous fat layer: absent, poorly developed, moderately, excessively (indicate the thickness of the fold in cm). Places of local disappearance or greatest deposition of fat. General obesity. Cachexia.

2. Swelling, its consistency, severity and distribution: limbs, face, eyelids, abdomen, lower back, general swelling. Pasty skin.

3. Saphenous veins: inconspicuous or dilated. Varicose veins (localization, severity, their pain).

4. Wen and other subcutaneous tumors and formations, their pain.

5. Soreness of the subcutaneous adipose tissue under pressure, a feeling of fluffiness and a gentle crunch (with emphysema of the subcutaneous tissue).

The lymph nodes.

1. Localization of palpable lymph nodes: occipital, parotid, submandibular, chin, cervical (anterior and posterior), supraclavicular, subclavian, subpectoral, axillary, elbow, inguinal, femoral, popliteal.

2. Size of lymph nodes in cm.

3. Shape: oval, round, irregular.

4. Surface: smooth, bumpy.

5. Consistency: hard, soft, elastic.

6. Are the nodes welded to the skin, surrounding tissue and to each other? Their mobility.

Musculoskeletal system.

1. Proportionality, the relationship between the parts of the skeleton. Bone deformation. Skull shape.

1. Degree of muscle development: normal, weak. Muscle atrophy and hypertrophy (general, local).

2. Tone: normal, increased (rigidity), decreased.

3. Muscle strength.

4. Muscle pain when palpated. The presence of compaction in the muscles.

1. “Drumsticks” (distal osteoarthropathy) - thickening of the peripheral phalanges of the fingers and toes.

2. Ossalgia: pain on palpation and tapping (especially the sternum, ribs, tubular bones, vertebrae).

3. Thickening and unevenness of the periosteum upon palpation (especially the tibia, radius and ulna, lower jaw, ribs, phalanges).

4. Softening of bones.

1. Inspection: configuration, swelling, hyperemia of the skin over the joints.

2. Palpation: change in local temperature, soreness, condition of the skin over the joints, condition of the articular ends and bone protrusions.

3. Noises when moving (crunching, creaking, clicking).

4. Range of motion in joints (active and passive). Limitation of mobility: rigidity, contracture. Excessive movements.

5. Shape of the spine, degree of mobility in the thoracic, cervical and lumbar regions, pain, symptoms of stress. Curvature of the spine: physiological, pathological. The magnitude of lordosis, kyphosis, scoliosis.

Measuring body temperature.

If it increases, a detailed description of the fever is provided. A graphical representation of the temperature profile (temperature curve) on the patient observation sheet is mandatory.

Respiratory examination.

Condition of the upper respiratory tract

1. Nose: difficulty breathing, nasal discharge, painful sensations. Participation of the wings of the nose in breathing.

2. Paranasal sinuses - palpation, percussion.

Examination of the chest.

Static inspection.

1. Shape of the chest: normal (normosthenic, hypersthenic, asthenic), pathological changes (barrel-shaped, paralytic, rachitic, funnel-shaped). Condition of the supraclavicular and subclavian fossae (smoothed or pronounced). Symmetrical clavicles. Expressiveness of the Louis angle. Width of intercostal spaces. Direction of the ribs: usual - oblique, or closer to vertical or horizontal (assessment is carried out on the lateral surfaces). Characteristics of the epigastric angle. The anterior-posterior size of the chest and its relationship with the transverse one. The position of the blades, the tightness of their fit, or the distance of the blades (pterygoid blades), symmetry. Asymmetry of the chest, protrusion or retraction of various areas of the chest.

Dynamic inspection.

1. Type of breathing: chest, abdominal, mixed.

2. Depth and rhythm of breathing: shallow, deep, rhythmic, arrhythmic, the presence of pathological breathing of Cheyne-Stokes, Biot, Grokk or Kussmaul.

3. Number of breaths per minute. The ratio of inhalation and exhalation.

4. Movements of the chest during breathing: uniform breathing, lag of one or the other half of the chest in a calm state and during deep breathing. Bulging or retraction of intercostal spaces. Participation in the act of breathing of auxiliary muscles. Measuring the chest circumference in cm at the level of the fourth intercostal space during quiet breathing, with deep exhalation and inhalation reflects the state of chest excursion.

Palpation of the chest.

1. Pain on palpation of the chest:

a) in places the pain of which is indicated by the patient;

b) trapezius muscles;

c) ribs and intercostal muscles;

d) points of exit of intercostal nerves.

2. Resistance, elasticity of the chest.

4. Palpation determination of pleural friction, or rare splashing phenomena.

Percussion of the lungs

1. Comparative percussion data: the nature of the percussion tone (sound) over symmetrical areas of the chest.

2. Topographic percussion data:

a) determination of the standing height of the apexes of the lungs in front and behind;

b) width of Krenig fields;

c) determination of the lower boundaries of the lungs (indicating the patient’s position: vertical or horizontal);

d) width of pulmonary roots;

e) mobility of the lower pulmonary edges (in cm) along the midclavicular, middle axillary and scapular lines on both sides.

Conclusion based on the results of percussion: in the presence of a pathological focus, a detailed description of the zone of altered percussion sound, its location, size, shape;

Auscultation of the lungs.

1. The nature of the main respiratory sounds over the entire surface of the lungs.

2. Presence of adverse respiratory sounds: their nature, localization, sonority.

3. Determination of bronchophony (listening to whispered speech).

III. Study of the cardiovascular system.

Study of arteries and neck veins.

1. Visible pulsation of arteries: temporal, carotid, jugular fossa, arteries of the extremities. Worm symptom. Condition of the neck veins. Venous pulse: positive, negative.

2. Condition of the arteries during palpation: temporal, carotid, aortic arch of the brachial (comparison of pulsation on both sides, wall thickening, tortuosity).

3. Arterial pulse on the radial arteries:

heart rate

rhythm (regularity) of pulse waves

uniformity,

filling

voltage

pulse wave rise rate

pulse value

symmetry

presence of pulse deficiency

the state of the vascular wall outside the pulse wave.

4. Pulse on the dorsum of the foot. If necessary, the overlying arteries of the lower extremities are examined.

5. Pseudocapillary Quincke's pulse.

6. Listening to the carotid and femoral arteries - double Traube tone, double Vinogradov-Durozier murmur. Listening to the jugular vein (spinning top sound).

7. Blood pressure on the brachial arteries. If necessary, it is also measured on the femoral arteries.

Inspection and palpation of the heart area.

1. Protrusion of the heart area - “heart hump”.

2. Visible pulsation: in the region of the heart, epigastric.

3. Apex impulse:

a) location;

b) character: positive or negative;

c) width (area); localized or spilled;

d) height: high, low;

e) strength: normal, weakened, strengthened;

f) changes in the shape of the apex beat:

elevating - with an increase in strength and height, indicates left ventricular hypertrophy,

dome-shaped - with an increase in area and height - with dilatation of the left ventricle;

4. Palpation determination of trembling in the precordial region (“cat’s purring”), its localization, in what phase of cardiac activity is determined.

5. Palpation determination of epigastric pulsation

with calm breathing,

with a deep breath,

exhale deeply.

6. Palpation pain and zones of hyperesthesia in the precordial region.

Heart percussion

1. Borders of relative and absolute dullness (order of determination: right, left, upper border, heart waist).

2. Width of the vascular bundle (in cm).

3. Heart configuration: normal, mitral, aortic, trapezoidal.

4. Diameter and length of the heart in cm, comparison with the required ones:

diameter = (height in cm - 4) / 10

length = (height in cm - 3) / 10

Auscultation of the heart

1. Heart sounds: frequency, rhythm, sonority (clear, dull), uniformity. Ratio of tone strength: strengthening or weakening of one of the tones, indicating localization. Splitting or splitting of tones. The rhythm of gallop (which one), quail.

2. Noises: relation to the phases of cardiac activity, their volume, places of maximum auscultation, conduction, timbre, duration. Pericardial friction sounds.

IV. Examination of the stomach and intestines.

Oral examination

1. Tongue: size, color, humidity, nature and severity of the papillary layer, presence of plaque, glossitis, cracks, ulcers.

2. Teeth: dental formula, mobility, carious changes, dentures, etc.

3. Gums: coloring, looseness, ulceration, necrosis, hemorrhage, purulent discharge, pain.

4. Soft and hard palate: coloring, plaque, hemorrhages, etc.

5. Pharynx, posterior wall of the pharynx.

6. Tonsils: size, color, consistency, state of lacunae.

Abdominal examination

1. Examination of the abdomen (standing, lying):

a) configuration: normal, protrusion of the abdomen (uniform or uneven), retracted abdomen, symmetry of the abdomen;

b) the condition of the midline of the abdomen, navel, groin areas;

c) participation of the abdominal wall in respiratory movements;

e) the presence of dilated saphenous veins (localization, severity, direction of blood flow);

f) data from percussion, succussion (ballot palpation) of the abdomen, the presence of free fluid in the abdominal cavity (ascites) and its level.

2. Abdominal circumference in cm (at the level of the navel).

3. Approximate superficial palpation:

a) degree of abdominal wall tension; localization of tension and rigidity;

b) pain;

c) zones of hyperesthesia;

d) peritoneal Shchetkin-Blumberg sign;

e) Mendel's symptom;

f) the presence of hernias of the white line of the abdomen.

4. Deep sliding palpation of the digestive tract according to Obraztsov-Strazhesko, percussion and auscultation of the gastrointestinal tract:

a) deep palpation of the intestine: determine the location, shape, thickness, mobility, displacement, pain, consistency, surface of various parts of the large intestine, rumbling;

b) auscultation of the intestine - listening to peristalsis, friction noise of the peritoneum;

c) appendicular symptoms: Rovzing, Sitkovsky, Voskresensky. McBurney's pain point.

5. Deep palpation of the stomach (greater and lesser curvature, pylorus. If the greater curvature of the stomach is not palpable, check its lower border by auscultation). Splash noise detection.

6. Deep sliding palpation of the pancreas according to Obraztsov-Strazhesko, palpation according to Grotto. The presence of symptoms that appear when the pancreas is damaged: Kerte's symptom, Kach's symptom, Murphy's symptom, Halstead's, Cullen's, Gray-Turner's, Gruewald's symptoms, pain in the Shaffard triangle, at the Dejerdain and Mayo-Robson points.

7. If there are indications, the anal area is examined (fissures, hemorrhoids, rectal prolapse) and a decision is made on the need for a digital examination of the rectum.

V. Study of the hepato-biliary system and spleen.

1. Liver.

Inspection of the right hypochondrium. Visible enlargement of the liver, its pulsation.

Palpation of the liver - properties of the edge and surface, pain.

Percussion of the liver. Determination of the upper border of the liver, the size of the liver in accordance with the Kurlov ordinates (in cm).

Auscultation of the liver area to detect friction sounds.

2. Gallbladder. Visible enlargement of the gallbladder, enlargement detected by palpation, pain in the gallbladder. The presence of palpation and percussion symptoms of the gallbladder: symptoms of Ortner, Murphy, Ker, Shaffard, Courvoisier. Presence of phrenicus symptom.

3. Spleen. Results of palpation examination of the spleen in the supine position, on the right side. Determination of the size of the spleen, characteristics of the surface of the spleen, properties of its edge, soreness, consistency (hard, soft). Percussion of the spleen (length and diameter dimensions). Auscultation of the spleen is performed to detect friction sounds.

VI. Examination of the urinary system

1. Inspection of the lumbar region: smoothing of contours, bulging, skin hyperemia, swelling of the renal region.

2. Palpability of the kidneys (their properties), mobility and displacement of the kidneys while lying and standing.

3. Pain points of the kidneys and ureters.

4. Pain when tapping the renal area at the back (Pasternatsky’s symptom).

5. Data from palpation and percussion of the bladder.

VII. Reproductive system

(points 3-5 are examined according to appropriate indications by consultant urologists and gynecologists)

1. Condition of the mammary glands: in women - the degree of their development, the presence of scars, fistulas, visible and palpable tumors, mastopathy, condition of the nipple. In men - the presence of gynecomastia.

2. Palpation of the lower abdomen in women (uterus and its appendages).

3. Pseudohermaphroditism male and female.

4. External genitalia in men: underdevelopment of the testicles, anorchism, cryptochism. Anomalies and deformities of the penis. Condition of the prostate gland (during rectal examination).

5. Vaginal examination in women: bimanual palpation, examination in mirrors.

VIII. Endocrine system

(points 2-3 are filled in if there is or suspicion of endocrine

disease)

1. Inspection and palpation of the thyroid gland, localization, size and consistency, soreness, mobility.

2. Correspondence of physical and mental development to age.

3. Correspondence of secondary sexual characteristics to the passport gender (presence of hirsutism, eunuchoidism, virulism, feminism).

4. Condition of the skin (moisture, thinning or roughening, presence of stretch marks, hyperpigmentation).

5. Violation of growth, physique and proportionality of individual parts of the body.

6. Weight loss. Obesity (degree of severity, predominant localization).

XI. Nervous system and sensory organs

(described by IV, V, VI year students who have completed a course in neurology)

1. Cranial nerves (cranial nerves):

A violation of the sense of smell is detected or confirmed using a set of bottles with aromatic liquids and indicates a violation of the first pair (olfactory nerve) of the cranial nerves (cranial nerves),

Impaired visual fields and visual acuity indicate pathology II doubles pairs. (optic nerve)

width of the palpebral fissures, ptosis of the upper eyelids, protrusion of the eyeballs (exophthalmos), shape and size of the pupils, pupillary reaction to light, accommodation and convergence. Volume of movement of the eyeballs. Nystagmus indicates disturbances of III, IV, VI (oculomotor, trochlear, abducens) pairs of the cranial nerves,

pain in the area of ​​the supraorbital, suborbital and mental foramina (exit points of the branches of the trigeminal nerve during palpation) indicates pathology of the V pair of the spinal nerve (trigeminal nerve),

Asymmetry of the face at rest and during facial movements, as well as a violation of taste sensitivity in the anterior 2/3 of the tongue is detected in disorders of the facial nerve (VII pair of facial nerves),

A decrease in hearing acuity, confirmed by tuning fork examination (Rine, Weber, Schwabach tests) or during audiometry, indicates a violation of the VIII pair of the cranial nerve (auditory nerve),

Impaired swallowing, asymmetry of the palatal folds (curtains), impaired phonation, impaired taste sensations in the posterior third of the tongue, loss or reduction of the pharyngeal and palatal reflexes may indicate pathology of the IX, X pairs of the spinal nerves (glossopharyngeal and vagus nerves).

Violation of the function of the sternocleidomastoid and trapezius muscles (raising the shoulders, turning and tilting the head) indicates a pathology of the XI pair of ranks (accessory nerve).

Impaired movements and trophism of the tongue, speech impairment indicate the possible involvement of the XII pair of the cranial nerve (hypoglossal nerve) in the pathological process.

2. Symptoms of oral automatism: proboscis, sucking reflexes, violent laughter and crying occur with disorders of the cerebral cortex.

3. Motor sphere:

a) muscle trophism (detection of atrophies);

b) volume and strength of movement in the limbs;

c) state of muscle tone;

d) reflexes, their severity and uniformity;

e) pathological reflexes (Babinsky, Rossolimo, Bekhterev, etc.);

4. Sensitive sphere: the nature of sensory disorders (hyper-, hypoanesthesia), their localization, type of sensitivity disorder (neural, segmental, conduction) is determined. Pain along the nerve trunks.

5. Coordination of movements: gait, Romberg pose (detection of ataxia). Finger-nose, knee-heel tests (detection of misses and intentional tremor).

6. Meningeal symptoms (stiff neck, Kernig's sign, Brudzinski's sign).

7. Symptoms of tension in the spinal cord roots (Lassegue’s, Wasserman’s, etc. symptoms)

8. Extrapyramidal system:

a) identification of parkinsonism syndrome (pallor, slowness of movements, trembling at rest, muscle rigidity);

b) hyperkinesis, their localization, frequency, intensity.

9. Gait (normal, ataxic, paralytic).

10. Autonomic nervous system: dermographism, detection of temperature asymmetries, blood pressure dynamics, diathermy tests, pulse tests, etc.

X. Mental state

(described by IV, V, VI year students who have completed a course in psychiatry).

Preservation of orientation in place, time and situation. Contact. Stability and focus of attention. Exhaustibility. Memory for current and past events. Psychomotor. Consistency and correctness of speech, its pace and expressiveness. Logical thinking. Orientation of interests and level of intelligence. Dominant and obsessive ideas. Mood, its stability and character (depressed, even, apathetic, euphoric, anxious, etc.). Affects. Suicidal thoughts and intentions. Behavior. Character traits.

Identification of symptoms indicating disorders of cranial innervation, sensory and motor areas, and vegetative status is the basis for prescribing a consultation with a nephrologist. Identification of symptoms of a mental disorder is the basis for prescribing a consultation with a psychiatrist. A consultation with a psychiatrist can only be prescribed with the consent of the patient.

NB! (pay attention!) The content and procedure for further preparation of the medical history must correspond to the specifics of each therapeutic department (indicated in the corresponding footnotes).

Preliminary diagnosis and its rationale

The collection of information about the patient is carried out in stages according to the general plan for the study of the patient:

the initial examination stage, which includes a survey and physical examination methods. The initial examination is followed by a preliminary diagnosis;

stage of detailed clinical, laboratory and instrumental clinical research, including special methods and consultations with specialists. Clinical laboratory and instrumental clinical examination is followed by a detailed clinical diagnosis, justified by all necessary and available methods research. Based on this diagnosis, all further activities of the doctor are planned and carried out: checking the diagnosis, establishing a prognosis, repeat examinations of the patient, treatment plan, observation, etc.;

the stage of successive and repeated studies during clinical observation and treatment of the patient. The stage of subsequent research, clinical observation and treatment of the patient is followed by a final clinical diagnosis, set out in the final epicrisis.

The main concepts that the doctor relies on at the initial examination stage are:

A symptom is a qualitatively new phenomenon, not characteristic of a healthy body, which can be detected using clinical research methods. A symptom is always a sign of a pathological process and is used for diagnosis and prognosis of the disease.

Syndrome is a stable combination of a number of symptoms about general pathogenesis, characterizing a certain pathological process. From a didactic point of view, it is convenient to distinguish syndromes of damage to anatomical structures and syndromes of violation of the functional state of organs and systems.

Cluster. Due to the fact that in each anatomical structure different types of pathological processes, within the framework of the syndrome, cluster analysis should be carried out, allowing us to consider a group of symptoms homogeneous in pathogenesis as a cluster, i.e. an independent unit with certain clinical and pathogenetic properties. Cluster analysis allows you to combine symptoms in order to solve complex issues that provide detail in the pathogenetic mechanisms of the development of the syndrome. Thus, cluster analysis provides logical continuity between a symptom, groups of symptoms reflecting one pathogenetic mechanism, and a syndrome.

A disease is a set of syndromes united by a single essence (common etiology).

Installation system and sequence

preliminary diagnosis:

1. Discussion of the obtained clinical data:

Explanation of identified symptoms from a pathogenetic point of view

Identification of syndromes of violation of specific anatomical structures and syndromes of violation functional state

Conducting cluster analysis to substantiate the pathogenetic mechanisms of the development of the pathological process.

Identification of the leading syndrome, main, additional and general syndromes.

Analysis of the clinical and anamnestic syndrome, i.e., determination based on the anamnesis of the nature of the course of the disease (acute, subacute, chronic, recurrent, protracted, slowly progressive, rapidly progressive, etc.);

2. Differential diagnosis

Recognizing disease by exclusion

(diagnostic algorithm method)

Differential diagnosis is the main method of making a diagnosis. The process of differential diagnosis as a process of cognition of the patient begins with the first glance at the patient and cannot be suspended while the patient is under the supervision of a doctor. Diagnostic working hypotheses during the study of the patient arise, replacing one another, until the last of them, having withstood a number of tests, becomes a substantiated diagnosis.

All syndromes identified in a given patient should be used as criteria in the process of differential diagnosis, taking into account the pathogenetic mechanisms of their development based on cluster analysis.

At the initial stage of differential diagnosis, it is necessary to list diseases that have significant similarities with the disease in a given patient. These include diseases that have similar leading syndromes, as well as additional and general syndromes. The leading, additional and general syndromes are usually referred to as the “image of the disease.” Consequently, for differential diagnosis, diseases that have a similar “image” are selected.

The next stage of differential diagnosis is to compare the leading syndrome, additional and general syndromes in the patient with the image of each disease included in the list of differential diagnostics. In this case, it is necessary to note both the similarity of the syndromes and the differences based on the presence or absence of signs characteristic of the suspected disease).

Of particular importance is the analysis of the clinical and anamnestic syndrome, which characterizes the dynamics of the disease.

The disease is excluded from the group included in the list for differential diagnosis if there is no coincidence of the leading syndrome, clinical and anamnestic, general and additional syndromes. An argument for excluding a disease from the differential diagnosis group is the presence of dividing factors, i.e. symptoms not characteristic of the disease being compared.

To facilitate differential diagnosis, four principles should be used.

The first is the principle of significant difference due to the patient’s absence of syndromes characteristic of the disease being compared.

The second is the principle of significant difference due to the presence of syndromes in the patient that are not present in the disease being compared.

The third is the principle of exclusion through opposition. The observed case is not the disease with which we are comparing, since in the latter a symptom (syndrome) directly opposite to our case is constantly encountered.

Fourth - the principle of exclusion through

discrepancy in the nature of the syndromes,

discrepancy (quantitative or qualitative) of symptoms.

3. Rationale for the preliminary diagnosis.

Based on the established similarity of the syndromes and course of the disease in a given patient with a certain nosological form of the disease, on the one hand, and their differences from the “disease pattern” in the compared diseases, based on the amount of information available at the time of differential diagnosis, it is concluded that the most similar disease is the most likely.

Note* The diagnosis of both the underlying disease and concomitant diseases is substantiated.

Formulation of a detailed preliminary diagnosis.

The preliminary diagnosis must be formulated in accordance with generally accepted classifications and include the following points

Nosological name of the disease

The form of the disease (clinical: acute or chronic - indicated for diseases that occur either acutely or chronically; clinical-morphological or pathogenetic - in accordance with the classification of the disease. For a number of diseases, the forms have specific names, for example, for coronary artery disease it is stable angina, acute heart attack myocardium, etc.)

The degree of activity of the process (if necessary in accordance with the classification of the disease)

Phase of the disease - indicated in the chronic course of the disease: exacerbation or remission

Stage of the disease (initial, stage of advanced clinical manifestations, terminal)

Variant of the course of the disease (fulminant - fulminant, subacute, chronic continuously relapsing or others, latent)

The severity of the disease (an integral characteristic of the severity of the patient’s condition: mild, moderate-severe, severe, extremely severe)

Enumeration of syndromes of violation of anatomical structures (with a polysyndromic clinical picture)

Enumeration of functional impairment syndromes, taking into account the degree of functional disorders. Syndromes of impaired functional state are a functional part of the diagnosis, ranked by degree of severity in accordance with approved classifications (for example, CHF II FC), or according to a universal gradation of 4 degrees: mildly expressed, moderately expressed, expressed or significantly expressed disorders.

Plan for additional studies of the patient.

Additional studies are divided into several groups.

Laboratory studies, including clinical laboratory, biochemical, serological, bacteriological, morphological, cytogenetic and other studies.

Functional: ECG, REG, RVG, measurement of venous pressure, blood flow velocity, study of external respiration function, etc.

Radiation studies, incl.

Ultrasound examinations (ultrasound), echocardiography (ECHO),

X-ray, radioisotope.

Endoscopic.

The medical history indicates all the data of laboratory, instrumental and other studies with the interpretation of the data obtained and consultations with specialists.

Clinical diagnosis and its rationale

A clinical diagnosis must be made and recorded in the medical history during the first three days of the patient’s hospital stay, after receiving the results of laboratory and instrumental research methods and the opinions of specialist consultants.

The clinical diagnosis is drawn up and justified according to the plan outlined in the “preliminary diagnosis” section, additionally referring to the results of laboratory and instrumental research methods.

The clinical diagnosis must be formulated in accordance with generally accepted classifications and contain the points reflected in the “preliminary diagnosis” section.

It is advisable to describe the rationale for the clinical diagnosis according to the following approximate plan:

b) note the results of laboratory and instrumental examinations, conclusions of specialist consultants, and also analyze the dynamics of the clinical picture of the disease during 1 - 3 days of observation of the patient in the hospital. Indicate whether these new data confirm the previously made preliminary diagnosis;

c) indicate what changes, additions and clarifications were made to the diagnosis in accordance with the newly obtained clinical, laboratory and instrumental data, i.e. newly identified clinical and (or) laboratory symptoms are grouped into syndromes or clusters;

d) if there is a need to abandon a previously made preliminary diagnosis, these changes should be carefully justified;

e) clarifications, additions or changes made when making a clinical diagnosis and concomitant diseases should be justified.

Differential diagnosis

The goal of differential diagnosis is to exclude diseases with a similar leading syndrome. This section provides a differential diagnosis for the leading syndrome. found in this patient.

To this end:

1. B clinical picture disease, the leading syndrome present in a given patient is identified.

2. Diseases in which a similar leading syndrome is observed are listed.

3. It is proven that the patient has a number of significant features of the leading syndrome that are not characteristic of the diseases included in the list for differential diagnosis.

4. It is proven that the patient does not have a number of significant symptoms and syndromes characteristic of differentiated similar diseases.

5. Based on this comparison of the clinical picture of a given patient with the clinical signs of these similar diseases, a conclusion is made about the true nature of the disease and the correctness of the clinical diagnosis.

Etiology and pathogenesis.

This section is described only in the educational history of the disease by students of IV - V - VI courses. Third year students in this section describe the mechanisms of development of the most striking and typical symptoms diseases, conduct cluster analysis, justify the belonging of these clusters to syndromes of damage to anatomical structures and syndromes of impaired functional state.

Students of IV - V - VI courses in this section describe the reasons causing the occurrence and development of this disease and its complications. Modern views on the etiology of the underlying disease are briefly described. In addition, based on examination data of the patient and the results of special research methods, specific etiological factors that led to the development of the disease in this patient are described. In all cases, it is advisable to also establish other possible provoking factors that contribute to the occurrence or exacerbation of this disease, including risk factors.

When describing the pathogenesis, theories of the pathogenesis of this disease and its complications are given, and the most likely pathogenetic mechanisms that occurred in the supervised patient are described. In the same section, it is necessary to provide a brief explanation of the mechanisms of all clinical symptoms and syndromes identified in this patient.

Treatment plan and rationale.

This section outlines the goals, objectives, basic principles and modern methods and means of treating this disease and preventing its complications (regimen, diet, medications and physical means, spa treatment) indicating the effectiveness of this or that therapy.

First of all, it is necessary to determine the real goals of treatment for a given patient: complete recovery, elimination or reduction of exacerbation of the disease, its complications, stopping the progression or regression of the disease, improving the prognosis, and ability to work.

a) etiological treatment, involving the elimination or correction of causative, provoking factors, risk factors, antimicrobial agents, etc.;

b) pathogenetic treatment, aimed at influencing the basic mechanisms of the disease in a given patient (inflammation, allergies, functional disorders, deficiency of certain factors, intoxication, etc.);

c) symptomatic treatment used when the first two are ineffective or impossible.

After this, based on ideas about the individual characteristics of the clinical course of the disease, the morphological and functional state of organs, as well as taking into account the social and psychological status of the patient, specific, optimal therapeutic and preventive measures are developed for this patient.

In relation to each direction of treatment, it is necessary to determine and justify the choice of specific therapeutic measures(regime, diet, medications, physiotherapy, exercise therapy, physical and surgical methods, spa treatment); clarify the dose, route and frequency of administration, taking into account the existing indications and contraindications for the patient. It is necessary to note possible undesirable (side) effects of all prescribed therapeutic measures. All medications are given on a prescription basis.

Note: This section can be completed in full only by fourth and fifth year students. VI year students, as well as practicing doctors, in this section describe only the treatment plan for this particular patient.

The diary reflects the results of the patient’s daily examination by the attending physician (student-supervisor). The purpose of keeping a daily diary is to reflect the dynamics of all manifestations of the disease, as well as the effectiveness of treatment and signs of possible side effects of medications.

First, the diary makes an assessment of the patient’s condition, describes the dynamics of complaints over the past day, including the number and nature of episodes of the disease (attacks of pain, suffocation, interruptions in heart function, etc.), evaluates sleep, appetite, stool, urination, and reflects accounting for diuresis. Then an analysis of the dynamics of objective data is provided (i.e., a brief description of the state of the internal organs and their changes in dynamics). The diary should reflect the physician's interpretation of new clinical symptoms and the results of additional research methods, as well as changes in treatment tactics.

Etiotropic drugs and basic drugs of a pathogenetic nature, indicators of measuring body temperature in the morning and evening, pulse, heart rate, number of respiratory movements, blood pressure, diuresis, the patient’s body weight are daily included in the patient’s observation sheet (sheet of the main indicators of the patient’s condition or temperature sheet). Medical prescriptions are entered daily into the medical prescription sheet.

Every 10 days of the patient’s stay in the hospital, as well as in the event of a sharp change in the patient’s condition or when new diagnostic signs are identified that significantly change the doctor’s understanding of the clinical diagnosis, a staged epicrisis is drawn up. It provides a brief doctor’s opinion on the clinical diagnosis for which the patient is in the hospital, the characteristics of the course of the disease and the presence of complications. A list of medications used at this stage of the patient’s treatment is also provided. The dynamics of the main signs of diseases are described in particular detail, including the dynamics of the results of laboratory and instrumental examination of the patient, indicating laboratory, electrocardiographic, X-ray, ultrasound, ECHO and other parameters identified in the patient over the past period. All side effects of the therapy used are described. On this basis, a conclusion is made about the adequacy of the prescribed therapy and its effectiveness. The plan for further treatment and examination of the patient is justified.

If the patient’s condition worsens, the doctor’s considerations are given about the possible reasons for such deterioration (violation of the regime, diet, progression of the underlying disease, effectiveness or inadequacy of prescribed therapy, etc.). If the diagnosis is unclear, especially when new symptoms of the disease appear, it is necessary to outline a plan for further examination of the patient, as well as a plan for further treatment.

Sheet of the main indicators of the patient's condition

During supervision, on a special sheet of the main indicators of the patient’s condition (temperature sheet), the doctor notes the curves of body temperature measurements in the morning and evening, pulse, heart rate, number of respiratory movements, graphical display of blood pressure, diuresis (the amount of liquid drunk per day and urine excreted) , frequency of defecation are entered daily into the patient’s observation sheet (sheet of the main indicators of the patient’s condition or temperature sheet). Indicators of the patient’s body weight, as well as information about the hygienic bath performed, in the absence of other indications, are noted once a week.

This sheet also contains the main medical prescriptions, in particular, etiological and pathogenetic treatments, as well as the dynamics of the main manifestations of the disease (number of attacks of pain, suffocation, liver size, swelling, etc.) (example).

The prognosis is based on data obtained during examination of the patient during supervision. It includes:

a) health prognosis (whether recovery or deterioration is possible with a chronic disease and under what conditions);

b) prognosis for life (whether the disease threatens the patient’s life);

c) prognosis for work (degree of disability - partial or complete, temporary or permanent). In accordance with this, a conclusion is made about the timing of temporary disability or referral of the patient to MSEC to determine the disability group.

Final clinical diagnosis

The final clinical diagnosis is made when the patient is discharged from the hospital, when he is transferred to another medical institution, or in the event of the patient’s death. The final clinical diagnosis includes:

a) main diagnosis;

b) complications of the underlying disease;

c) concomitant diagnosis.

The final clinical diagnosis may differ slightly from the preliminary diagnosis and from the clinical diagnosis previously given to the patient. However, all changes and clarifications of the diagnosis must be reflected in the text of the medical history (in diaries, rounds of the head of the department, associate professor, professor, stage-by-stage epicrisis, final epicrisis).

The final epicrisis (discharge, transfer, post-mortem) is drawn up in the same cases as the final clinical diagnosis. It is a brief description of the entire medical history and includes the following sections:

Last name, first name, patronymic of the patient, date (time, if necessary) of admission and discharge (death).

Final clinical diagnosis.

Main complaints upon admission (briefly).

Basic anamnestic data (briefly), giving an idea of ​​the duration, nature and characteristics of the course of the disease and its complications, as well as information about previous other diseases.

Basic pathological data on organs.

Data from laboratory and instrumental research methods (upon admission and upon discharge or death): clinical tests of blood, urine, feces, sputum, results of biochemical, functional, radiological studies, data from other research methods, as well as opinions of specialist consultants.

Treatment carried out in the hospital: regimen, diet, medications (their dosage and duration of use), physical research methods, operations, etc.

Evaluation of the results of treatment in a hospital based on the dynamics of the main manifestations of the disease. The patient's condition at discharge.

Inpatient conclusion: discharged to work (work schedule), for outpatient follow-up treatment at a clinic, transferred to another hospital, sent for follow-up treatment to a sanatorium, sent to MSEC to determine the disability group.

Recommendations regarding regimen, diet, working conditions and lifestyle, secondary prevention, drug treatment (name of drug, dose, methods of administration, duration of treatment) or other methods of treatment. Recommendations for sanatorium-resort treatment.

Bibliography

This section is completed only by fourth and fifth year students. Third and sixth year students, as well as practicing doctors, do not fill out this section. A list of domestic and foreign literature used by the curator when writing this case history is provided.

Curator’s signature __________________ Date _________________

Patient examination methods

When examining a patient, subjective and objective methods are used. However, this division of research methods is not entirely correct, since the subjective data that the doctor obtains by questioning the patient are often a reflection of objectively identified changes. For example, a patient complains of vomiting blood, which is bleeding from a vessel located in the stomach, destroyed by an ulcer, or the patient complains of the release of a significant amount of foul-smelling sputum, which is associated with gangrenous decay of lung tissue, etc. However, for the convenience of the study, this division is up to the present time is saved.

Subjective methods for examining a patient

Questioning. Subjective research methods include questioning, which is based mainly on the patient’s memories and is therefore called anamnesis. Questioning the patient usually begins with identifying general, i.e., “passport” data. The significance of age lies in the fact that diseases such as scarlet fever, diphtheria, measles, partly rheumatism, etc., are characteristic of young age; other diseases, such as atherosclerosis and malignant neoplasms, are more typical for the elderly. What matters is whether the patient’s appearance matches his age.

If the patient looks older than his age, this indicates a recent or current serious, debilitating illness.

If, on the contrary, the patient looks much younger than his age, then this suggests that he has disorders of the endocrine glands.

Gender matters in that some diseases, such as peptic ulcers, are more common in men, and conversely, gallstones are more common in women.

Data about the patient’s place of residence can be used for diagnostic purposes, since certain diseases are often common in some areas, for example, malaria occurs in swampy areas, rheumatism in areas with a damp climate, etc. It is important to know the patient’s profession. Those who work in dusty conditions and constantly inhale a lot of dust may develop bronchitis and pneumoconiosis; Painters, printers, and other workers exposed to lead may experience lead colic.

All data obtained from questioning the patient, as well as the results of an objective study and diaries of the further course of the disease are recorded in the medical history.

General data about the patient, for example, home address, profession, social status, are entered into the medical history in the emergency department by the nursing assistant on duty. medical personnel. The remaining sections of the medical history are completed by the doctor.

Patient's complaints

First, you need to listen to the patient’s complaints regarding his health, then these complaints are detailed by the patient’s answers to the doctor’s questions. For example, if a patient complains of a cough, it is important to know whether it is dry or with sputum production. In the latter case, it is necessary to clarify whether there is any blood in the sputum, whether it resembles raspberry jelly or a type of rust, whether there is pus in it, what the smell is, how much sputum is produced per day, whether the patient produces a lot of sputum in the morning immediately after sleep. As for pain, if it accompanies a cough, you should find out in which half of the chest it is felt or more clearly indicate the location of the pain, its nature, etc.

Based on the answers received, it can already be assumed that the patient under study has a lung disease. However, the patient may have a number of other signs that are important for recognizing this disease, which the patient did not mention in his complaints, so the doctor must ask a number of additional questions regarding the body system whose disease is suspected. In the above example, the patient should be asked if he had a cough before the onset of this disease, and if he did, what causes the cough or intensifies it (breathing, talking, inhaling cold air, changing body position, etc.), have you had any asthma attacks, what causes them, etc. It is important to ask about chills, sweating, etc.

For a more complete picture of the patient’s condition, it is necessary to ask him a number of questions regarding other body systems, for example, is there any palpitations or shortness of breath with slight physical exertion; is there any pain in the heart area or a feeling of interruptions; is there nausea, heartburn, belching, pain in the epigastric region before and after eating, is there vomiting, diarrhea, constipation, etc. Regarding genitourinary system you should find out whether there is an increase in urination, pain when urinating, or whether there has been a change in the color of urine (the color of beer, meat slop); for women, it is important to know whether there are any disorders of the menstrual cycle, leucorrhoea, etc. Then the state of the nervous system and sensory organs is determined: does the patient suffer from headaches, insomnia, dizziness, memory loss, irritability, visual impairment, hearing, smell etc.

Questioning the patient in this manner makes it possible to judge the disorders in his body. The news is that many diseases begin with their own symptoms and develop in a typical way.

Questioning about the disease. The totality of data obtained from questioning about the development of the disease is called the medical history. The following questions are usually asked.

1. When and how the disease began, suddenly or gradually, what were its first signs.

2. In what sequence did the various signs of the disease develop? Were there periods of improvement and deterioration in the patient’s condition, and if there were, what reasons, in the patient’s opinion, contributed to the deterioration.

3. What treatment has been used so far and its effectiveness.

Questioning about the patient's life

Some diseases may be associated with illnesses suffered a long time ago, sometimes even in childhood; In addition, the development and course of this disease can be influenced by other previous diseases, as well as the patient’s working and living conditions, the environment in which he grew up and developed, diseases among family members, various habits, for example, abuse of smoking, alcohol, drugs, etc. d. The totality of all data obtained during a conversation with the patient in this direction is called a life history.

The sequence of collecting a life history is as follows: first, get acquainted with biographical data, then find out heredity, previous diseases, sexual and family life, working and living conditions and, finally, bad habits.

Objective methods of examining the patient

Objective research methods are divided into basic and auxiliary. The main ones include inspection, feeling (palpation), tapping (percussion) and listening (auscultation). Ancillary methods include measuring body temperature, height, weight, chest circumference, daily amount of urine, and sputum.

Laboratory tests include blood, urine, gastric contents, sputum, bacteriological tests of blood, pus, etc. instrumental studies These include blood pressure measurements, electrocardiography, phonocardiography, sphygmography, fluoroscopy, laryngoscopy, gastroscopy, cystoscopy, sigmoidoscopy, etc. Histological examination of pieces of patient tissue is called a biopsy.

Methods of clinical examination of the patient

Lecture No. 2

Topic 1.2 “METHODS OF EXAMINATION OF A PATIENT: SUBJECTIVE, OBJECTIVE DATA”

Subjective examination of the patient: sources of information, sequence and rules for obtaining information.

Objective methods of examining the patient: examination, palpation, percussion, auscultation. Diagnostic value of these methods.

Features of nursing examination of the patient.

Nursing diagnoses, their classification. The concept of monitoring and caring for the patient.

Basic methods of examining a patient

Symptoms of the disease, on the basis of which a diagnosis can be made, treatment prescribed and its effectiveness assessed, can be obtained by examining the patient, which includes a subjective and objective examination.

1.Subjective examination of the patient

Obtaining information by interviewing a patient is called a subjective examination.

First, general information about the patient is collected (last name, first name, patronymic, age). Knowledge of the patient’s profession and living conditions sometimes allows us to find out the cause of the disease.

When questioning about the symptoms and development of the disease itself - anamnesis of the disease - you need to get accurate answers to the following questions: 1) what the patient is complaining about; 2) when the disease began; 3) how it started; 4) how it proceeded. Studying the patient's main complaints allows us to make a preliminary conclusion about the nature of the disease. For example, high fever and sudden onset are characteristic of infectious diseases. Complaints of pain in the heart area, arising in connection with physical activity and radiating to the left arm, make one think about angina pectoris. Abdominal pain that occurs 1-2 hours after eating or at night on an empty stomach suggests a duodenal ulcer. When determining the course of the disease, it is often necessary to ask the patient additional questions to clarify which conditions intensify the painful symptoms or relieve them; what effect did previous treatment have? Additional questions include the following: working and living conditions, the environment in which the disease began, intensification or weakening of symptoms, what treatment was given.

Information about the patient's life - life history - often has great importance to determine the present disease. It is necessary to find out working and living conditions at different periods of life, find out whether the patient has bad habits (smoking, alcohol abuse, drug addiction), what diseases he has suffered, operations, mental trauma, sex life, family structure, psychological situation.

By collecting data on heredity, they find out the health of the family and the longevity of immediate relatives. It should be established whether relatives had diseases that could affect their offspring (syphilis, tuberculosis, alcoholism, cancer, heart disease, nervous and mental diseases, blood diseases - hemophilia, diseases associated with metabolic disorders). Knowledge about unfavorable heredity helps to establish the patient’s predisposition to these diseases. The life of an organism is inextricably linked with the external environment, and the occurrence of diseases always depends on the influence of the environment: sick parents often give birth to weakened children who become easily ill under unfavorable living conditions. Unfavorable heredity must be taken into account and preventive measures taken

2. Objective methods of examining the patient

Objective methods of the patient allow us to obtain the sum of reliable symptoms necessary to establish a diagnosis. An objective examination consists of: 1) examination; 2) feeling (palpation); 3) tapping (percussion); 4) listening (auscultation).

Inspection

Upon examination, the general appearance of the patient and his general condition are determined - satisfactory, moderate, severe and very severe. First, the patient’s position and the condition of the external integument (skin, mucous membranes) are determined, then individual parts of the body are examined (face, head, neck, torso, upper and lower extremities).

Patient position

Active is the position of the patient when the patient is able to independently

come back, sit down, stand up.

A passive position is when the patient is very weak, exhausted, unconscious, usually in bed and cannot change his position without assistance.

With some diseases, patients feel relatively normal only in a certain, forced position. In patients suffering from gastric ulcers, pain is relieved in the knee-elbow position. With heart disease, the patient, due to shortness of breath, tends to take a sitting position with his legs dangling.

State of consciousness

There are several states of consciousness: clear, stupor, stupor, coma.

Stupor (numbness) is a state of deafness, the patient is poorly oriented in the surrounding environment, answers questions sluggishly, late, the patient’s answers are meaningless.

Stupor (subcoma) is a state of hibernation; if the patient is brought out of this state by loud calling or braking, he can answer the question, and then again go into deep sleep.

Coma (complete loss of consciousness) is associated with damage to the centers of the brain. In coma, there is muscle relaxation, loss of sensitivity and reflexes, and there are no reactions to any stimuli (light, pain, sound). Coma can occur with diabetes mellitus, cerebral hemorrhages, poisoning, chronic nephritis, and severe liver damage.

In some diseases, disorders of consciousness are observed, which are based on excitation of the central nervous system. These include delusions and hallucinations (auditory and visual).

Facial expression allows us to judge the internal state of the patient. It can express anxiety, melancholy, fear. With fever, redness of the cheeks, agitation, and sparkling eyes are observed. A pale, puffy face with drooping eyelids occurs in patients suffering from kidney disease. With tetanus, a typical facial expression resembles a sarcastic smile.

A fixed gaze directed at one point occurs in patients with meningitis. Bulging eyes and shiny eyes are observed with Graves' disease. In case of poisoning with alcohol, drugs, uremia, constriction of the pupils is observed, and in case of atropine poisoning, the pupils are dilated. When the liver is damaged, the sclera becomes yellow.

General body structure

There are three main types of human constitution: normosthenic, asthenic, hypersthenic.

Normosthenic type characterized by proportionality in body structure, moderately developed subcutaneous fatty tissue, strong muscles, and a cone-shaped chest. The length of the arms, legs and neck corresponds to the size of the body.

For asthenics characterized by a predominance of longitudinal dimensions over transverse ones. The neck is long and thin, the shoulders are narrow, the shoulder blades are often distant from the chest, the epigastric angle is sharp, the muscles are poorly developed, the skin is thin and pale. Subcutaneous fatty tissue is underdeveloped, the diaphragm is low. Asthenics have lowered blood pressure and increased metabolism.

U hypersthenics transverse dimensions are emphasized. They are characterized by significant development of muscles and subcutaneous fat. The chest is short and wide, the direction of the ribs is horizontal, the epigastric angle is obtuse, the shoulders are wide and straight. The limbs are short, the head is large, the bones are wide, the diaphragm is high, the metabolism is low, and there is a tendency to high blood pressure.

Examination of the skin and mucous membranes - allows you to detect discoloration, pigmentation, peeling, rashes, scars, hemorrhages, bedsores, etc. The change in skin color depends on the color of the blood, the thickness of the skin, and the lumen of the skin blood vessels. The color of the skin may change due to the deposition of pigments in its thickness.

Paleness of the skin and mucous membranes can be permanent or temporary. Pallor may be associated with chronic and acute blood loss (uterine bleeding, peptic ulcer). Pallor is observed with anemia and fainting. Temporary pallor can occur due to spasm of skin vessels during fear, cold, or chills.

Abnormal redness of the skin depends on the expansion and overflow of small vessels with blood (observed during mental excitement). The red color of the skin in some patients depends on a large number of red blood cells and hemoglobin in the blood (polycythemia).

Cyanosis - a bluish-violet coloration of the skin and mucous membranes is associated with an excessive increase in carbon dioxide in the blood and insufficient oxygen saturation. There are general and local cyanosis. General cyanosis develops with cardiac and pulmonary failure; with some congenital heart defects, when part of the venous blood, bypassing the lungs, mixes with the arterial blood; in case of poisoning with poisons (Berthollet salt, aniline, nitrobenzene), which convert hemoglobin into methemoglobin. Cyanosis of the face and extremities can be observed in many lung diseases due to the death of their capillaries (pneumosclerosis, emphysema, chronic pneumonia).

Local cyanosis, which develops in certain areas, may depend on blockage or compression of the veins, most often due to thrombophlebitis.

Jaundice is the coloring of the skin and mucous membranes due to the deposition of bile pigments in them. With jaundice, a yellow coloration of the sclera and hard palate is always observed, which distinguishes it from yellowing of other origins (tanning, use of acryquine). The intensity of the icteric color varies from light yellow to olive green. A weak degree of jaundice is called subicterus.

Jaundice discoloration of the skin is observed when there is an excess content of bile pigments in the blood. This occurs when the normal outflow of bile from the liver to the intestine through the bile duct is disrupted when it is blocked by a gallstone or tumor, with adhesions and inflammatory changes in the bile ducts. This form of jaundice is called mechanical or congestive.

The amount of bile pigments in the blood can increase with liver disease (hepatitis), when bile formed in the cell enters not only the bile ducts, but also the blood vessels. This form of jaundice is called parenchymal.

Hemolytic jaundice also occurs. It develops as a result of excessive formation of bile pigments in the body due to significant breakdown of red blood cells (hemolysis), when a lot of hemoglobin is released, due to which bilirubin is formed (hemolytic jaundice). Occurs in congenital and acquired instability of erythrocytes, malaria, as well as in case of poisoning with various poisons.

Bronze or dark brown coloration of the skin is characteristic of Addison's disease (with insufficiency of the adrenal cortex).

Increased pigmentation can cause changes in skin color. Pigmentation can be local or general. Sometimes the skin has limited areas of pigmentation - freckles, birthmarks. Albinism is the partial or complete absence of pigmentation; the absence in certain areas of the skin is called vitiligo. Small areas of skin devoid of pigment are called leucoderma, but if they appear on the site of a rash, they are called pseudoleukoderma.

Skin rashes and hemorrhages. The most characteristic rashes occur with skin and acute infectious diseases.

In allergic conditions, urticaria may develop, which resembles a rash from a nettle burn and is accompanied by itching. There may be redness of the skin in a limited area due to vasodilation. Large pink-red patches on the skin are called erythema.

The tubercles are an easily palpable collection of cells in the skin. Such formations are observed in rheumatism.

Skin moisture depends on sweating. Increased humidity occurs with rheumatism, tuberculosis, and Graves' disease. Dryness occurs with myxedema, diabetes mellitus and diabetes insipidus, diarrhea, and general exhaustion.

It is important to evaluate skin turgor - its tension and elasticity. Skin turgor depends on the content of intracellular fluid, blood, lymph and the degree of development of subcutaneous fat. A decrease in turgor is observed with dehydration and tumors.

Hemorrhages are observed with bruises, skin diseases, infectious diseases, etc. Hemorrhages occur with sepsis, anemia, and vitamin deficiency. Hemorrhages into the skin come in various sizes and shapes.

Condition of hair and nails. Excessive hair growth in areas free of hair indicates endocrine disorders. Hair loss and fragility are characteristic of Graves' disease, and nested hair loss is characteristic of syphilis. Hair loss also occurs due to skin diseases - favus, seborrhea. Brittleness and splitting of nails is observed in cases of vitamin metabolism disorders and diseases of the nervous system. With fungal infections, nails become dull, thickened and crumble.

Bedsores occur as a result of impaired blood circulation and the integrity of the surface layers in bedridden patients in areas of greatest pressure. Bedsores can involve the subcutaneous fat layer and muscles.

Features of nursing examination. Nursing diagnoses. concept of monitoring and caring for the patient.

Stage 1 - obtaining information from the patient, his relatives, health workers, medical staff. documentation Subjective data - the patient’s ego opinion about his condition. Objective data are data obtained as a result of examination of the patient, the examiner’s opinion about the patient’s condition. During the examination, we obtain data: about the patient’s physical, psychological, social and spiritual problems

Stage 2 - registration of nursing diagnoses. The diagnosis takes into account the patient’s real and potential problems, indicating the possible cause of their occurrence (headache caused by increased blood pressure). When making a diagnosis, the m/s determines the patient’s condition. The patient's condition is considered satisfactory when the symptoms of the disease are moderate. He is on the floor in bed rest and completely takes care of himself. The condition is of moderate severity - the symptoms of the disease are pronounced, the patient is on bed rest, there are restrictions on self-care.

In heavy condition symptoms of the disease are expressed, the patient is on bed rest or strictly bed rest. Self-care is completely lost.

Stage 3 - based on the patient’s condition, we determine the scope of nursing interventions. In a satisfactory condition, the type of s/intervention is advisory, the s/s is obliged to give the patient and his family all the necessary information - about the nature of the disease, regimen, diet, examination, expected result, treatment, duration; provide current information about examination data and provide the patient with opportunities for self-care.

In a moderately severe condition, the type of intervention is partially compensatory, i.e., providing the patient with compensation for the lack of self-care, in addition, training relatives manipulations by care

In severe conditions, the type of intervention is fully compensated, i.e. providing full care to the patient and teaching loved ones the necessary care procedures.

Determining goals of care: short-term (within one week), long-term (more than 1 week).

Drawing up a plan for interventions:

Independent activity - does not require special instructions.

Dependent - only as prescribed by a doctor.

Interdependent - in interaction with health workers and relatives.

Independent activities include nursing activities, patient information, psychological support, monitoring the patient and the results of treatment.

Monitoring the patient includes the dynamics of the symptoms of the disease and possible complications. Treatment monitoring refers to assessing the effectiveness and identifying side effects of drugs. Then, based on the data obtained, a support plan (CAP) is drawn up.

Stage 4 - implementation of the care plan according to the standards.

Stage 5 - assessment of the results of care. For example: goals achieved, or goals partially achieved, or care goals not achieved.