What is a clinical examination. The purpose of the clinical examination. Methods of examination basic and additional. Family and sexual history. Questioning on this section should be confidential, without the presence of other patients.
1.General research methods - These are research methods used in the study of sick animals, regardless of the nature of the disease.
General research methods include:
Inspection-inspectio
Palpation-palpatio
Percussion-percussio
Inspection- the most ancient, simple, accessible method of objective examination of sick animals, carried out under natural or artificial lighting with the naked eye or using lighting devices.
Types of inspection:
General examination - examination of a sick animal from head to toe, which can be used to examine the physique, fatness, body position in space, mucous membranes, leg, hairline, behavioral reactions, localization of the process, the act of breathing, eating, defecation, urination, expiration and their character.
Local examination - examination of the area that corresponds to the localization of the disease process, while paying attention to the nature of changes in the state of the body, organ, functions.
Auscultation- A research method based on listening to sounds that occur in functioning organs.
Immediate-ear
Mediocre - with a phonendoscope, stethoscope
Asculations can examine the heart, lungs, gastrointestinal tract and there are sounds of working organs and those additional sounds that occur during changes (noises).
1. When examining the heart
1.1. Electrodiagnostics- recording of the potential difference of bioelectric tones arising in the myocardium in the process of its excitation.
For recording use electrocardiography type EKPSCH-3; EKPSCH-4 (M-060), EKPSCH-4 (M-061), EXPCHT-4, EPCAR, EK-873, etc.
With the help of cardiography, you can identify:
1.all kinds of arrhythmia
2.organic disorders of the heart
3. violation of intracardiac circulation
1.2.Vectocardioscopy, vectrocardiography- study of the general electrical heart sound during observation or recording, devices such as VEKS-1P, VEKS O.1M, VEKS-01, etc. are used for this purpose.
1.3.Vallisidography-record mechanical movements bodies associated with the cardiac cycle, which can be used to judge the state of myocardial contractility.
1.4.Phonocardiography-recording of sound phenomena arising in the heart. The recording is carried out on phonoelectrocardiographs such as FECP-2, VEKS-01, etc.
1.5. Sphygmography - arterial pulse recording
1.6 Oscillography - a way to record blood pressure
1.7. Phlebography - recording the dynamics of changes in the lumen of venous vessels and the properties of the venous pulse
1.8. Phlebography - measurement of the venous pulse
2. When examining the respiratory organs.
2.1. Endoscopy - internal examination of the larynx using an endoscope or a SHOG device (a spatula with an illuminator by V. I. Gabriolavichus); device PLM-2 (obtaining pulmonary sputum, author V. I. Gabriolavichus)
2.2. Phonometry - a study using a sounding tuning fork
2.3. Pneumography - a graphic display of the forms of breathing and respiratory movements of the chest.
2.4. Rhinography - graphic recording of the strings of inhaled air
2.5.X-ray examination-detection of changes using x-rays
3. When examining the gastrointestinal tract.
3.1. Pharyngoscopy - internal examination of the pharynx using a pharyngoscope
3.2. Laparoscopy - examination of the abdominal cavity using a laparoscope
3.3. Ruminography - graphic recording of scar reduction with a ruminograph
3.4. Tonometry - measuring the tone of the scar strength using a tonometer
3.5.Endoradio sounding-for measuring pH and pressure
3.6. Radiography - finding foreign substances using X-rays
3.7. Probing - examination of the stomach, proventriculus in order to detect the acidity of gastric juice
4. When examining the organs of the urinary system.
4.1. Catheterization - for taking urine samples.
4.2 Cystoscopy - examination Bladder using a cystoscope
5.Research nervous system.
5.1.Electroencephalography is a method of recording electrical potentials that occur in nerve cells.
Additional research methods include LABORATORY Study. For laboratory research during life, the following are taken:
-Call- examines microscopically, chemically, and if infection is suspected bacteriologically, for invasion - caprological; - Gastric juice- biochemical analysis, microscopic examination; - Urine- chemical examination of urine for pH, protein, sugar, ketone bodies, blood pigments, myoglobin, indican, bile pigments, bile acids; - Blood- the study of the blood system includes: a) the study of the physicochemical properties of blood - density, coagulation rate, retraction of a blood clot, viscosity b) biochemical examination of blood: the amount of hemoglobin, reserve alkalinity, bilirubin, total protein, phosphorus, calcium, sugar, etc. c) morphological composition of blood - the number of leukocytes, platelets, erythrocytes, etc.
Spend Feed research-determination of nutritional value, bacterial contamination, the presence of toxic substances. Additional research methods include pathological - anatomical autopsy, based on the detection of characteristic changes in the internal organs in various diseases.
Introduction
Clinical examination of the patient is an art that has been polished for years in the daily work of a doctor.
Patients with various surgical pathologies, often life-threatening and requiring emergency care, sometimes consisting in the need for bloody interventions, need certain features of both clinical and laboratory and special examination methods. This is primarily due to the nature of the manifestations of diseases, their urgency, the rapid development of dangerous complications, the mass flow of victims of accidents, etc.
The results of a clear, quick, correct and high-quality examination of a surgical patient determine the timeliness of the correct diagnosis, and, consequently, the effectiveness of treatment.
Timely and correct diagnosis of the disease depends on a systematic and thorough examination of the patient. At the same time, the doctor uses subjective and objective research methods: first, by questioning, he studies the patient's complaints, the history (anamnesis) of his illness and life, then examines the objective status of the patient (direct, or physical examination), using methods of examination, palpation, percussion and auscultation, then conducts laboratory and instrumental studies.
Despite the significant progress made in the development of methods of laboratory and instrumental diagnostics, the doctor's ability to detect signs of the disease by direct examination of the patient continues to be the foundation of the practice of the clinician. The ability to conduct a detailed questioning and confident knowledge of the skills of studying the objective status often allow the doctor to make the correct diagnosis without using any additional research methods. In other cases, the pathological symptoms detected at the same time make it possible to determine the direction of further diagnostic search and the laboratory and instrumental methods necessary for this.
clinical examination patient subcutaneous
Methods of clinical examination of the patient
Medical activity in a simplified form can be represented in the form of two main actions: making the correct diagnosis and prescribing adequate treatment. However, behind the external simplicity of these actions lies a huge amount of work, experience, and knowledge. Diagnostics (from the Greek diagnostikos - able to recognize) - a section of medical science that outlines research methods for recognizing diseases and the patient's condition in order to prescribe the necessary treatment and preventive measures. The term "diagnosis" also refers to the entire process of research of the patient, observation and reasoning of the doctor to determine the disease and condition of the patient. Diagnostics as a scientific discipline consists of three main sections:
study of methods of observation and research (physical and laboratory-instrumental) of the patient - medical diagnostic equipment;
study of diagnostic value symptoms of diseases - semiology (from the Greek. semejon - sign), or symptomatology;
the study of the characteristics of medical thinking in recognizing a disease, the ability to logically generalize individual symptoms - medical logic, or a diagnosis technique.
Methods of examination of patients are divided into two large groups: subjective and objective.
On subjective examination all the necessary information comes from the patient himself during his questioning (interrogatio) - the collection of anamnesis.
Objective examination involves obtaining the necessary diagnostic information by the doctor himself using special research methods - the main ones: general and local inspection (inspectio), feeling - nalation (palpatio), percussion - percussion (percussio), listening - auscultation (auscultatio). Additional (auxiliary), which include: laboratory (blood test, urine test, etc.), instrumental (X-ray, endoscopic, ultrasound, etc.), histological, histochemical, immunological and others.
Clinical methods of examination.
Clinical methods of examination include:
Interrogation of the patient (clinical conversation);
External examination of the patient;
Examination of the temporomandibular joint and masticatory muscles;
Oral examination:
Periodontal examination;
Examination of the edentulous alveolar part.
Interrogation of the patient (anamnesis). The collection of anamnesis (from the Greek. anamnesis - I remember) is the first stage of the examination of the patient, who is offered to reproduce the life history from memory.
The anamnesis consists of the following successively presented sections:
1) complaints and subjective state of the patient;
2) the history of the disease;
3) the history of the patient's life.
The range of questions that the doctor asks the patient depends on the nature of the disease. In some cases, the anamnesis is brief and the doctor does not need to go into the history of life, in others, the anamnesis should be collected in detail, especially in that part of it that is of greatest interest for making a diagnosis.
For example, when a patient contacts a traumatic incisor defect, the anamnesis will be brief, because the etiology of the lesion is known and everything that is required for treatment (therapeutic, orthopedic) can be clarified upon examination. Another thing is when the patient complains of a burning sensation that appeared in the mucous membrane, under the prosthesis. Here, the anamnesis, like all examinations, will be detailed. It is necessary to examine not only the organs of the oral cavity, but also other organ systems with the involvement of doctors of another specialty.
Often patients present complaints that seem to them to be the main ones, but from the point of view of the doctor they are secondary. For example, the patient pays attention to the ugly position of the front tooth, without noticing the anomalies of the dentition in the form of their narrowing. The doctor must identify both secondary and major causes of the disease, focusing on the latter. Particular attention is paid to complaints of pain. Here it is necessary to find out the degree of severity, nature, frequency, localization of pain.
When collecting an anamnesis, it is important, first of all, to find out the earliest manifestations of the disease, the nature and characteristics of its course, the type and amount of treatment performed. It is also necessary to find out the time of loss of teeth, complaints about the state of the gastrointestinal tract.
In a number of diseases (for example, diseases of the temporomandibular joint), you should talk with the patient about the probable causes that, in his opinion, caused this disease.
You can not conduct a survey of the patient, limited to mean questions and content with the same mean answers. The conversation should be expanded, skillfully and carefully ascertain the patient's emotional state, his attitude to the disease and treatment, readiness for long-term therapy and the desire to help the doctor's efforts. This will make it possible to get an idea of his mental originality, the knowledge of which plays a significant role in the tactics and behavior of the doctor, both during medical manipulations and during dynamic monitoring of the patient.
When collecting an anamnesis, the place of birth and place of residence, home conditions, working conditions at work, nutrition, past diseases are ascertained. The importance of this or that item of the anamnesis of life is determined by the clinical picture of the disease. Knowing the place of birth and life of the patient is important, since the so-called marginal pathology is possible. For example, with an excess of fluoride in drinking water in a given area, a focus of endemic fluorosis occurs, in which tooth enamel is affected.
When children are treated for dentoalveolar anomalies, anamnesis is collected from the parents. In this case, the doctor tries to get answers to the following questions: the condition of the mother during pregnancy, how the births proceeded, how many there were, whether this child was born full-term, with what weight, by which account, in what way it was fed (breast or artificially) and up to which time.
The diseases carried by the child and their course are also specified. It turns out the time of eruption of milk teeth, the reasons for their premature loss, the time of the change of teeth, as well as the age when the child began to walk and talk.
Data are collected on living conditions, nutritional habits, and the nature of chewing (chewing quickly, slowly on one side, on both sides). It is important to find out the way of breathing day and night (through the mouth or through the nose, sleeping with the mouth open or closed), the favorite position of the child during sleep, bad habits and which ones (sucking fingers, tongue, biting nails, pencil, etc.).
It is clarified whether orthodontic treatment was performed before (at what age, for how long, with what devices, with what results, whether there were operations in the oral cavity (when, which ones), whether there was an injury, what discomfort the patient feels at the moment and what he complains about (aesthetic, functional disorders).
It is necessary to find out how the patient successfully used prostheses, and if not, then for what reason. This information is important for planning and prognosis of orthopedic treatment.
In connection with the existence of hereditary diseases with anomalies of the chewing and speech apparatus (lower macrognathia, deep bite), one should be interested in the presence of anomalies in close relatives.
In an adult patient, unlike a child, many questions disappear when clarifying the anamnesis. During the conversation, the doctor determines the degree motivation for treatment(mood) for dental treatment. Some adult patients stop treatment, unable to bear the difficulties.
Despite the widespread development of laboratory and instrumental studies, the use of computers in diagnostics, the role of questioning the patient should not be underestimated. It belongs to the oldest and classic examination methods.
The famous Russian doctor G.A. Zakharyin considered questioning the patient an art. He wrote: "No matter how much you listen to the patient and do not tap out, you will never be able to accurately determine the disease if you do not listen to the testimony of the patient himself, if you do not learn the difficult art of examining the mental state of the patient."
External examination of the patient. All patients should have a facial examination. This is done without the patient noticing. During the survey, pay attention to:
The condition of the skin of the face (color, turgor, rash, scars, etc.);
The severity of the chin and nasolabial folds (smoothed, moderately pronounced, deepened);
The position of the corners of the mouth (raised, lowered);
Rice. 2.1. Anatomical formations of the lower part of the face: a - nasolabial fold; b - filter; c - upper lip; g - corner of the mouth; d - line of closing lips; f-g - red border of the lips; h - chin crease
The line of closing of the lips (the presence of jamming);
The degree of exposure of the anterior teeth or alveolar part when talking and smiling;
The position of the chin (straight, protrudes, sinks, shifted to the side;
Symmetry of the halves of the face (Fig. 2.1);
The height of the lower part of the face (proportional, enlarged, reduced).
An objective examination of the patient begins with an external examination. According to the appearance of the patient, facial expression, one can get an idea of the functional state of the central nervous system (depression, fear, etc.). When examining the skin of the face, pay attention to their color, the presence of asymmetry, scars, ulcerations and other abnormalities.
When examining the face, they also pay attention to the state of facial muscles at rest and during conversation.
The tension of the circular muscles of the mouth, the muscles of the chin may indicate a violation of the shape of the dental arches in the anterior section. On examination, the proportions of the face, the severity of the nasolabial and chin folds are determined. The decrease in the lower third of the face is associated with a decrease in the interalveolar height with anomalies (for example, with a deep bite), or due to abrasion, loss of teeth. An increase in the lower part of the face is observed with an open bite.
Finding out and establishing the above adverse factors in patients requires the periodontist to involve orthodontists and orthopedic dentists in the diagnosis and treatment in the future.
If necessary, the patient is asked leading and clarifying questions. So, for example, in the presence of scars, they find out the cause (burn, consequence of injuries, diseases, operations), prescription, the effectiveness of the treatment, the patient's attitude to his appearance, etc. At the same time, attention is paid not only to the content of the answer, but also to how the patient responds (clear speech, soundless breathing). This complements the degree of informativeness of the external examination, since with anomalies of the masticatory-speech apparatus, facial and dental signs are essential.
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For example, a combination of such facial features as protrusion of the middle part of the face against the background of an increase in the height of its lower part and smoothing of the nasolabial and chin folds, gaping of the oral fissure (the soft tissues surrounding the oral fissure are tense) with diastemas, tremas, protrusion and exposure of the upper incisors, under which the lower lip is tucked; allow at this stage of the examination of the patient to assume the presence of such an anomaly of the masticatory-speech apparatus as upper macrognathia.
Rice. 2.2. The division of the face into three parts: a - upper; b - average; in - the lower part. Explanations in the text
In dentistry, the division of the face into three parts has become widespread (Fig. 2.2):
- top- located between the border of the scalp on the forehead and the line connecting the eyebrows;
- middle- its boundaries are the line connecting the eyebrows, and the line passing along the base of the nasal septum;
- lower- from the base of the nasal septum to the lower point of the chin.
In general, the division of the height of the face into three parts is conditional, since the position of the points according to which the division is carried out is very individual and can change during a person's life. For example, the border of the scalp on the forehead is located differently in different subjects and can move with age. The same applies to the lower part of the face, the height of which is not constant and depends on the type of closure and the preservation of the teeth. The middle third of the face is the least variable. Despite the fact that it is impossible to see a natural proportionality between the sizes of these parts of the face, in most faces they have a relative correspondence, which provides an aesthetic optimum.
Visual and metric assessment of the face in its various dynamic states, it was revealed (V.A. Pereverzev) that during a conversation the lower lip is more active, and therefore the lower dentition is most often exposed. With a high (long) upper lip upper teeth exposed slightly or completely covered by it. During a smile, the picture changes - activity upper lip increases, due to which there is a significant exposure of the upper teeth with a lesser severity of the lower ones (normally by 1/3 of their height).
Regarding the dentition, according to V.A. Pereverzev, more than 80 are known signs of the beauty of a smile. In its formation, the leading role belongs to the dentition and teeth (the color of the teeth, their shape, size, position, relief, integrity, relative position in the dentition relative to the edges of the lips and other parts of the face, proportionality between themselves, with the whole face and its parts, correspondence the shape of the teeth, the shape of the face, etc.).
In doing so, the following signs of a harmoniously developed face:
Its three parts (upper, middle and lower) are approximately equal in height;
The nasolabial angle ranges from 90-100°;
The angle of convexity of the face is 160-170°;
Sagittal inclination of the upper anterior teeth within 90-100°;
The transversal inclination of the upper anterior teeth is from 5 to 10°, and the same indicator for the lower teeth of the same name is 0°;
The bending angles of the upper dentition, upper lip and horizontal profiling of the palpebral fissures are the same and vary within 170°;
The width of the filter is equal to the width of the two upper anterior central incisors;
The interorbital width is equal to the width (length) of one eye, and both of these parameters are identical to the width of the two upper incisors;
The height of the ear is equal to the height of each third of the face, and in the sagittal plane it is in harmony with the profile of the nose.
For orthopedic purposes, it is important to distinguish between two sizes height of the lower part of the face:
The first is measured with closed dentition; while the height of the lower part of the face is called morphological or occlusal;
The second is determined in a state of functional rest of the masticatory muscles, when the lower jaw is lowered and a gap appears between the teeth. This is - functional height.
In orthodontics, various measurements are carried out on the patient's face (determining the type of face and the height of its parts, the magnitude of the angles of the lower jaw, the length of its body) using compasses, goniometers and rulers with a millimeter scale.
Face outlines in front are most often defined as rectangular, conical or obverse-conical, depending on the ratio of the width between the angles of the lower jaw and between the anterior sections of the ear tragus. Measurement of parts of the face (upper, middle and lower) is useful before and after treatment.
Angles of the lower jaw(right and left) are measured in patients to establish their value for various dentoalveolar anomalies. Measurements are also taken before and after treatment. In an indirect way, the angle of the lower jaw is measured on a photograph, teleroentgenogram, on a radiograph or tomogram of the angle of the lower jaw.
The data obtained by measuring parts of the face and angles of the lower jaw by direct or indirect methods are conditional, since it is not always possible to establish their true value due to the thickness of the soft tissue layer, the unequal severity of the angles of the lower jaw and possible projection distortions on the radiograph. Despite the relative reliability of these data, they still contribute to a more detailed study of the configuration of the face with anomalies of the chewing and speech apparatus.
Examination of the temporomandibular joints and masticatory muscles. Diagnosis of diseases of the temporomandibular joint is based on the data of anamnesis, clinical examination of the oral cavity and the joints themselves, functional tests, and the results of x-ray studies.
During a conversation with the patient it is necessary to find out his complaints. Most often, patients complain of clicking in the joint, pain, limited mouth opening, crunching, headache, hearing loss. Many patients do not complain, but their examination reveals one or another pathology of the joint. Thus, the study of the temporomandibular joint is mandatory for patients with pathology of the dentition (anomalies, complete or partial loss of teeth, deformation, increased abrasion, periodontal disease, etc.).
Then it should be clarified when the disorders called by the patient, for example, clicking in the joint, appeared and what he associates them with (trauma, loss of teeth, flu, wide opening of the mouth during tooth extraction, etc.). An important point in the collection of anamnesis is to establish the connection between tooth loss and joint disease, as well as whether the patient received a prosthesis and whether relief came after that.
At the end of the interview, the patient is joint palpation by placing fingers on the skin, in front of the tragus of the auricle or by inserting fingers into the external auditory meatus.
Palpation- the use of fingers (usually, the pads of the terminal phalanges of the thumb, index, middle fingers, less often the little finger) to study the tone of the masticatory muscles, localize painful points in them, study the bone base of the prosthetic bed, as well as study the displacement and compliance of the oral mucosa, in particular - bridles and dangling combs.
During palpation of regional lymph nodes, their size, consistency, mobility and soreness are assessed. Usually examine the submandibular, submental and cervical lymph nodes. Unchanged lymph nodes have a size from lentils to small peas, single, soft elastic consistency, mobile, painless.
The palpation of the masticatory muscles at rest and with clenched teeth is also important, so it allows you to determine the presence of dysfunctions or parafunctions of the masticatory muscles and is an unfavorable factor in the development of periodontal diseases.
When palpation of the joint, pain can be detected, tremors, clicking and crunching are often felt. Therefore, palpation plays a role here. auscultation, although noises, crunching, clicking can be heard with a phonendoscope.
In addition, the introduction of noise in analog form into a computer (if appropriate programs are available) makes it possible to obtain their spectral analysis. This diagnostic method is called arthrophonometry(A.Ya. Vyazmin; E.A. Bulycheva).
Palpation allows you to detect smoothness or jerkiness, amplitude of movements of the heads of the lower jaw during opening and closing of the mouth, synchronism of movements of the left and right heads. At the same time, it is possible to note clicking, crunching, their combination and synchrony with various phases of mouth opening.
The heads of the lower jaw are characterized by two types of movement, determined by palpation, namely, normal, smooth without going beyond the top of the articular tubercle and movement with a large amplitude, reaching the top of the articular tubercle or to the side. Some of these excursions may be on the verge of subluxation. Finally, there may be a habitual dislocation with a complete protrusion of the head from the articular cavity, beyond the top of the tubercle.
To functional tests includes checking the excursion of the lower jaw when opening and closing the mouth. In this case, the following two types of its movements can be noted. With the first, called direct (normal, progressive, smooth), the trajectory of the incisal point on the sagittal plane does not shift to the side when opening and closing the mouth. In the second - wavy (zigzag, stepped) incisal point when the lower jaw moves to the right or left of the sagittal plane, forming a wave or zigzag, a step.
When the trajectory of the incisal point combines elements of the direct and wave-like movement of the lower jaw, one speaks of a combined movement. This type also includes those trajectories that, when opening the mouth, have a rectilinear direction, and when closing, they are distorted by a shift or zigzag.
Difficulty opening the mouth can occur both when the mouth is narrowed, and when the movements of the lower jaw are difficult due to muscle or articular contracture. In itself, difficulty in opening the mouth indicates a certain pathology. In addition, it interferes with many manipulations associated with prosthetics (insertion of impression trays or prosthesis). At the same time, the degree of separation of the dentition when opening the mouth is established.
On palpation chewing muscle proper(Fig. 2.3 a) the thumb is placed on its front edge, the rest are located along the rear edge. The muscle is gently squeezed by the fingers. You can palpate it with your index finger from the side of the oral cavity, with your thumb - from the outside. Thus, the degree of development and severity of the muscle, its tone, areas of compaction and pain points, if any, are determined.
Rice. 2.3. Scheme of palpation of the masticatory (a) and medial pterygoid (b) muscles
temporalis muscle palpated by intraoral access and outside - in the temporal region. In the oral cavity, with the index finger, the place of attachment of the muscle to the coronoid process is examined. Outside, on the right and left, the muscle is palpated with four fingers of each hand, placing them in the temporal region.
Front surface medial pterygoid muscle(Fig. 2.3 b) is examined with the index finger sliding up the pterygomandibular fold from the retromolar region of the lower jaw. Its lower part is also palpated by intraoral access, when the index finger is lowered into the distal sublingual region, to the angle of the lower jaw. During palpation of the medial pterygoid muscle, the index finger is also directed along the mucous membrane of the vestibular surface of the alveolar process of the upper jaw distally and upward, beyond the alveolar tubercle.
Examination of the oral cavity. After an external examination, an examination of the oral cavity is carried out using a dental mirror, probe, tweezers. Inspection begins with an examination of the condition of the red border of the lips and corners of the mouth. At the same time, attention is paid to their color, size, the presence of elements of the lesion. Then sequentially examine the vestibule of the oral cavity, the condition of the dentition and periodontal, the mucous membrane of the oral cavity.
When examining the vestibule of the oral cavity, its depth is noted. The vestibule is considered shallow if its depth is not more than 5 mm, medium - 8-10 mm, deep - more than 10 mm. Normally, the width of the marginal (free) gingiva is approximately 0.5-1.5 mm and is relatively constant, in contrast to the attached gingiva, which depends on the shape of the alveolar part, the type of bite and the position of individual teeth. Attached gum passes into the mobile mucous membrane of the transitional fold. Normally, the attached (alveolar) gum serves as a kind of buffer between the muscles of the lips and the marginal gum. With insufficient width of the alveolar gum, the tension of the lips and the tension of the frenulum entail a recession of the gingival margin.
Of particular importance is the inspection of the frenulum of the lips. The normal frenulum is a thin triangular mucosal fold that has a wide base on the lip and ends in the midline of the alveolar process approximately 0.5 cm from the gingival margin.
There are short (or strong) frenulums with local attachment at the top of the interdental papilla, the movement of the lips in this case causes displacement of the gingival papilla between the central incisors or ischemia of the mucous membrane at the site of attachment of the frenulum. Medium frenulums are attached at a distance of 1-5 mm from the top of the interdental papilla, and weak ones - in the region of the transitional fold.
After examining the vestibule, they proceed to the examination of the oral cavity itself. The development and course of periodontal diseases is influenced by the position of the tongue, it is necessary to check the condition of the frenulum of the tongue, the place of its attachment. Examination of the mucous membrane of the tongue can give the doctor additional information about the general condition.
Dentitions are carefully examined. Normally, the teeth fit tightly to each other, thanks to the contact points form a single dentoalveolar system. When assessing the dentition, the relationship of teeth, the presence of dental deposits, the degree of wear of crowns, the presence of carious cavities and defects of non-carious teeth, the quality of fillings (especially on contact and cervical surfaces), the presence and quality of dentures are taken into account.
The deformation of the dentition, the close position of the teeth, the presence of three and diastema are a predisposing factor in the development of periodontal disease.
The examination of the dentition is completed by determining the type of bite and identifying the symptoms of traumatic occlusion.
Consistently proceed to the study of periodontal tissues. During the inspection of the gums, its color, surface, consistency, contour and location of the gingival margin in relation to the crown of the tooth, size, bleeding, and soreness are evaluated.
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normal gums are pale pink, dense, moderately moist, interdental papillae of a pointed shape. Inflammation of the gums is one of the main symptoms of periodontal disease. Signs of inflammation of the gums are: hyperemia, cyanosis, swelling, ulceration, bleeding.
Rice. 2.4. Dental diagnostic tools
After examination, palpation of the mucous membrane of the gums and the alveolar part is carried out. At the same time, the consistency of the gums is assessed, areas of soreness, the presence of bleeding and discharge from the pockets are determined.
When examining the oral cavity, the doctor uses a dental mirror, which may be provided with a light to illuminate the distal parts of the oral cavity. In addition to it, the set of tools (Fig. 2.4) includes dental tweezers with curved ends and curved probes - pointed and with an olive-shaped tip and notches. The first is designed to study the marginal fit of fixed dentures, the second - to determine the depth of periodontal pockets.
Examination of the oral cavity should be carried out in a certain sequence:
Examination of the oral mucosa;
Examination of teeth and dentition;
Periodontal examination.
Examination of the oral mucosa. With a general clinical description of the state of the mucous membrane of the upper and lower jaw, in addition to morphological features (see Fig. 1.29), which are of applied importance, it is necessary to note the color, humidity, the presence of scars, polyps, aphthae, erosions, ulcers, petechiae, hemangiomas, papules, vesicles and other pathological manifestations (leukoplakia, lichen planus). Moreover, when assessing the state of the mucous membrane, the presence of defects in the dentition is important.
In the presence of certain changes in the mucous membrane, the doctor makes an appropriate entry in the medical history, which reflects the localization of changes, their qualitative and quantitative characteristics. It should be noted that there is a large group of diseases of the oral mucosa. At the same time, there are quite a few somatic diseases, one of the manifestations of which are changes in the mucous membrane. Therefore, when certain changes in the mucous membrane are detected, an additional examination by doctors of other specialties is often required.
Normally, the mucous membrane is pale pink or pink, moist, shiny. However, it must be remembered that violations of salivation and salivation (scanty, abundant) distort the perception of the color and moisture of the mucous membrane. In addition, with a number of diseases, it can become inflamed, becoming edematous, loosened and bleed, its hyperemia is noted, sometimes combined with cyanosis.
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- Introduction
- 1.3 Examination of patients
- 1.3.1 General examination of patients
- 1.3.2 Consciousness
- 1.3.3 Position of the patient
- 1.3.5 Facial expression
- 1.3.9 Lymph nodes
- 1.3.11 Body temperature
- Literature
Introduction
Clinical examination of the patient is an art that has been polished for years in the daily work of a doctor.
Patients with various surgical pathologies, often life-threatening and requiring emergency care, sometimes consisting in the need for bloody interventions, need certain features of both clinical and laboratory and special examination methods. This is primarily due to the nature of the manifestations of diseases, their urgency, the rapid development of dangerous complications, the mass flow of victims of accidents, etc.
The results of a clear, quick, correct and high-quality examination of a surgical patient determine the timeliness of the correct diagnosis, and, consequently, the effectiveness of treatment.
Timely and correct diagnosis of the disease depends on a systematic and thorough examination of the patient. At the same time, the doctor uses subjective and objective research methods: first, by questioning, he studies the patient's complaints, the history (anamnesis) of his illness and life, then examines the objective status of the patient (direct, or physical examination), using methods of examination, palpation, percussion and auscultation, then conducts laboratory and instrumental studies.
Despite the significant progress made in the development of methods of laboratory and instrumental diagnostics, the doctor's ability to detect signs of the disease by direct examination of the patient continues to be the foundation of the practice of the clinician. The ability to conduct a detailed questioning and confident knowledge of the skills of studying the objective status often allow the doctor to make the correct diagnosis without using any additional research methods. In other cases, the pathological symptoms detected at the same time make it possible to determine the direction of further diagnostic search and the laboratory and instrumental methods necessary for this.
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1. Methods of clinical examination of the patient
Medical activity in a simplified form can be represented in the form of two main actions: making the correct diagnosis and prescribing adequate treatment. However, behind the external simplicity of these actions lies a huge amount of work, experience, and knowledge. Diagnostics (from the Greek diagnostikos - capable of recognizing) - a section of medical science that outlines research methods for recognizing diseases and the patient's condition in order to prescribe the necessary treatment and preventive measures. The term "diagnosis" also refers to the entire process of research of the patient, observation and reasoning of the doctor to determine the disease and condition of the patient. Diagnostics as a scientific discipline consists of three main sections:
study of methods of observation and research (physical and laboratory-instrumental) of the patient - medical diagnostic equipment;
the study of the diagnostic value of the symptoms of diseases - semiology (from the Greek. semejon - sign), or symptomatology;
the study of the characteristics of medical thinking in recognizing a disease, the ability to logically generalize individual symptoms - medical logic, or a diagnosis technique.
Methods of examination of patients are divided into two large groups: subjective and objective .
At subjective survey all the necessary information comes from the patient himself during his questioning (interrogatio) - the collection of anamnesis.
objective examination involves obtaining the necessary diagnostic information by the doctor himself using special research methods - the main ones: general and local inspection (inspectio), feeling - nationality ( palpation ), percussion - percussion (percussio), listening - auscultation (auscultatio). Additional (auxiliary), which include: laboratory (blood test, urine test, etc.), instrumental (X-ray, endoscopic, ultrasound, etc.), histological, histochemical, immunological and others.
1.1 Subjective examination of patients
The method of questioning (taking an anamnesis) in the clinic of internal diseases is of great importance in the process of diagnostic search. It is always carried out before the physical examination of the patient. According to various authors, a methodically correctly collected anamnesis makes it possible to make a correct diagnosis in 50–70% of cases without resorting to an objective examination of patients. Without exaggeration, the founder of the anamnestic method in the diagnosis of diseases is the outstanding Russian clinician Grigory Antonovich Zakharyin.
The subjective examination includes several sections: general intelligence about sick (passport part), complaints sick, story present diseases (anamnesis morbi), story life sick (anamnesis vitae).
Let's take a closer look at each of these sections.
General intelligence ( passport part ).
The doctor receives this information at the first contact with a sick patient. The passport part includes: surname, name, patronymic; age, gender, education, profession, position, place of work, home address, date of admission, by whom the patient was referred. Each of the listed items of the passport part for an experienced doctor is not just formal information, but, above all, information that has a deep meaning and gives impetus to logical thinking. For example, the patient's school age, adolescence is most often associated with a disease such as rheumatism and almost never with coronary heart disease, atherosclerosis. On the contrary, old and old age, as a rule, is associated precisely with the latest diseases. Specifying the profession of the patient, the doctor first of all thinks about a possible occupational disease, or at least about negative impact occupational hazards on the body. There is a group of hereditary diseases ": linked" with sex. For example, hemophilia only affects men.
The remaining columns of the passport part are most often filled in for statistical purposes.
Complaints sick
Collecting complaints requires great skill. To avoid mistakes and waste of time, it is necessary to strictly comply with several mandatory requirements. First of all, it must be remembered that many patients, especially the elderly and old, have several diseases, respectively, many complaints. Therefore, the doctor must clearly isolate the main (main) complaints, and then the rest (associated). To achieve this goal, the most correct and adequate first question is "What worries you the most?" If the anamnesis is collected immediately upon admission of the patient. If this happens several days after admission, the question should be rephrased: “What was your biggest concern when you were admitted to the hospital? ”No one will dispute that the main complaints are the most vivid subjective sensations of the patient (pain in the heart, shortness of breath, headache, etc.), which make the patient seek help from medical professionals. Therefore, asking the question “What worries you (or worries you) most of all?”, Through them we most realistically approach the underlying disease. At the same time, the doctor must remember that the patient’s complaints and the localization of the pathological process do not always coincide (for example, pain in epigastric region in the abdominal form of myocardial infarction, pain in the right hypochondrium with croupous pneumonia of the lower lobe of the right lung, etc.) But to clarify the localization of the pathological process, the doctor has a huge arsenal of objective research methods (examination, palpation, percussion, etc.). ).
The second indispensable requirement in the collection of anamnesis is the detailing of complaints. For example, if a patient is worried about coughing, then we must clarify whether it is dry (without sputum) or wet (with sputum). If the cough is wet, then we specify the amount of sputum secreted per day, its nature, color (purulent, serous, hemorrhagic), etc. Detailing concerns both the main and accompanying complaints. After clarifying the main complaints, the following question is asked: "What else worries you?", logically assuming that the patient in response will state related complaints.
One of the mandatory requirements when collecting complaints is their active identification by the doctor himself. Due to various circumstances, patients sometimes forget to state part of the complaints or individual (often very important) details of the anamnesis. In order to avoid such leakage of information, the doctor himself must identify these complaints using the “hint method”. For example, if during the conversation with the patient there were never any complaints from of cardio-vascular system, then the doctor himself should ask if there are pains in the heart, palpitations, interruptions in the work of the heart, shortness of breath, swelling in the lower extremities, etc. The same clarifying questions-hints are asked in relation to other organs and systems.
Thus, when collecting complaints, it is necessary to isolate the main and accompanying ones, to detail each of them, and also to actively identify those complaints and details of the anamnesis that the patient voluntarily or involuntarily missed.
Story present diseases ( anamnesis morbi ).
This section should reflect the onset of the disease, its further development up to the present. Many novice doctors make the same mistake when asking the question "When did you get sick?" In response, the patient, as a rule, names the date (year, month) of the most striking manifestations of the disease, associated in most cases with the next exacerbation of the disease. As a result, the doctor receives information only about a short episode of the disease, lasting at best a few weeks. In fact, with a more thorough questioning, the "track record" of the disease sometimes totals 10-15 years or more. To avoid such a mistake, it is necessary to ask correct and clear questions, the wording of which does not allow ambiguity. For example, if we have a patient with typical manifestations of angina pectoris, and we want to clarify the onset of the disease, the question should be formulated as follows: "When for the first time in your life and under what circumstances did you experience attacks of retrosternal pain?" Such a question excludes ambiguous interpretation and the patient is "forced" to remember that "very very" first, initial period of the disease. When the first goal is achieved, the doctor must tactfully, but persistently, force the patient to recall the entire further chronology of the development of the disease. Was the patient admitted to the hospital for examination at the onset of the first signs of illness? If so, when and which hospital? What examination was carried out and its results. What was the diagnosis? Were there subsequent exacerbations of the disease? How often and how did they manifest themselves? What was the treatment? Often the name of the drugs gives a clue to the diagnosis. Has the treatment been effective? Have you been treated or examined in other clinics? Last hospitalization? In the course of the questioning, we clarify issues related to temporary or permanent disability. Is it possible that a disability group has been established for the patient due to the disease? What and when?
The logical conclusion of an. morbi should contain information on why and under what circumstances the patient is currently re-admitted to the hospital if the history is taken from an inpatient. If the patient once again came to the clinic, then the motives for such a visit are clarified. A typical motivation in both cases is another deterioration in well-being, its manifestations, which forced the patient to call " ambulance"or contact the local therapist himself, who send him to the hospital.
Story life sick ( anamnesis vitae ).
When starting this section of the anamnesis, it must be remembered that the main goal of the anamnesis vitae
- establish those factors environment(including domestic, social, economic, hereditary, etc.), which one way or another could contribute to the emergence and further development of the disease. In this regard, the following sections should be reflected in the patient's life history in chronological order:
Childhood and youth. Where and in what family was he born, the profession of his parents? Was he born on time, what kind of child? Breastfed or artificially fed? When did you start walking and talking? Material and living conditions in childhood, general state of health and development (did you lag behind your peers in physical and mental development?). When did you start studying and how did you study at school? Further study. Was he exempted from physical education during his studies? For men, it is specified whether he served in the army (if not, then why?), in what kind of troops he served.
Working and living conditions. Beginning and further labor activity in chronological order. It is important to establish not only working conditions, but also whether there were occupational hazards during work. Mode of work (day or night work, its duration).
Housing conditions: sanitary characteristics of the dwelling, its area, on which floor the apartment is, how many family members live in the apartment.
Characteristics of nutrition: regularity and frequency of food intake, its usefulness, dry food, hasty food, addiction to any food.
How he spends his free time, organization of recreation. How does he spend his vacation? Physical activity, sports and physical education.
Family and sexual history. Questioning on this section should be confidential, without the presence of other patients.
It turns out the marital status (at what age he married or got married), the composition of the family and the health of its members. In women, the state of the menstrual cycle is ascertained (the time of the appearance of the first menstruation, when they were established, their duration, intensity, soreness, the time of the onset of menopause), pregnancy and childbirth, their course, abortions and their complications, miscarriages. In men, the time of the onset of puberty (the appearance of a mustache, beard, the onset of wet dreams), the characteristics of sexual life, are found out.
Heredity.
The male and female pedigrees of the patient are specified. The health status of relatives. If they died, you should find out at what age and from what disease it happened. Did the parents and close relatives suffer from a disease similar to that of the patient?
Past illnesses.
Acute diseases are indicated in chronological order, while the presence of concomitant chronic diseases is indicated. It is important first of all to identify those past diseases that can be pathogenetically associated with the present disease.
Bad habits.
This section of the anamnesis is also desirable to collect without witnesses in view of the delicacy of the questions asked. Information is collected about smoking (how long and what he smokes, the number of cigarettes or cigarettes smoked per day). Use alcoholic beverages(at what age, which ones, how often and in what quantity?), drugs (promedol, morphine, opium, cocaine, codeine, etc.), sleeping pills and sedatives, strong tea and coffee.
Allergic and drug history.
First of all, it is clarified whether the patient has taken medications in the past and present. If so, how did you endure them, were there any adverse reactions or manifestations of allergies (fever, rashes on the body, itching, manifestations of shock). From what medicine severe allergic reactions were specifically observed? The name of the drug - the allergen is placed on the title page of the medical history, as well as on the outpatient card. It is clarified whether there were blood transfusions and what are their consequences.
The following are the possible cases food allergies, allergic reactions to household chemicals, cosmetics, exposure to cold, etc.
1.2 Methods of objective examination of patients
As already mentioned, there are basic and auxiliary (additional) methods of objective examination of patients.
1. Main methods objective surveys sick :
inspection - inspectio, feeling - palpatio, percussion - percussio, listening - auscultatio.
2. Auxiliary ( additional ) methods :
measuring, laboratory, instrumental, histological, histochemical, immunological, etc.
Let's consider them in more detail.
1.3 Examination of patients
Allocate:
General inspection - examination of the patient "from head to toe".
Local (regional, local) - inspection by systems. For example, examination of the chest, heart, abdomen, kidneys, etc.
Main requirements at carrying out inspection
Good illumination of the room, comfortable conditions, observance of the "technics" of the inspection, strict sequence, regularity of the inspection.
1.3.1 General examination of patients
The sequence of the general examination of patients:
1 General condition of the patient.
2 State of consciousness of the patient.
3 Physique and constitution of the patient.
4 Facial expression, examination of the head and neck.
5 Examination of the skin and visible mucous membranes.
6 The nature of hair and nails.
7 Development of the subcutaneous fat layer, the presence of edema.
8 Status of the lymph nodes.
9 Assessment of the condition of muscles, bones and joints.
General examination of patients, as a rule, is supplemented by palpation.
General state ie sick maybe be extremely heavy heavy middle gravity and satisfactory . Approximate data on the general condition can be obtained already at the beginning of the inspection. However, most often a complete picture of the patient's condition occurs after an assessment of consciousness, the position of the patient in bed, a detailed examination of the systems and the establishment of the degree of dysfunction of the internal organs. However, when describing the objective status of a patient, they traditionally begin with a description general condition sick.
1.3.2 Consciousness
The word "consciousness" in Russian has several meanings, in particular, Ozhegov's dictionary indicates five meanings, among which we note the following:
human ability to reproduce reality in thinking; mental activity as a reflection of reality (that is, consciousness is sometimes called the totality of human mental processes);
the state of a person in his right mind and memory, the ability to be aware of his actions, feelings (a narrower use of the term, equal to the functional state of the brain).
When considering alterations in consciousness, there are:
BUT. Long violations :
1) quantitative forms of violation ( syndromes oppression );
2) qualitative forms of violation ( syndromes obscurations ).
B. Paroxysmal violations :
1) syncope;
2) epileptic seizures (including derealization and depersonalization syndromes).
Sequential degrees of loss of consciousness are called:
1) stun (obtundation),
2) sopor ( corresponds to English. stupor),
3) coma .
workingclassificationviolationsconsciousness ( Konovalov A.N. et al., 1982) - adapted version
I. quantitative forms violations :
clear : Full preservation of consciousness with active wakefulness, equivalent perception of oneself and adequate response to the environment.
Stun :
Moderate: Partial disorientation in place, time, situation; moderate sleepiness. The answers are slow, delayed, but correct. The reaction of the extremities to pain is active, purposeful. Control over the functions of the pelvic organs is preserved.
Deep: An almost constant state of sleep. With errors, he can report his name, surname. To establish even a short-term contact, repeated appeals, a loud call with the use of painful stimuli are necessary. Control over the functions of the pelvic organs is weakened. The coordinated protective reaction to pain is preserved.
sop op . Switching off consciousness with the absence of verbal contact. Speech and mimic-manual contact is impossible. No commands are executed! Immobility or reflex movements, but responds to pain with coordinated defensive movements. Sphincter control is broken. Vital functions (respiration, cardiac activity) are preserved. Pupillary, corneal, swallowing, cough and deep reflexes are preserved.
Coma : Complete shutdown of consciousness with a total loss of perception of the environment and oneself, and with more or less pronounced neurological and autonomic disorders.
Moderate (I): "Unawakened." Lack of reactions to any external stimuli, except for strong pain. Reactions to pain are not coordinated, not aimed at eliminating the stimulus. Pupillary and corneal reflexes are preserved. Swallowing is severely difficult. Sphincter control is broken. Respiration and cardiovascular activity are relatively stable.
Deep (II): Absence of any reactions to any stimuli, including severe pain. Complete absence of spontaneous movements. Hyporeflexia or areflexia. Preservation of spontaneous respiration and cardiovascular activity in severe disorders.
Transcendental (III): Bilateral transcendental mydriasis, the eyeballs are motionless. Total areflexia, diffuse muscle atony; the grossest violations of vital functions - disorders of the rhythm and frequency of breathing or apnea, severe tachycardia, blood pressure is critical or not determined.
Etiologically isolated brain, hyperglycemic, hypoglycemic, uremic, renal, hepatic, hypoxic, anemic, intoxication, hypochloremic Russian and other coma. In addition, there are also pseudo-comatose states, which will be discussed in the course of neurology.
II. Long quality violations consciousness
quality disturbances of consciousness (syndromes of obscuration, confusional states) are characterized by a predominant disorder in the quality, content of consciousness with more intact activation. They are more common in diffuse brain lesions, for example, against the background of intoxication (alcohol, croupous pneumonia, etc.).
Allocate delirium, oneiroid, amentia and twilight consciousness .
Delirium (delirium) - hallucinatory stupefaction with a predominance of true visual hallucinations and illusions, figurative delirium. hallucinations - false, inadequate perception of the surrounding reality by the senses. Patients see, hear, feel things that are not really there. Allocate visual, auditory and tactile hallucinations.
Oneiroid (oneirism) - obscuration of consciousness with an influx of involuntarily arising fantastic ideas that flow like a scene from one another, in combination with depressive or manic disorders and the possible development of a catatonic stupor.
amentia (amentia) - clouding of consciousness with the phenomena of incoherent speech (speech disorganization), confusion and motor excitation of an untargeted nature.
Twilight consciousness - sudden and limited in time (minutes, hours, days) loss of clarity of consciousness with complete detachment from the environment or with its fragmentary and distorted perception, while maintaining the usual automated actions.
Common signs of confusion syndromes are:
1) the patient's detachment from the environment with an indistinct, difficult, fragmentary perception of it;
2) different kinds disorientation - in place, time, surrounding persons, situation, own personality, existing in various combinations;
3) a certain degree of incoherent thinking, which is accompanied by weakness or impossibility of judgment and speech disorders; full or partial amnesia of the period of clouding of consciousness.
Paroxysmal disorders of consciousness will be considered in senior courses.
1.3.3 Position of the patient
Active : the patient arbitrarily changes position in bed, can serve himself.
passive : due to severe weakness, severity of the condition or loss of consciousness, he cannot independently change the position of the body or individual parts, even if it is very uncomfortable for him.
forced : this is the position that the patient occupies consciously or instinctively, while his suffering is relieved, pain or painful sensations are reduced.
Active in bed . This situation can be observed in fractures of the lower extremities in patients with skeletal traction.
The most characteristic forced postures of patients:
They sit, leaning forward, leaning on the edge of the bed or a chair during an attack of bronchial asthma: in this position, expiratory dyspnea decreases due to the additional connection of muscles shoulder girdle to exhale.
Sitting with legs down, head thrown back, with heart failure ( orthotop but eh ): the stagnation of blood in the lungs decreases, the pulmonary circulation is unloaded, and thus shortness of breath decreases.
They lie on the affected side with exudative pleurisy, lobar pneumonia, pneumothorax (air in the pleural cavity): the respiratory excursion of a healthy lung is facilitated.
They lie on the diseased side with dry pleurisy: the excursion of the diseased half decreases, the pain in the chest disappears.
They lie on the sick side with suppurative lung diseases (bronchiectasis, abscess, gangrene): cough decreases, sputum secretion is evil.
They take a knee-elbow position or lie on their stomach with an exacerbation of gastric ulcer: the mobility of the stomach decreases and pain decreases.
They lie with a bent leg in the hip and knee joints - with acute appendicitis, paranephritis (inflammation of the perirenal tissue): pain decreases.
They lie on their side with the head thrown back and the legs brought to the stomach with meningitis (the position of the "question mark", "pointing dog").
1.3.4 Body type and constitution
Physique is a combination of morphological features (height, weight, body shape, muscle development, degree of fatness, skeletal structure) and proportionality (harmony) physical development.
The height of the patient is determined by a stadiometer or anthropometer. Distinguish growth low, below average, average, above average, high. Growth above 190 cm - gigantism, less than 100 cm - dwarfism.
Weight is determined by medical scales, chest circumference - by a centimeter tape or tape measure. Assessment of physical development is currently carried out according to special evaluation tables ("regression scales"). Special indices have not lost their significance: Quetelet, Bouchard, Brugsch, Pigne.
Degree fatness determined by the level of development of muscles and subcutaneous fat layer. To assess fatness, the skin is captured in a fold with the thumb and forefinger in the area of the shoulder, lower third of the chest, abdomen or thigh. With a skin fold thickness of 2 cm, the development of the subcutaneous fat layer is considered normal, less than 2 cm - reduced, more than 2-3 cm - increased.
Constitution - this is a set of morphological and functional features of the body, partially inherited, partially acquired in the process of life under the influence of the environment. There are three constitutional types:
Normosthenic - the ratio of the anteroposterior and transverse dimensions of the chest is proportional and is 0.65-0.75, the epigastric angle is 90 °, the muscles are well developed; clavicle, supraclavicular and subclavian fossae are moderately expressed, the ribs are directed moderately obliquely down.
Asthenic - the longitudinal dimensions of the body predominate: the limbs and neck are long, the chest is narrow, the epigastric angle is less than 90 °, the muscles are poorly developed, the supra- and subclavian fossae are deep, the clavicles are sharply contoured, the intercostal spaces are wide, the ribs are directed almost vertically. Parenchymal organs of small size, the heart is "hanging", the mesentery is long, prolapse of the kidneys, liver, and stomach is often noted. These people are easily excitable, there may be an increase in function thyroid gland, and some decrease in the function of the gonads. More prone to diseases of the lungs and gastrointestinal tract.
Hypersthenic type - transverse dimensions prevail over longitudinal ones. The muscles are well developed, the neck is short and thick; the epigastric angle is more than 90°, the ratio of the anteroposterior and transverse dimensions of the chest is more than 0.75; the intercostal spaces are narrow, the supraclavicular and subclavian fossae are not pronounced, the ribs are directed horizontally. These individuals have slightly increased function of the gonads and reduced - the thyroid gland. More often, a violation of lipid metabolism, a tendency to arterial hypertension and coronary artery disease, cholelithiasis and urolithiasis are detected.
1.3.5 Facial expression
Expression faces - a mirror of the mental and physical state of the patient. Facial expression is an important diagnostic feature in a number of diseases.
· "Mitral face" (facies mitralis) - typical for patients with mitral stenosis: against the background of pallor, cyanotic "blush" of the cheeks, cyanosis of the lips, tip of the nose and ears;
· "Corvisar's face" (facies Corvisari) - a sign of severe chronic heart failure: the skin of the face is yellow-pale with a bluish tint, puffy, dull eyes, cyanosis of the lips, mouth half-open, severe shortness of breath;
face with Itsenko-Cushing's syndrome (adenoma of the anterior pituitary gland with increased function of the adrenal cortex): round, moon-shaped, red, shiny face, hirsutism (growth of beards and mustaches in women);
Face with Graves' disease (facies Basedovica) (hyperfunction of the thyroid gland): a lively, rich in facial expressions, pronounced bulging eyes (exophthalmos), eyes shine and express fright or surprise, sometimes "frozen horror";
face with myxedema (significant decrease in thyroid function) - facies mixedematica: dull, puffy, with sluggish facial expressions, swollen, indifferent look, narrow palpebral fissures;
face with acromegaly (increased production of growth hormone of the anterior pituitary gland - facies acromegalica): the nose, lips, superciliary arches, lower jaw, tongue are sharply enlarged;
face with kidney diseases (facies nephritica): pale, puffy, swelling of the eyelids, "bags" under the eyes;
face with tetanus: violent, "sardonic smile" (lips stretched in a smile, and wrinkles on the forehead, as in sadness);
The "face of Hippocrates" is typical for patients with peritonitis (inflammation of the peritoneum) or in an agonal state: pale with a bluish tint, cheekbones and nose are pointed, sunken eyes, an expression of suffering, drops of sweat on the forehead;
face with lobar pneumonia: one-sided blush (on the side of the inflamed lung), the wings of the nose are involved in the act of breathing;
face with pulmonary tuberculosis (facies fthisica): pale, thin face with a bright blush on the cheeks, shiny eyes, consumptive blush of a tuberculous patient.
1.3.6 Examination of the skin and mucous membranes
When examining the skin and mucous membranes, pay attention to the color, the presence of rashes, scars, scratching, peeling, ulcers; on elasticity, elasticity (turgor), moisture.
The color (color) of the skin and mucous membranes depends on: the development of blood vessels; conditions of peripheral circulation; melanin pigment content; skin thickness and translucency. Healthy people have flesh-colored, pale pink skin.
Pathologicalcoloringskin:
pallor: with acute bleeding, acute vascular insufficiency (fainting, collapse, shock); with anemia (anemia), kidney disease, some heart defects (aortic), cancer, malaria, infective endocarditis; with subcutaneous edema due to compression of capillaries; with chronic poisoning with mercury, lead. True, the pallor of the skin can also be in practically healthy individuals: with fright, cooling, an underdeveloped network of skin vessels, low transparency of the upper layers of the skin;
redness (hyperemia): with anger, excitement, high temperature air, fevers, alcohol intake, carbon monoxide poisoning; with arterial hypertension (on the face); with erythremia (increased levels of red blood cells and hemoglobin in the blood);
bluish coloration (cyanosis). Cyanosis is caused by a high content of reduced hemoglobin in the tissues, which gives a blue color to the skin and mucous membranes. Cyanosis is diffuse (general) and local. General cyanosis most often occurs with diseases of the lungs and heart failure. Local cyanosis is a consequence of local stagnation of blood in the veins and its difficult outflow (thrombophlebitis, phlebothrombosis). General cyanosis according to the mechanism of occurrence is divided into central, peripheral and mixed. Central occurs in chronic lung diseases (pulmonary emphysema, sclerosis of the pulmonary artery, pneumosclerosis). It is caused by a violation of blood oxygenation in the alveoli. The skin is diffusely cyanotic and usually warm to the touch. Peripheral cyanosis (acrocyanosis) often occurs with heart failure, venous congestion in the peripheral parts of the body (lips, cheeks, phalanges of the fingers and toes, the tip of the nose). They are cold to the touch. Mixed cyanosis carries the features of the central and peripheral.
Jaundice. Allocate true and false jaundice. True jaundice is caused by an increase in the content of bilirubin in the blood and tissues. According to the mechanism of occurrence, true jaundices are: a) suprahepatic (hemolytic) due to increased breakdown of red blood cells;
b) hepatic (with liver damage); c) subhepatic (mechanical) due to blockage of the bile ducts. False jaundice is the result of taking large doses of certain drugs (acryquine, quinine, etc.), as well as foods (carrots, citrus fruits). At the same time, the sclera of the eyes are not stained, the exchange of bilirubin is within the normal range. Jaundice is best seen in daylight. First of all, it appears on the sclera of the eyes and oral mucosa.
Pale earthy skin tone: with advanced cancer with metastases.
Bronze color - with adrenal insufficiency (Addison's disease).
Vitiligo is depigmented areas of the skin.
Leukoderma - white spots with syphilis.
Color "coffee with milk": with infective endocarditis.
Skin rashes. They are, first of all, a sign of a number of infectious, skin, allergic diseases, but can also be a manifestation of therapeutic diseases.
- Blistering rash, or urticaria - with nettle burns, allergies.
Hemorrhagic rash (purpura) - skin hemorrhages of various sizes (small punctate petechiae, large bruises) are observed with hemophilia (decrease or absence of plasma coagulation factors), Werlhof's disease (thrombocytopenia), capillary toxicosis (impaired capillary permeability), leukemia, allergic conditions, scurvy ( vitamin C deficiency).
- Herpes rash (blistering rash) with influenza, lobar pneumonia, malaria, immunodeficiency states.
Scars on the skin: after operations, burns, wounds, injuries, syphilitic gums (star-shaped scars), tuberculosis of the lymph nodes; whitish scars (striae) on the skin of the abdomen after pregnancy or red with Itsenko-Cushing's disease ( endocrine disease- hypercortisolism).
Other skin formations: "spider veins" (telangiectasia) with active hepatitis, cirrhosis of the liver; multiple nodules with tumor metastases; xanthelasma (yellow spots) on the upper eyelids in violation of cholesterol metabolism (diabetes mellitus, atherosclerosis); varicose veins, thickening and redness of the skin along the vessels (thrombophlebitis).
Turgor (elasticity, elasticity) of the skin depends on: the degree of development of fatty tissue, moisture content, blood supply, the presence of elastic fibers. With preserved turgor, a fold of skin taken with the fingers quickly straightens out. Skin turgor decreases in the elderly (over 60 years of age), with severe exhaustion, dehydration (vomiting, diarrhea), and circulatory disorders.
Humidityskindeterminedon thetouch. Increased humidity is physiological (in the summer in the heat, with increased muscular work, excitement) and pathological (with severe pain, asthma attacks, fever, severe intoxication, thyrotoxicosis, tuberculosis, lymphogranulomatosis, heart failure).
Dryness of the skin is noted with loss a large number liquids (with indomitable vomiting, diarrhea, vomiting of pregnant women, diabetes and diabetes insipidus, myxedema, scleroderma, chronic nephritis).
Excessive peeling of the skin is observed with various intoxications.
1.3.7 Character of hair and nails
Violation of hair growth most often indicates a pathology of the function of the genital and other endocrine glands. Loss and severe fragility of hair is noted with Graves' disease; with myxedema - loss of eyelashes, eyebrows, hair on the head; with severe liver damage - hair loss in the armpits and pubis; with syphilis - nested or total alopecia. Male-type hair growth (hirsutism) is observed in women with Itsenko-Cushing's disease, tumors of the adrenal glands. Nails are normally smooth, pink. Thin, brittle, exfoliating nails, spoon-shaped impressions ( kaylonychia ), transverse and longitudinal striation on them are observed with iron deficiency anemia, lack of vitamin B 12, hypo- and hyperfunction of the thyroid gland. In chronic suppurative diseases of the lungs (abscesses, bronchiectasis, tuberculosis), nails appear in the form of " sentries pieces of glass "
1.3.8 Development of the subcutaneous fat layer, the presence of edema
The development of the subcutaneous fat layer can be normal, increased or decreased. The fat layer can be distributed evenly or its deposition occurs only in certain areas. The thickness of the subcutaneous fat layer (degree of fatness) can be judged by palpation. For these purposes, with two fingers, take a fold of skin with subcutaneous tissue along the outer edge of the rectus abdominis muscle at the level of the navel, the lateral surface of the shoulder or at the angle of the shoulder blade and measure its thickness with a caliper. Normally, the thickness of the skin fold should be within 2 cm, a thickness of less than 1 cm is regarded as a decrease, and more than 2 cm - as an increase in the development of the subcutaneous fat layer. The latter is noted in various forms of obesity (alimentary exogenous, pituitary, adiposogenital, etc.). Insufficient development of subcutaneous fat is due to the constitutional features of the body (asthenic type), malnutrition, dysfunction of the digestive system. Extreme exhaustion is called cachexia . It is observed in advanced forms of tuberculosis, malignant tumors. In modern conditions, a more accurate idea of the degree of fatness of a person gives the definition of such an indicator as index masses body .
The body mass index (BMI) is calculated as the ratio of body weight (in kg) to the square of height (in m 2). BMI standards, as well as the classification of overweight are presented in Table 1.
Table1 .
Classificationexcessmassesbodyandobesityonindexmassesbody
Previously, a variety of proportionality indices were widely used: Pignet, Bouchard, Quetelet (height-weight). Currently, great importance is given to measuring the waist circumference (OT). The relationship between OT and the risk of developing type 2 diabetes has been proven, coronary disease hearts (see table 2).
Table2 .
Increased Risk |
high risk |
|
Waist circumference and risk of metabolic complications
Edema is a pathological accumulation of fluid in soft tissues, organs and cavities. According to their origin, they are:
1) general edema: cardiac, renal, hepatic, cachexic (hungry);
2) local : - inflammatory, angioedema, with local compression of the vein by a tumor, lymph nodes.
According to the predominant mechanism of occurrence (pathogenesis), they are divided into hydrostatic, or congestive (with heart failure, impaired local venous outflow with thrombophlebitis, compression of the vein by a tumor, lymph nodes, etc.);
hypooncotic - due to a decrease in oncotic blood pressure with large protein losses (renal, cachexic, partially hepatic edema);
membranogenic - due to increased permeability of cell membranes (inflammatory, angioedema); mixed .
Diagnosis of edema is carried out using:
1) examination - the edematous limb is enlarged, its contours are smoothed, the skin is stretched, shiny;
2) palpation - when pressing with the thumb in the region of the tibia, sacrum, rear of the foot, a hole forms on the skin;
3) control weighing of the body in dynamics;
4) control over the water balance (the ratio of the amount of liquid drunk and excreted during the day with urine). A healthy person should excrete in the urine at least 80-85% of the amount of fluid they drink;
5) measurements of the circumference of the abdomen and limbs in dynamics;
6) determination of fluid in the cavities by palpation, percussion, instrumental (X-ray, ultrasound) methods;
7) determination of tissue hydrophilicity (tendency to edema) using a sample McClure - Aldrich : 0.1-0.2 ml of saline sodium chloride solution is injected intradermally in the forearm area. The resulting papule should normally resolve no earlier than after 45-50 minutes, and with a tendency to edema - faster.
ATtable3 data on the most frequent differential diagnostic signs of cardiac and renal edema are presented.
signs |
Cardiac edema |
Renal edema |
|
heart diseases: defects, ischemic heart disease, arterial hypertension, etc. |
kidney disease: glomerulonephritis, pyelonephritis, amyloidosis |
||
Edema localization |
on the lower limbs |
on the face, "bags under the eyes" |
|
Times of Day |
by the end of the day |
||
The nature of the edema |
dense, pits remain for a long time |
soft, loose, mobile, dimples quickly disappear |
|
Skin color over edema |
cyanotic |
1.3.9 Lymph nodes
They are determined mainly by palpation. The size of the lymph nodes is 3-5 mm. They are located in the pits (depressions), their consistency approaches the consistency of fatty tissue, so they are not normally palpable. Enlargement of lymph nodes is systemic (generalized) or limited (regional). A systemic increase is noted in blood diseases - lymphogranulomatosis, leukemia, sarcoma, tuberculosis infection; limited - with local inflammatory processes(tumor, tonsillitis, phlegmon, abscesses, etc.). Palpation also pays attention to value, pain, consistency solidarity between yourself and with skin, scars on the skin, fistulas over the lymph nodes.
Palpation of the lymph nodes is carried out with the fingers of the entire hand, pressing them against the bones (lower jaw, ribs, etc.). 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.
Muscles can be developed well or poorly, their tone is normal, increased or decreased. They may be painful and often present with tonic or clonic seizures. Well-developed muscles in people engaged in physical labor, sports. In emaciated and seriously ill patients, their pronounced atrophy is observed. Unilateral muscle atrophy develops after injuries of the limbs and especially with damage to the nerve trunks. To detect unilateral muscle atrophy, it is necessary to measure the volume of a healthy and diseased limb at the same level in centimeters. The strength of the muscles of the hands is set using a dynamometer or the patient is asked to squeeze the hands of the doctor simultaneously with both hands and weaker muscles are determined by the difference in the strength of their pressure.
When examining the shoulder flexors, the patient bends the arm at the elbow joint and holds it, and the doctor tries to straighten it. The resistance force on the affected side will be weaker.
To study the extensors of the shoulder, the doctor tries to bend the patient's arm, which is extended at the elbow joint, and is held in this position. Similarly, determine the strength of the muscles of the legs.
1.3.10 Muscle, bone and joint assessment
Spine has four physiological curves: cervical region- convexity forward (cervical lordosis), in the thoracic region - convexity backwards (thoracic kyphosis), in the lumbar region - convexity forward (lumbar lordosis), in the area of the sacrum and coccyx - convexity posteriorly. flexion and extension, lateral movements, soreness of the vertebrae.
As a result of rickets, congenital dysplasia of the vertebrae, and the tuberculous process, a hump with a posterior bulge (pathological kyphosis) may develop. With curvature of the spine anteriorly, lordosis develops, to the side - scoliosis. Perhaps a combined lesion - kyphoscoliosis.
Bones. It is necessary to pay attention to their shape (curvature, deformation), surface and soreness. Curvature and deformation of bones occurs as a result of rickets, syphilis, osteomyelitis, and may be a manifestation of such diseases as osteochondrosis - rophia, osteochondropathy, poorly fused bone fractures. In patients with blood diseases, when tapping in the region of the sternum, ribs, and tibia, pain is noted.
In chronic diseases of the bronchi and lungs (bronchiectasis, abscesses, tuberculosis), birth defects heart, infective endocarditis, fingers and toes take the form of "drum sticks" (thickening of the terminal phalanges), and the nails form "watch glasses" - Pierre-Marie-Bamberger syndrome.
joints. In the study, it is necessary to pay attention to the shape (configuration), the volume of active and passive movements, the presence of effusion in them, the color of the skin over the joints and its temperature. In an acute inflammatory process in the joints (arthritis), the joints swell, increase in volume, the skin above them is hyperemic, edematous, hot to the touch, movements in the joints are sharply limited due to pain. With rheumatoid arthritis, stiffness and deformity of the joints steadily develop, and then bone ankylosis. Defiguration of the joints is also noted in deforming osteoarthritis, gout.
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A general study begins after registration and anamnesis. It includes the determination of habitus, skin, lymph nodes, mucous membranes and measurement of body temperature.
Definition of habitus. By habitus is meant appearance animal at the time of the study: the position of the body in space, fatness, physique, constitution and temperament.
The position of the body in healthy animals can be naturally upright or naturally recumbent, in some diseases it is forcedly recumbent or upright. A forced position is characterized by the fact that animals cannot quickly change it in accordance with the changing situation. Thus, a forced recumbency is noted in certain febrile diseases, when dogs and cats lie huddled in a corner and do not rise or rise when shouted.
Under the physique understand the degree of development of muscles and bones. When assessing it, the age and breed of the animal are taken into account. Distinguish between weak, medium and strong physique.
With a strong physique in animals, the chest is wide and deep, the legs are strong, strong, the ribs are steep with wide intercostal spaces.
With an average build, the muscles of the shoulder, thigh, limbs are well defined, the backbone is strong.
A weak physique is characterized by poor muscle development, a thin and long neck, a narrow chest, and long, thin limbs.
Fatness of dogs and cats determined by inspection and palpation. In short-haired animals, fatness is determined by examining the external forms of the body, and in long-haired animals, by palpation. Distinguish good, satisfactory and unsatisfactory fatness. With good fatness, animals have rounded body contours, with unsatisfactory fatness - angular, with satisfactory - muscles are moderately developed, deposition subcutaneous fat palpable at the base of the tail, in the fold of the knee.
animal constitution- this is a set of anatomical and morphological features of the body, which are based on hereditary and acquired properties, which determine both its functional and reactive capabilities under the influence of environmental factors. There are four types of constitution: rough, tender, dense and loose. The definition of types is based on the development of the skeleton, muscles, skin and subcutaneous connective tissue.
When assessing temperament, attention is paid to the speed and degree of the animal's reaction to external stimuli, the behavior of dogs, the expression of the eyes, movements, ears and tail are observed. Depending on these factors, animals are distinguished with a lively and phlegmatic temperament. Dogs and cats with a lively temperament actively respond to external stimuli by playing with their ears, tail, changing the expression of their gaze, and head position. Their movements are fast and energetic. But with such animals, certain precautions should be observed, as they can be aggressive. Dogs and cats with a phlegmatic temperament are inactive and lazy.
Skin studies of dogs and cats
The skin is examined by inspection and palpation, determining the condition of the coat, skin moisture, its smell, temperature and elasticity. Inspection on non-pigmented areas establishes the color of the skin, its integrity, the nature of the lesions, as well as the condition of the coat (cleanliness, shine, tightness, density and uniformity).
Palpation determines the temperature of the skin, its moisture content and elasticity. To determine the temperature of the skin, the nose and tip of the tail are palpated and compared with the temperature on the lateral surfaces of the chest. Skin moisture is determined by stroking with the palm of your hand on various parts of the animal's body. Shedding of scales of the epidermis at the same time, the absence of greasy deposits on the fingers indicates dry skin. Wetness of the fingers after palpation indicates sweating, and the presence of greasy plaque on the crumbs of the fingers indicates moderate skin moisture. To determine the elasticity of the skin on the back, it is gathered into a fold, pulled, and then released, trying to hold the hair between the fingers. In healthy animals, straightening of the fold occurs immediately. Loss or decrease in elasticity is accompanied by a delay in this process, and if there are no or less than 10 hairs left between the fingers, it is considered that the hair is well kept in the skin.
Examination of mucous membranes. In dogs and cats, the conjunctiva, the mucous membrane of the nose and mouth are examined. At the same time, attention is paid to their color, integrity, the presence of overlays, hemorrhages and secretion.
In carnivores, the conjunctiva is pale pink, but when animals are excited, it turns pink-red. The mucous membrane of the oral cavity is pale pink, very often has dark pigmentation. The study of the nasal mucosa is difficult due to the narrow nasal openings and the slight mobility of the wings of the nose, therefore, if necessary, they resort to the help of a rhinoscope.
For examination of the conjunctiva, the thumb of one hand is placed on the upper eyelid, and the other on the lower. Then press on the lower, while pulling up the upper eyelid. To study the mucous membrane of the lower eyelid, pressure is applied to the upper one, and the lower one is pulled down.
When analyzing the mucous membrane of the oral cavity, the lips, cheeks, gums, tongue and hard palate are examined. To do this, the dog's mouth is opened with the help of two ribbons applied to the upper and lower jaws behind the fangs, or the owner of the dog puts his hand under the lower jaw, covers it, pressing his fingers on the cheeks. The cheeks are pressed between the molars, the dog opens its mouth and cannot close it.
Measuring the body temperature of dogs and cats
Thermometry is an objective research method that facilitates the diagnosis of diseases.
Measure body temperature in dogs and cats with a maximum mercury thermometer. Before the introduction, it is shaken, holding the mercury reservoir with the index finger, after which it is lubricated with oil or petroleum jelly. Better place to measure body temperature - the rectum, where the thermometer is inserted with a slight rotational movement, then fixing it on the tail with the help of a tail pulp. Animals during this procedure are held by the head Measurement time - 8-10 minutes.
Normal body temperature in dogs fluctuates between 37.5-39.0 ° C, and in cats 38-39.5 ° C. It should be borne in mind that it depends on age, sex, breed, and external temperature. Puppies, kittens, bitches and cats have higher temperatures than adults and males. Its minimum indicators are noted in the second half of the night, and the maximum are recorded in the evening hours.
Examination of the circulatory organs of dogs and cats
The cardiovascular system is examined by inspection, palpation, percussion and auscultation.
Heart study. The heart of carnivores is located between the 3rd and 7th ribs, with 3/7 of the heart located on the right side of the chest. The anterior border runs along the anterior edge of the 3rd rib, the upper border is 2-3 cm below the horizontal line of the scapular-shoulder joint, and the posterior border reaches the 7th rib.
Animal heart study begin with examination and palpation of the cardiac region in order to determine the cardiac impulse, when examining the region of which, oscillatory movements of the chest are noticed. By palpation, the heart impulse is examined in the standing position of the animal. Determine its rhythm, strength, localization and distribution. The most intense cardiac impulse is felt in the region of the 5th intercostal space in the lower third of the chest. On the right, it is felt weaker and is fixed in the 4-5th intercostal space.
Percussion of the heart area is carried out in order to establish the boundaries of the organ. The upper border is determined by the rear vertical line of the anconeus. Percussion starts from the edge of the scapula and leads down to the transition of the pulmonary (atympanic) sound into a dull one. This line is the upper clinical border of the heart. Normally, it is 1-2 cm below the shoulder joint. Below the upper cardiac border is an area of absolute cardiac dullness. The posterior border is determined along the line connecting the ulnar tubercle and the maklok, while the plessimeter is moved to the next intercostal space stepwise up and back until the sound passes into the pulmonary one. Normally, the posterior border of the heart in dogs reaches the 7th rib. In addition, when the animal is in a sitting position, the part of the heart region covered with the sternum is also percussed.
In various diseases, there may be an increase, decrease and displacement of the boundaries of the heart. An increase in the boundaries is observed with hypertrophy of the heart, cardiac dropsy, pericarditis, expansion of the heart, and a decrease in alveolar emphysema, pneumothorax.
Auscultation of the heart determines the strength and clarity of tones, frequency and rhythm, as well as the presence or absence of noise. Auscultation is carried out in the region of the 4-6th intercostal space on the left and 4-6th on the right. In carnivores, the tones are loud, clear, it should be borne in mind that they normally have respiratory arrhythmia, and sometimes embryocardia, characterized by heart tones of the same strength and timbre with equal pauses. When diagnosing heart defects by auscultation, you should know the points of best audibility. Such a point for the bicuspid valve in dogs is the 5th intercostal space in the middle of the lower third of the chest, for the aortic semilunar valves - the 4th intercostal space under the horizontal line from the humeral tubercle, and the pulmonary artery - on the left in the 3rd intercostal space along the upper edge of the sternum. best place audibility of the right AV valve is the 3rd-4th intercostal space in the lower half of the third of the chest.
In various diseases, changes in heart sounds can be noted in the form of their amplification, weakening, accentuation, rhythm of heart tones, and murmurs associated with cardiac activity.
Study of the arterial pulse of animals
The arterial pulse is examined by palpation with crumbs of 2-3 fingers of superficially located arteries, under which there is a solid base. Pay attention to the frequency, rhythm and quality of the pulse. To determine the pulse, examine the femoral artery in the groin, the brachial artery on the medial surface of the humerus above the elbow joint, or the artery of the saphenous immediately above the hock joint between the Achilles tendon and the deep flexor of the fingers. In newborn puppies pulse rate per minute is 180-200. In adult dogs- 70-120, at cats- 110-130. When determining the quality of the pulse, the filling of the arteries, the magnitude of the pulse wave, its shape, and the tension of the vascular wall are taken into account. Depending on the filling, a full pulse is distinguished (the diameter of the vessel during the filling period is twice the thickness of its two walls) and an empty pulse (the lumen of the artery is less than the thickness of its two walls).
According to the magnitude of the pulse wave, the blood filling of the artery and the tone of the vascular wall are judged. Depending on the size, a large pulse is distinguished, characterized by good filling of the arteries, and a small pulse, in which the artery is poorly filled, its expansions are almost not expressed and are felt by the fingers in the form of weak jolts.
The rhythm of the pulse is judged by the periodicity in time and the correctness of the alternation of its phases in accordance with the rhythm of the heart. Based on this, there are rhythmic and arrhythmic pulses.
Respiratory studies of dogs and cats
The respiratory system is examined by methods of examination, palpation, auscultation, percussion. If necessary, resort to special methods: radiography, fluoroscopy, fluorography, plegaphony, rhinography, etc. The upper respiratory tract and chest are examined.
The study of the upper respiratory tract begins with an examination of the nasal openings. Pay attention to the condition of the wings of the nose, the nature of the exhaled air, nasal discharge, examine the accessory cavities of the nose. When examining exhaled air, attention is paid to its smell, which in some diseases can be putrid, sweetish, etc. In the presence of nasal discharges, their nature (mucous, serous, purulent, putrefactive, etc.), quantity (abundant, scarce,) frequency (constant or periodic), color, symmetry are determined.
Studies of the adnexal cavities are carried out by inspection, palpation and percussion. On examination, a change in the configuration of the sinuses is established. Palpation determines the sensitivity and softening of the bones of the maxillary and frontal sinuses. Percussion of the sinuses is carried out with the butt of a percussion hammer without a plessimeter. At the same time, they cover the eyes of the animal with the palm from the side from which the study is carried out. With the help of percussion, the nature of the sound is determined, by which the presence of exudate in the cavities is judged. In healthy animals, the adnexal cavities are filled with air and the sound during percussion is boxy, and during inflammatory processes (due to the presence of exudate), it becomes dull and dull.
The larynx and trachea are examined by inspection, palpation and auscultation.
On examination, the presence of deformation and a change in the volume of these organs are revealed. In some diseases, edema is found in the larynx. An internal examination of the anterior parts of the larynx can be carried out through the oral cavity.
Palpation of the larynx begins from the lower part of the neck, moving the fingers forward to the intermaxillary space, feeling the larynx. At the same time, its soreness, temperature, and the presence of swelling are determined.
Then, fingers are moved down from the larynx, feeling the trachea in order to establish changes in its integrity, sensitivity, and temperature.
Auscultation of the larynx and trachea is performed using a phonendoscope. In healthy dogs, inhalation and exhalation are heard, phonetically reproduced as the sound "x", called laryngeal breath sounds. In the region of the trachea, it is called tracheal breathing.
Chest examination of dogs and cats
The study of the chest begins with its examination, while establishing the shape and size, type, frequency, strength, symmetry and rhythm of respiratory movements. The shape of the chest in healthy dogs and cats is moderately round. With atelectasis of the lungs, it decreases in volume, becomes flat, and with emphysema - barrel-shaped.
The type of breathing is mixed-thoracic, although in some breeds it is predominantly chest. Disease respiratory system and related organs entails a change in the type of breathing. In animals with a mixed type of breathing, the thoracic type may be the result of a disease of the diaphragm, thoracic dropsy; with an injury or fracture of the ribs, the type of breathing becomes abdominal.
The respiratory rate is determined by the number of breaths per minute. In dogs, it ranges from 12 to 24, and in cats - 20-30. The number of respiratory movements is counted by the number of inhalations and exhalations according to the fluctuations of the chest or during auscultation of the trachea. The respiratory rate is influenced by the age, breed, constitution and physiological state of the animal. Females and young dogs breathe faster than older and males.
Depending on the strength, breathing can be moderate, deep and shallow.
The determination of the symmetry of respiratory movements is carried out by comparing the excursions of the left and right chest walls. To do this, they stand in front of the animal so that both sides of the chest can be clearly seen. Uniform chest excursion on both sides indicates the symmetry of breathing.
Under the rhythm of breathing understand the sequential alternation of the phases of inhalation and exhalation. At the same time, inhalation, as an active phase, is shorter than exhalation and the ratio between them is 1:1.6. The most common rhythm disturbance is shortness of breath. At the same time, if it is caused by a violation of inspiration, they speak of inspiratory dyspnea, exhalation - expiratory, and if difficulty in breathing occurs in both phases, then they speak of mixed dyspnea.
Palpation of the chest carried out in order to establish temperature, sensitivity, tangible vibration noise. Sensitivity is determined by pressing the knuckles along the intercostal spaces. In case of pain, the animals avoid palpation and show aggressiveness.
The temperature and tangible vibrations of the chest are determined by placing the palm on various parts of it. Local temperature increase is most often observed with pleurisy. With fibrinous pleurisy, pericarditis, when the surface of the pleura or pericardium becomes rough, a peculiar vibration of the chest is palpated.
Percussion of the chest carried out in order to establish the topographic boundaries of the lungs, to detect pathological changes in them or the pleura. For percussion, it is better to put the dog on the table, using the digital method. To do this, the finger of one hand is pressed tightly against the chest wall in the intercostal space, and a medium-strength blow is applied with the finger of the other. Percussion determines the posterior border of the lungs along the lines of the maklok, ischial tuberosity and scapular-shoulder joint. Percussion from front to back. The posterior percussion border along the maklok line reaches the 12th rib, along the line of the ischial 11th tubercle - up to the 11th, and the scapular-shoulder joint - up to the 9th. Most often, an increase in the boundaries of the lung occurs with alveolar or interstitial emphysema, and a decrease occurs with intestinal flatulence, hypertrophic cirrhosis of the liver, and some other diseases.
: 1 - along the line of maklok; 2 - along the line of the ischial tuberosity; 3 - along the line of the scapular-shoulder joint.
Pathological changes in the lungs or pleura are detected by percussion from top to bottom along the intercostal spaces within the established boundaries of the lung. At the same time, in healthy animals, an atympanic or clear pulmonary sound is established. With pneumonia, pulmonary edema and other pathological conditions, accompanied by filling the lungs with fluid or the accumulation of the latter in the pleural cavity, the sound becomes dull or dull. With a significant expansion of the lungs due to an increase in residual air in alveolar emphysema, the percussion sound becomes boxy, and when air cavities are formed in the lung tissue, which is noted in interstitial emphysema, it becomes tympanic.
Auscultation of the chest carried out in order to establish the nature of respiratory noise. For this, two methods are used: direct and instrumental. With the direct method, auscultation is carried out with the naked ear through a sheet or towel. Mediocre - carried out using a phonendoscope or stethoscope.
Auscultation should be carried out in a certain sequence: starting with listening to areas with the best audibility of breath sounds, followed by moving to places with poorer ones. To comply with this rule, it is recommended that the chest of the animal on each side be conditionally divided into three parts: upper, middle and lower. Then the upper and middle parts are divided into two halves by a vertical line. It turns out five zones of listening. Auscultation in them is carried out in the following order: anterior middle area, posterior middle, anterior superior, posterior superior and inferior.
On auscultation of the chest of healthy dogs, an intense and loud breath noise is heard during the inspiratory phase and partly at the beginning of the exit. This type of breathing is called vesicular. Immediately behind the scapular-shoulder girdle during the inhalation and exhalation phase, a loud respiratory noise is heard, phonetically resembling the letter "x" and called bronchial breathing.
In various diseases, the nature of physiological respiratory sounds may change and pathological ones may occur. This manifests itself in the form of an increase or decrease in vesicular respiration, the appearance of bronchial respiration in areas that are not characteristic of it, the appearance of pathological noises (various wheezing, friction and pleural noises, etc.).
Examination of the digestive organs of dogs and cats
In the study of the digestive organs, methods of examination, examination, palpation, auscultation, percussion are used. If necessary, they resort to probing the esophagus and stomach, radiography and fluoroscopy, laboratory studies of gastric juice, feces, etc.
Studies of the digestive system are carried out according to the following scheme: the act of taking food and water, the oral cavity, pharynx, esophagus, abdomen, stomach and intestines, monitoring the act of defecation.
When examining the act of taking food and water, special attention is paid to appetite and the act of swallowing.
Appetite is examined by observing the animal while eating. It is influenced by the physiological state of the animal, the environment, the quality and type of food, feeding time. There may be a lack, decrease, increase, perversion of appetite. It decreases or is absent in various pathologies of infectious, invasive and non-infectious origin. An increase in appetite accompanies some pathologies that occur with metabolic disorders (diabetes mellitus), and is also observed in the recovery stage after a disease. Perversion of appetite, characterized by the eating of inedible objects, is noted with a deficiency in the body of mineral salts, hyperacidity in the stomach, rabies, etc.
In diseases of the central nervous system, lesions of the tongue, lips, teeth, chewing muscles, there is a disorder in the intake of food and water, which manifests itself in an unusual form of this process.
With lesions of the pharynx and esophagus, the act of swallowing is disturbed. This phenomenon is characterized by pain during swallowing food. Animals squeal, worry, sometimes there may be ejection of food masses through the nose (regurgitation). The complete impossibility of swallowing is noted with paralysis of the pharynx, rabies, botulism, encephalitis.
Vomiting may be the result of overfeeding. In this case, it is most often single, the vomit corresponds to the normal contents of the stomach. Frequent vomiting is characteristic of lesions of the gastric mucosa, poisoning, diseases of the central nervous system, liver and other organs. In these cases, pay attention to the color and smell of vomit.
Examination of the oral cavity, pharynx and esophagus of dogs and cats
Oral cavity researched mainly by inspection. For internal inspection capture upper jaw between the thumb and forefinger, squeezing the lip between the teeth, and the fingers of the other hand pull the lower jaw somewhat. For the same purpose, the Baicher mouth wedge or animal mouth fixator (FPZh-1) is used in dogs. Pay attention to the mucous membrane of the oral cavity, its color, moisture, integrity. Examine the tongue, teeth, determine the nature of salivation. When examining teeth, attention is paid to the correctness of their erasure, integrity, condition of the gums.
Throat examined by inspection and palpation. For examination, after setting the yawner, the base of the tongue is pressed against the lower palate with a spatula, after which the condition of the walls of the pharynx and tonsils is established. Palpation of the pharynx is carried out by squeezing the region of the upper edge of the jugular groove slightly above the larynx with the fingers of both hands, while paying attention to the soreness of the pharynx, the presence of tissue infiltration in its region and foreign bodies in its cavity.
Esophagus are examined by inspection, palpation, and also by setting the probe. By inspection, the patency of the food coma is established. Palpation - sensitivity of the esophagus, the presence of pathological infiltrates, tumors, foreign bodies. To detect narrowing and blockage of the esophagus, they resort to probing it. For this purpose, a set of Sharabrin rubber probes or medical probes of various numbers are used in dogs, depending on the size of the dog. For setting the probe or "x"-shaped yawn of the Sharabrin system. With the help of these yawns, the working end of the probe is directed along the hard palate, then its end bends down, then falling into the cavity of the pharynx and esophagus.
Examination of the abdomen, stomach, intestines and liver of dogs and cats
When researching belly methods of examination, palpation, percussion and auscultation are used, and, if necessary, a test puncture of the abdominal wall.
Inspection determines the volume and shape of the abdomen, the symmetry of its walls. An increase in the volume of the abdomen is observed with intestinal flatulence, gastric overflow, coprostasis, abdominal dropsy, enlarged liver, bladder. Local violations of the shape of the abdomen are observed with umbilical and mesenteric hernias, abscesses of the abdominal wall. A decrease in the volume of the abdomen occurs with exhaustion, prolonged diarrhea.
Palpation of the abdominal walls is carried out immediately on both sides with both hands. Soreness, tension of the abdominal wall, the state of some organs of the abdominal cavity are determined. Increased tension of the abdominal walls and severe soreness give rise to suspicion of peritonitis. In addition, palpation can establish an increase in the liver, the presence of intussusception and intestinal coprostasis.
Percussion examines the stomach, intestines, liver, and auscultation determines the nature of the peristalsis of the stomach and intestines.
The puncture of the abdominal wall is carried out in order to diagnose peritonitis and ascites. It is done in the lower abdomen in the area of the last two pairs of nipples, departing from the white line of the abdomen 1-1.5 cm.
Examination of the stomach carried out by inspection, palpation, auscultation, percussion, and, if necessary, radiography. The stomach is located in the left half of the abdominal cavity and in dogs reaches the abdominal wall near the 12th rib. With strong filling, it goes beyond the costal arch, lies on the abdominal wall and reaches the umbilical region. Inspection determines the shape and volume of the abdomen. Palpation of the stomach is carried out in a standing position, pressing with the fingers of both hands, applied behind the costal arches on both sides, inward and forward. At the same time, the position of the stomach, its filling and soreness are determined.
When examining the intestines use auscultation, external palpation and examination in the abdomen. In this case, it should be borne in mind that the small intestine occupies mainly the right half of the abdominal cavity, and the thick one - the left.
On examination, pay attention to the abdominal wall in the region of the right and left hungry pits. A protrusion in the region of the left hungry fossa is usually characteristic of flatulence of the large intestine, and in the region of the right - of the small intestine.
The most important method for examining the intestines of animals is palpation. It is carried out in the standing position of the animal, evenly squeezing the lateral surfaces of the abdomen on both sides. At the same time, the degree of fullness and sensitivity of the intestine is established. Auscultation of the intestine makes it possible to judge the nature of peristalsis.
When examining the act of defecation, attention is paid to its frequency (in animals on a meat diet, once a day). The disorder of the act of defecation is manifested in the form of diarrhea, constipation, pain during defecation.
Liver examined by palpation and percussion. Palpation is carried out by placing the animal on its right side, as a result of which the liver is displaced to the abdominal wall. After that, they bring their hand to the right under the last rib and feel for the edge of the liver. Percussion of the organ is carried out with the animal in a standing position, immediately behind the posterior border of the lung. On the right side, the area of hepatic blunting in dogs is located within the 10-13th rib, and on the left - in the 11th intercostal space.
Study of the urinary system of animals
Includes the study of the process of urination, the study of the kidneys and bladder, if necessary, conduct a study of the urine of animals.
When examining the process of urination, attention is paid to the posture of the animal at this moment, duration, frequency, as well as the total amount of urine and its appearance. The posture during urination depends on the sex: males raise the pelvic limb, females - the tail and squat. The number of urination depends on the conditions of detention. Usually dogs urinate 3-4 times a day, but in free keeping much more often.
kidneys are examined mainly by the method of external palpation through the abdominal wall. At the same time, attention is paid to the location of the kidneys, their size, shape, sensitivity, consistency, surface condition. For palpation, both thumbs are placed on the lumbar region, the rest on the stomach on both sides behind the last rib. Then move the fingers up the abdominal wall to the last thoracic vertebra, evenly pressing them towards each other. The left kidney is found in the anterior left corner of the hungry fossa under the 2nd-4th lumbar vertebra. The right kidney is examined in the anterior corner of the hungry fossa under the first and third lumbar vertebrae. With various diseases, it is possible to establish an increase and decrease in the kidneys, a change in their surface, sensitivity. An increase can be observed with pyelonephritis, hydronephrosis, a decrease - with cirrhosis, pain - with inflammation and urolithiasis.
The main research method bladder in dogs and cats is palpation through the abdominal wall. The bladder is located in its lower region in front of the pubic fusion. The study is carried out with the animals in a sitting position, for which the fingers are placed on the abdominal wall in the area of the bladder and light pressure towards each other is probed. In decorative breeds of dogs and cats, the bladder is examined through the rectum. To do this, after appropriate treatment of the index finger, it is inserted into the rectum, and the opposite hand is pressed against the abdominal wall. The study of the bladder makes it possible to judge its filling, sensitivity. With inflammation, pain is noted during palpation, tumors are detected by the presence of dense bodies, and urinary stones are in the form of solid formations that are displaced by palpation.
Study of the nervous system of dogs and cats
In the study of the nervous system, the behavior of the animal, the state of its skull and spinal column, sense organs, skin sensitivity, motor sphere, reflex activity.
The behavior of an animal is judged by the results of observations of its reaction to external stimuli (call, the approach of a stranger, giving food, etc.). Violation of behavior is manifested in excitation, depression, soporous or coma. The most characteristic increase in excitability in rabies, which turns into a riot. Dogs break loose from the chain, run away from home, cats attack people and animals. Oppression is accompanied by a delay in the functions of nervous activity. Animals are inactive, the reaction to stimuli is sharply reduced. With stupor, animals are in a state of deep sleep, from which they can be awakened only when exposed to strong stimuli. A characteristic sign of a coma is the loss of reflexes and consciousness.
Research methods skull and spinal column are inspection, palpation and percussion.
During the examination, the shape and volume of the skull, its symmetry, as well as the presence of spinal deformities are determined.
On palpation, sensitivity, temperature of local tissues, hardness of bone formations, and their deformation are established. The spinal column is palpated, starting from the cervical vertebrae and ending with the vertebrae of the tail root.
The skull is percussed with a finger, and in large dogs with the butt of a percussion hammer for small animals. At the same time, attention is paid to the nature of the sound and the reaction of the animal to percussion. In the presence of exudate in the sinuses, dullness of the sound is noted. The spinal column is percussed with a hammer without a plessimeter from the slope of the withers to the root of the tail, paying attention to the presence of pain.
Investigation of the sense organs of dogs and cats includes the study of vision, hearing, smell, taste.
The state of vision is judged by its organs (eyelids, eyeball), the reaction of the pupil to a light stimulus. The latter is determined by closing the examined eye for 2-3 minutes. In this case, in healthy animals, the pupil dilates and quickly returns to normal after the eye is opened. To test for a decrease or loss of vision in dogs, their eyes are alternately closed and led to an obstacle. With the loss of vision, the animal does not notice them.
Hearing is examined by closing the eyes of the animals and then reproducing the usual sound stimuli: whistling, shouting. With damage to the nervous auditory apparatus, these sounds are perceived worse.
The sense of smell is also checked after the elimination of visual analyzers. Dogs and cats are brought objects or food, the smell of which they are well aware of. With a decrease in the sense of smell, animals do not react to these odors.
Taste is determined based on the reaction of animals to various feeds and unusual substances.
Study of skin sensitivity. In the study of skin sensitivity, attention is paid to the reaction of the skin when exposed to tactile, pain and temperature stimuli.
The study of tactile sensitivity is carried out after closing the eyes of the animal. Then, with a light touch, individual hairs in the withers, abdomen, auricle or nostrils are irritated. When tactile nerve endings are stimulated, a response of animals occurs in the form of contraction of the corresponding skin areas. Lack of reaction indicates the disappearance of tactile sensitivity.
Pain sensitivity is determined by tingling the skin with the tip of the needle. It starts from the distal parts of the limbs and goes up to the region of the croup or scapula, and then the spinal column and ends on the neck of the animal. Healthy dogs and cats look around, tuck their ears in, fan their tails, bite, scratch.
Temperature sensitivity is determined by touching different parts of the skin with test tubes filled with hot or cold water which are applied alternately.
Study of the motor sphere of dogs and cats
The study of the motor sphere includes the determination of the activity of movements, muscle tone and coordination of movements.
The determination of the activity of movements is carried out by the method of inspection. In this case, partial (paresis) or complete loss of motor function (paralysis) may be noted.
Muscle tone is examined by palpation. Depending on muscle tension, it can be moderate, low or high. With reduced tone, the muscles are flabby, the range of motion of the limbs is wide, and the joints are often bent; with increased - there is a strong muscle tension, they become dense, and passive movements are made with difficulty.
In a clinical examination of the nervous system, superficial and deep reflexes are checked. Superficial reflexes include skin and mucous membranes. From the skin, a tail reflex is determined, accompanied by pressing the tail to the body.
The abdominal reflex is also indicative, characterized by a strong contraction of the abdominal muscles in response to a light touch, as well as the anal reflex, which is manifested by contraction of the anal sphincter when touching the skin in the anus. Of the reflexes of the mucous membranes in dogs, the most indicative is sneezing. It is checked by irritating the nasal mucosa with a light object (feather, match).
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