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ODESSA NATIONAL MEDICAL UNIVERSITY
FAMILY MEDICINE AND GENERAL PRACTICE DEPARTMENT
Subject Title: “General Practice - Family Medicine”
Students’ Study Guidelines for practical sessions for 6th year Medical Faculty
students
MODULE 1: «ORGANIZATIONAL ASPECTS OF PRIMARY HEALTHCARE
IN UKRAINE, ITS PRIORITY ROLE IN THE DEVELOPMENT AND REFORM
OF HEALTHCARE. FEATURES OF OUTPATIENT CARE»
CONTEXT MODULE 4: “Medical and Social Aspects of Public Health – the Base for
Prevention and Treatment”
Lesson 9: «TREATMENT TACTICS FOR THE MOST COMMON THERAPEUTIC
CONDITIONS »
Year: 6 th
Faculty: Medical
Approved
By the department methodical board
“____”_____________20__
Protocol № ______
Department Head
___________Velichko V.I., M.D., PhD.
Odessa
Subject lessons:: "The non-medical THERAPEUTIC AID IN DISEASES most common
therapeutic" – 6 hours
I. Relevance of the theme:
In the daily activities of family physicians are often encountered patients who complain of acute
abdominal pain due to various reasons. Only high professional skills, deep knowledge of
pathophysiological mechanisms of pain, ability to skillfully conduct examination of the patient and
give thorough and correct evaluation of the identified characteristics determine the accuracy and
timeliness of care in outpatient and, if necessary - and stationary phases demonstrate literacy and
competence doctor .
Symptoms and syndromes of which one manifestation is abdominal pain may be signs of various
diseases. Ability to quickly establish the correct diagnosis determines the timeliness of necessary
medical treatment (surgical or therapeutic).
The problem of correct assessment and treatment of abdominal pain is one of the most difficult in
modern internal medicine clinic. This, on the one hand, diversity is caused by diseases (surgical,
therapeutic, gynecological, etc.), for which abdominal pain is the leading clinical syndrome, on the
other - with unusual opportunity of course, when these or other signs of abdominal pain is atypical,
which may cause diagnostic errors.
II. Learning objectives:
Know:
Interaction of a family doctor with the secondary and tertiary medical care.
Indications and contraindications for the management of patients on an outpatient basis (first
level), day care, the organization of hospitals at home.
The influence of family on the recovery process and reducing the risk of pathological conditions.
Conducting dolikovuvannya patients after hospitalization and rehabilitation on an outpatient basis.
Conduct medical and social disability expertise on an outpatient basis.
Using the developed program of family issues, including existing risk factors, assess psychological
state and health of the family, spending the prevention, early detection, treatment, and
rehabilitation in identifying functional and organic disease therapeutic.
Able to:
Use of software developed by family problems, the prevention,
Treatment and rehabilitation in identifying functional and organic disease therapeutic.
Conduct medical and social assessment of disability on an outpatient basis.
III. Interdisciplinary integration
Number p / Disciplines Know Be able
1.
Previous (providing) disciplines:
-History of Medicine;
-Economy
Medical statistics;
Medical Law;
Historical path of development of insurance medicine.
Types of financing primary health care.
Statistical Methods of calculating health indicators.
Legal Principles of health care.
Identify key historical premise for the development of health insurance.
Carry out comparison between the major sources of financing health care.
Perform the calculation of basic indicators used in medical statistics.
2.
The following courses (those that are provided):
Management;
And social medicine.
Basic principles of organization and management of institutions of medical care.
Social aspects of medical care based on medical insurance.
Calculate the cost of medical services to patients.
3.
Inner integration:
(Between subjects of this discipline)
Organization of non-medical care at the most common
diseases of therapeutic
Fold model of health facility in mortgage health insurance.
Contents subject classes:
Causes of abdominal pain
General abdominal pain may be one or a combination of reasons, most frequent and significant
are:
• inflammatory damage to the peritoneum;
• tension or spasm of the stomach and / or intestines;
• stretching capsules organ (eg liver);
• abdominal ischemia due to excessive tension ripple, intussusception, hernia is pinched.
Based on the common characteristics define five groups of reasons that cause the development of
acute abdominal pain:
I. Disorders of parietal peritoneum:
• caused by chemical irritation:
- Perforatyvna gastric ulcer or duodenal ulcer;
- Pancreatonecrosis;
- Intestinal perforation;
• caused by bacterial infection:
- Perforation appendectomy;
- Inflammation of the pelvis;
- Perforation of the bowel walls;
- Bacterial inflammation of internal organs.
II. Obstruction of internal body cavities:
• small or large intestine;
• biliary tract,
• ureters;
• bladder.
III. Vascular:
• embolism or rupture of vessels;
• vascular thrombosis;
• ischemia with inverted or squeezing;
• sickle cell anemia.
IV. Internal capsule sprain organ (liver, spleen, kidneys).
V. Diseases of the anterior abdominal wall (mesentery root deformity, pathology of muscle).
Although the causes of pain can be different, his character in the abdomen largely depend on
innervation.
Somatic pain - is the sympathetic nervous system fibers of the parietal peritoneum, the changes
which are a source of pain. The patient describes this pain as sharp, burning, piercing and one that
increases with the change of body position and movements. Pain has a clearly defined localization.
Reflex mechanisms causing stiff muscles over the pain area, determined by palpation intestine.
Abdominal pain - caused by irritation of receptors located in the visceral peritoneum, which
respond to increased intracavitary pressure or obstruction of hollow organ. Unlike parietal, mainly
of visceral pain has a clear localization, often combined with signs of irritation of the vegetative
nervous system: nausea, vomiting, feeling of palpitation, paleness of skin and uncontrolled
sweating.
Diaphragmatic pain - pain caused by holding on the phrenic nerve impulses from the diaphragm,
liver, stomach, spleen of irradiation in the shoulder. In fact, this pain is a variant of visceral pain.
Coughing and breathing movements tend to reinforce the pain.
Pereymopodibnyy pain - defined as colic, may be repeated periodically. Shortenings caused by
extremely strong hollow organ (cramps).
Indirect (reflected) pain - occur in case of visceral pain-sensitive fibers of cerebrospinal nerves. An
example might be a pain in the right upper quadrant abdominal and subclavian area during
diaphragmatic pleurisy piddiafrahmalnomu or abscess. The pain reflected from the bodies of the
chest, often accompanied by abdominal muscle rigidity. A sure sign it is that it decreases during
inspiration, whereas pain caused by abdominal pathology, available for two phases of respiration.
Palpation abdomen not reflected increases pain, and sometimes may even reduce it.
Pain metabolic origin - it is a classic manifestation of abdominal pain of varying intensity and
localization, which occurs in the development of uremia and in patients with diabetes. Porphyry in
acute pain or colic lead poisoning may mimic pain of intestinal obstruction. It should be
remembered that pain may stratify the metabolic nature of pain in the pathology of the abdominal
cavity.
Psychogenic pain - diverse in nature and localization of pain. Is found mostly in girls or women
suffering from hysteria. Sometimes combined with nausea or vomiting, stiff muscles of the
abdominal wall. Even if there is a spasm of abdominal wall muscles, it takes a little while and
disappears if to distract the attention of the patient.
Abdominal pain origin of atherosclerosis - atherosclerotic lesions in mesenteric vessels occurs
pereymopodibnyy abdominal pain, especially after meals, and disappears after administration of
spasmolytic. Besides obliterating arteriosclerosis caused similar pain can be obliterating
trombanhiyit, coarctation of abdominal aorta. When embolism or thrombosis of superior
mesenteric artery pain arises suddenly and spread with signs of peritonitis and vascular collapse.
Mesenteric artery embolism more common in patients with infective endocarditis with myocardial
infarction and in cardiac arrhythmia.
Persistent and acute abdominal pain can predetermine abdominal aorta aneurysm, pulsing, and its
presence can be set during abdominal palpation and auscultation. Severe abdominal pain may
occur if rozsharovuyuchiy aortic aneurysm.
The most frequent causes of acute abdominal pain can be acute appendicitis, acute cholecystitis,
hepatic colic, perforation of hollow organs (stomach, intestines), acute pancreatitis, acute
cholangitis, intestinal obstruction, hernia is pinched, kink or break ovarian brush, ectopic
pregnancy, acute salpingitis or adnexitis.
Significantly less acute abdominal pain can cause rupture aortic aneurysm, mesenteric vascular
thrombosis, acute pyelonephritis, increased Peptic ulcers, shingles, acute urinary delay, closed
abdominal trauma.
Sometimes the cause of acute abdominal pain are hematoma, splenic infarction, pneumonia,
myocardial infarction, diabetic ketoatsydoz, diseases of blood.
Although the family doctor may well know the existence of certain diseases in the patient's
complaint of acute abdominal pain is always unexpected and require quick action. In these
circumstances, priority generally acquire simple examination methods - survey, inspection,
palpation, percussion, auscultation. These methods allow to determine a preliminary diagnosis and
range of further laboratory and instrumental investigations.
When you review observed sharp paleness of skin and mucous membranes. When peritonitis - dust
eyes, pale gray color, covered with drops of cold sweat. Pay attention to the shape and appearance
of the stomach anterior abdominal wall: inserted into the stomach is characteristic for hollow
organ perforation, swollen and asymmetrical - for bowel obstruction. Soon after the onset of the
surface of the tongue forms a white, yellow or brown plaque. With increasing phenomena of
intoxication it becomes dry as the brush. An important role should evaluation pulse and blood
pressure. As the development of peritonitis pulse rate increases and decreases its content.
During the survey of patients with acute abdominal pain doctor must be answered the following
questions:
1. Getting pain - a gradual, slow, sudden.
2. Intensity - mild, moderate, strong.
3. Dynamics - styhannya and growth, changes in character.
4. The nature of pain - constant, pereymopodibnyy.
5. Depth - superficial and deep.
6. Dependence on pain: movements, urination, bowel movement.
7. Localization of pain - in a particular location, diffuse outside the stomach.
8. Stability - stable (in the one place), migrating.
9. Irradiation pain - posehmentarna, reflected in the affected organs.
10. Effects of drugs - drugs used, their effectiveness.
If the patient complains of abdominal pain, the survey must be out:
1. As the pain started - suddenly or developed gradually.
2. Expressive of pain in general and on where the pain is most pronounced.
3. Where irradiyuye pain.
4. What is the duration of pain.
5. What factors enhance or reduce pain.
6. Which other manifestations of the disease are available simultaneously with the pain - vomiting,
diarrhea, constipation, dyzurichni manifestations.
7. Is there a relationship pain with meals or water.
8. Is not related to abdominal pain or menstrual cycle disorders (in women).
Following inspection, auscultation and abdominal palpation, a minimum availability:
1. Asymmetry belly.
2. Vypynan unusual in the area of the anterior abdominal wall.
3. Bloating.
4. Visible intestinal peristalsis.
5. The anterior abdominal wall rigidity.
6. Painful or flashing formations are defined palpatorno.
7. Symptoms of peritoneal irritation.
8. Intestinal noises.
First make the approximate surface abdominal palpation. Deep palpation should be conducted very
cautiously, because it can cause muscle tension protective anterior abdominal wall that will not
further evaluate the condition of the abdominal cavity. Palpation abdomen to identify signs of
peritonitis, perforation of hollow organ to appear "doshkopodibnyy stomach.
With limited peritonitis in weakened patients, elderly people stress the anterior abdominal wall
muscles may be absent.
Percussion abdomen to determine the boundaries of liver dullness or her disappearance, which is
typical for hollow organ perforation, the presence of free fluid in the abdominal cavity, defined by
bleeding. Intestinal obstruction appears tympanit pronounced due to the accumulation of gases in
the intestines.
Auscultation to evaluate peristalsis of the stomach, to identify "pleskotu noise, sound 'of falling
drops, which allows suspected ileus.
When microclysters study can detect pathological processes in the distal part of the rectum (eg,
tumors) and adrectal fiber, sharp pain front wall of the rectum, indicating the accumulation of fluid
in the pelvic cavity. Reduction of sphincter tone anus and rectum ampullary enlargement
(symptom Obukhivska hospital) - typical signs of bowel obstruction.
Vaginal study to evaluate the condition of organs and to the differential diagnosis of acute
abdominal diseases. Painful cervical displacement indicates the involvement of inflammation of
internal genital organs.
The main symptoms of abdominal pathology, appear during the first period. Among the most
common are:
• severe abdominal pain;
• nausea;
• vomiting;
• jaundice;
• bleeding,
• general (collapse, intoxication, fever).
It should be noted that acute abdominal pain is a subjective feeling that each patient can interpret
differently. The ability to objectively assess the degree and nature of pain depends from character,
intelligence, cultural level and conditions, which was patient during of pain.
When a patient survey to determine the onset of pain and most likely causes.
Early pains Features include:
• pain that is sudden, for an internal organ perforation (eg, acute pain, like a dagger blow to the
perforation of the stomach, pain during bowel perforation);
• sudden severe pain from the beginning can mark at break aortic aneurysms (aortalhiyi), inverted
ovarian spontaneous pneumothorax;
• pain intensity with a gradual rise (within minutes or hours, sometimes days) for an acute
appendicitis, cholecystitis, diverticulitis, intestinal obstruction, acute mesenteric ischemia, acute
urine delays, etc.;
• slow (several days or even weeks) development of pain, characteristic of malignant neoplasms
(eg, development obturatsionnoy intestinal obstruction in colon tumor).
Often, abdominal pain combined with other symptoms, identification and analysis which has
important diagnostic value.
Acute abdominal pain in combination with collapse and anemia gradually increasing, typical:
• abdominal aortic aneurysm rupture;
• uterine tube rupture in the presence of ectopic pregnancy;
• Ovarian apoplexy (in case of major bleeding).
Acute abdominal pain in combination with a lower blood pressure (BP) often occurs when:
• Abdominal variant of acute myocardial infarction;
• rozsharovuyuchiy abdominal aorta aneurysm;
• Acute adrenocortical insufficiency;
• mesenteric thrombosis;
• acute pancreatitis,
• rupture of uterine tube in the presence of ectopic pregnancy (with minor bleeding);
• perforatyvniy gastric ulcer and duodenal ulcer;
• spontaneous pneumothorax;
• pinched diaphragmatic hernia.
Acute abdominal pain combined with fever occur if:
• Shingles;
• nyzhnochastkoviy acute pneumonia;
• diaphragmatic pleurisy;
• recurrent disease;
• acute appendicitis;
• acute cholecystitis;
• acute adnexitis;
• acute abscess;
• rheumatocelis;
• acute pyelonephritis;
• acute pericarditis;
• Liver abscess;
• piddiafrahmalnomu abscess;
• emerald kidney;
• poliarteriyiti lumpy;
• acute mesenteric lymphadenitis.
Combination of abdominal pain with repeated vomiting may occur if:
• cholelithiasis;
• hastralhichniy form of acute myocardial infarction;
• acute pancreatitis,
• acute stomach turn;
• diabetic ketoatsydozi;
• bowel obstruction;
Peptic Ulcer • acute gastric and duodenal ulcer;
• inverted legs ovarian cysts or tumors;
• hastrytychniy Toxoinfectio form of food.
Combination of abdominal pain with diarrhea occurs when:
• aggravation of chronic pancreatitis;
• enterokolitychniy Toxoinfectio form of food;
• Crohn's disease;
• Syndrome Zolingera-Alison;
• Ulcerative colitis;
• ulcerative intestinal tuberculosis.
Acute abdominal pain in combination with Hepatomegaly occurs when:
• pravoshlunochkoviy failure due to acute pulmonary artery thromboembolism or myocardial
infarction of right ventricle;
• bezzhovtyanychniy form of acute hepatitis B;
• Budd-Chiari syndrome.
Acute abdominal pain in combination with changes in urine occurs when:
• Chronic lung disease;
• myocardial kidneys;
• rheumatocelis;
• acute intermityvniy Porphyry.
Acute abdominal pain in combination with constipation may occur if:
• bowel obstruction;
• Ring lead poisoning;
• Diverticulitis;
• atonichniy dyskinesia intestines.
In children, unlike adults, abdominal pain may have other causes. Yes, children under 6 months of
abdominal pain often conditioned air hit in the stomach or intestine, causing a kind of colic occurs.
A child can cry, pull legs prytyskaty to their stomach and within an hour to behave adequately.
After the departure of gases child can calm down. Typically, such kolkopodibnyy pain in children
aged 6 months disappeared themselves. Newborns also may suffer from obstruction of the stomach
or intestinal tract. This is evidenced by vomiting or bloating.
In children after the age of six typical cause of abdominal pain is inflammation of the stomach and
intestines caused by virus or bacterial infection. Abdominal pain accompanied by diarrhea,
vomiting, high fever, nervous excitement and a general concern. Sometimes decreases appetite and
the child refuses to eat.
Older children may experience abdominal pain because of influenza or acute respiratory viral
infection. When examining a child with abdominal pain can identify angina, high body
temperature, runny nose, headache, vomiting. Another possible cause of abdominal pain may be
inguinal hernia. Often together with pain in lower abdomen marked vomiting. In preschool
children the cause of abdominal pain can be constipation, urinary tract infection, pneumonia. If the
cause is constipation, the pain is significantly reduced or disappears after a bowel movement.
Urinary tract infection accompanied by high fever, discomfort in urine. When available cough
associated pneumonia, high body temperature, chest pain. Another possible but less common cause
may be food poisoning, in which abdominal pain is spasmodic character, while vomiting and
diarrhea.
In school-age children cause abdominal pain may be inflammatory processes in the mucosa of the
stomach, kicks in the stomach, urinary tract infection, viral infection.
Acute abdomen
Acute abdomen - is a collective concept, which combines various abdominal diseases, which is a
common sign, in most cases, the need for urgent surgical care.
Acute abdomen - a kind of complex that combines symptoms:
• severe abdominal pain, which occurs within hours or days;
• dyspepsychni symptoms (nausea, vomiting);
• signs of peritoneal irritation;
• general condition of the affected hard.
For correct evaluation of abdominal pain and determination essentially pathological process
should:
• the place of maximum pain sensation and its irradiation;
• clarify the circumstances on which of pain and its reduction (violation of diet, sudden
movements, exercise, excitement, vomiting, defecation, etc.);
• identify related indigestion (swelling, vomiting, diarrhea), the ratio of these events in time
coincidence with the change of color of skin, urine, feces.
When fizykalnyh study patient should pay attention to:
• appearance;
• facial expression, facial expressions, behavior (or moving constraint concern), the move, forced
postures, breathing part of the stomach, skin color, mucous membranes, the status of pupils;
• area of skin hiperalheziyi, perkutornoho pain, pain with palpation of certain organs, stress the
anterior abdominal wall, symptom-Schotkina Blyumberha;
• bloating, the presence or absence of peristalsis, muscle tension, jaundice;
• changes in other organs and systems - availability of aortic atherosclerosis and coronary arteries
(myocardial infarction, mesenteric vascular thrombosis), acetone smell from mouth, softening
eyeballs (diabetic prekoma), cyanosis, swelling pain of the flat surface of the liver (heart failure ).
The most common cause of acute abdominal pain for which diagnosed acute abdomen:
I. Diseases of the abdomen:
• pinched hyly esophageal aperture diaphragm;
• perforation of stomach ulcer or ulcer;
• cholelithiasis and acute cholecystitis (hepatic colic);
• acute intestinal obstruction;
• acute appendicitis;
• acute pancreatitis, pankreatonekroz;
• acute mesenteric vascular thrombosis.
II. Gynecologic Disease:
• ectopic pregnancy;
• Twisted legs cysts;
• sharp adnexitis;
• Ovarian apoplexy.
III. Kidney and Urinary Tract:
• urolithiasis;
• Acute pyelonephritis;
• myocardial kidneys.
IV. Other diseases:
• nervous system disease;
• acute pneumonia;
• spontaneous pneumothorax;
• myocardial infarction;
• rozsharovuyucha aortic aneurysm.
Differential diagnostic signs of diseases that are often the cause of priority setting of acute
abdominal syndrome.
Clinical and diagnostic features perforatyvnoyi gastric ulcer or duodenal ulcer:
• ulcerative anamnesis;
• sudden "kyndzhalnyy" pain in the epigastric area (with gastric ulcer) or right pidreber'yi (with
duodenal ulcer);
• patient lies on his back or right side, fear stir;
• utyahnenyy stomach, "doshkopodibnyy, not involved in the act of breathing;
• positive symptoms of peritoneal irritation;
• perkutornoho - the disappearance of liver dullness;
• radiography - gas right under the dome diaphragm.
Clinical and diagnostic features of acute appendicitis:
• appearance of sudden pain around the navel, which then shifts in zduhvynnu site;
• The pain may spread to the perineum, the egg or mother nature cramps;
• nausea, one-or two shot vomiting, usually in early disease;
• protective muscle tension and symptoms of peritoneal irritation in the right zduhvynniy site;
• positive symptoms Schotkina-Blyumberha, Rovzinha, Sitkovskoho;
• fever without chill or slight fever;
• leukocytosis, neutrophilic palychkoyadernyy shift.
Clinical and diagnostic signs of acute cholecystitis (acrimoniously cramps):
• pain in the right pidreber'yi of irradiation in the back, right thigh;
• local pain in the right pidreber'yi;
• symptoms of peritoneal irritation (with destructive forms);
• fever, chills;
• repeated vomiting of bile;
• positive symptoms Ortnera, Myusi;
• patient lies mainly on the right side, but fear to move, stiffness, as in perforatyvniy ulcer, no;
• neutrophilic leukocytosis, accelerated subsidence rate of erythrocytes (SHZE).
Clinical and diagnostic features of acute pancreatitis:
• intense pain in upper abdominal area that arises suddenly, some time after consuming fatty or
spicy food, alcoholic drinks;
• pain in shingles or irradiyuye pidreber'ya and back;
• pain too severe, often permanent, sometimes accompanied by seizures;
• repeated vomiting, often relentless, which brings no relief;
• swollen abdomen, delay vyporozhnen and separation of gases;
• hiperamilazemiya.
Clinical and diagnostic features of acute intestinal obstruction:
• pereymopodibnyy intense abdominal pain, which varies period of silence, and then restored;
• counter nausea and repeated vomiting of food, then bile, then vomiting faecalis;
• thirst;
• lack vyporozhnen departure and gases;
• intolerable tenesmus;
• patient lies on the right side or in a knee-elbow position during attacks of pain expressed anxiety;
• enlarged abdomen due to uneven gas inflated gut loops;
• soft abdomen, no peritoneal irritation symptoms, sometimes defined distended intestinal loop
with waves of peristalsis;
• perkutornoho - areas of high tympanitu;
• auscultatory - peristaltic loud noises, with floor-tional gut paralysis - "dumb" stomach;
• rectally - rectum empty and bloated;
• abdominal breathing excursions reserved.
Clinical and diagnostic features of mesenteric vascular thrombosis:
• embolohenne available source, general or other atherosclerotic vascular process, prerequisites
venous thrombosis;
• pereymopodibnyy intense abdominal pain, accompanied shokopodibnym condition;
• lack of peristalsis in abdominal auscultation, widespread painful palpation;
• pain too severe, sometimes unbearable, slightly decreased while the knee-elbow position
patients;
• one-or two shot vomiting, with obstruction - Multiple;
• Frequent small bowel with admixtures of blood;
• hiperleykotsytoz palychkoyadernym with neutrophilic shift.
Treatment
Factors which define the treatment of pre-hospital stage:
• lack of distinctiveness of clinical symptoms, especially at an early stage;
• lack of family doctors for long-term opportunities for patient monitoring with the assessment of
the dynamics of development and changes of clinical symptoms and syndromes;
• address the issue of timely hospitalization;
• feasibility of choosing the optimal therapy before and during transportation of patients in
hospitals.
Acute surgical diseases, the first manifestations of which are abdominal pain required
hospitalization in early surgical hospital, because of how much time elapsed from onset to
hospitalization, depending on the number of complications and death. Thus, mortality among
hospitalized within 24 hours of onset over more than half the deaths among patients who provided
assistance during the first period.
The basic rule of acute abdominal pain is for urgent measures to identify causes of pain and, if
necessary - Emergency hospitalization, because this patient subject to immediate evacuation to
hospital inpatient facility.
Urgent hospitalization feasible if at least one of the following symptoms:
• severe abdominal pain that developed suddenly;
• repeated vomiting, which does not bring relief;
• protective abdominal muscle tension;
• positive-symptom Schotkina Blyumberha;
• severe general condition of the patient - Light eyes, pointed nose, a strange concern, vascular
collapse, and gases vyporozhnen delay or severe diarrhea, flatulence pronounced.
Medical care in the prehospital phase of acute surgical diseases include:
• identification and assessment of vital signs and dangerous syndromes;
• maintaining vital functions of the patient during the time needed to transport patients in the
hospital;
• swift and targeted transport of patients in the hospital.
With suspected acute abdomen displayed a hunger strike. Given the inability of various
intravenous fluids, sometimes advisable to give the patient weak sweet tea.
If you can provide local cooling abdomen (ice pack), it should do, not forgetting the need for
general warming of the patient.
Gastric lavage, enema cleansing with suspected acute abdomen contraindicated.
The use of analgesic
When abdominal pain, caused by acute abdominal disease at the prehospital stage of the drug and
nenarkotychnyh of analgesics are contraindicated. Their use can lead to further diagnostic errors,
which could cost the life of the patient. While supporters say the appointment of medicines that
early administration of analgesics is the prevention of pain and shock should be conducted to treat
nonspecific pain, such opinion is unfounded and wrong.
Antibacterial agents
In the case of fast delivery of patient in hospital to determine the final diagnosis purpose
antibacterial agent should be avoided.
Antispasmodic Tools
Can be assigned to the hepatic or renal colic, irritable bowel syndrome, if the doctor is no doubt he
set the accuracy of diagnosis.
Infusion therapy
Fluid in the prehospital phase may be a safe way to transport a patient. Intravenous infusion
therapy can be carried out before and during transporuvannya patient in hospital. Most necessary is
a infusion therapy in shock, Peptic ulcer perforation, acute intestinal obstruction, acute
pancreatitis, peritonitis, bleeding vnutrishnoocherevynniy.
IV. To subject test questions, algorithms, structural logic.
What vzayemovidnosny family doctor with the secondary and tertiary medical help?
What are the contraindications for keeping patients in outpatient facilities.
How to develop programs of family problem?
How to conduct dolikovuvannya patients after their hospitalization and rehabilitation on an
outpatient basis?
How provodytymedyko social disability expertise on an outpatient basis?
V. Materials for self-control (tests, tasks).
Tests.
1.What clinical syndrome is typical for acute appendicitis?
A Symptom Murphy
B Symptom-cardiology musset
C Symptom Kert
D Symptom Babinskoho
E Symptom Razdolsko
2.Constant symptom in acute appendicitis?
A Dry tongue
B Fever
C Nausea
D Bloating
E Stomachache
3.Retroperitoneal appendicitis most of all like disease?
A Pancreas
B Stomach
C Firefox uterus
D Kidneys
E Rectum
4.Excretion of black blood in feces is a sign?
A Hemorrhoid
B Acute pancreatitis
C Ulcer bleeding
D Varicose veins strahovodu
E Dyvertykulytu
5. Differential diagnosis of acute appendicitis should be held more often than all of:
A Acute gastroenteritis
B Perforation body gently
C Acute cholecystitis
D Crohn's disease
E Right-adnexitis
6. The presence in patients with chronic calculous cholecystitis is indication?
A Conservative treatment
B Surgical treatment
C Spa treatment
D Not an indication for treatment
E Setting dispensary supervision
7. Characteristics of hepatic colic?
A Icterus
B Shakes
C Pain in the right subcostal area
D Repeated vomiting
E All characteristic
8. In a endoscopy can detect everything, except?
A Type of gastritis
B Mallory-Weiss syndrome
C Volume of blood loss
D Zollinhera-Ellison syndrome
E Stenosis zavorotnyka
9. The main antidote of heparin?
A Mannitol
B Merkazolil
C Protaminsulfat
D Methionine
E Trental
10. Halstead characteristic symptom?
A Acute appendicitis
B Cirrhosis
C Strokes
D Acute pancreatitis
E Chronic liver failure
11. What's Below equip the largest effect of thrombolytic
A Poliglycine
B Heparin
C Fenilin
D Reopoliglyukin
E Streptokinase
12. What's Below is characteristic lehnevoyi artery thromboembolism?
A Cyanosis of lips
B Overload left half heart
C Overuse of the right half of the heart
D The presence of chronic venous insufficiency tender limbs
E For breast pain
Case problem:
Patient G., 1936 addressed to the receiving ward complaining of pain in the bottom part of
stomach, vomiting, nausea, fever to 38 º C. From the anamnesis it is known that sick over 3 days,
when there were complaints vyschenadanni. When you review draws attention to local
perkutornoho palpatorna and soreness in the right area and zduhvynniy slabopozytyvnyy
Blyumberha syndrome. What can diagnose the disease in sick?
Patient D., 1947 complaining of pain in the upper epigastric area, nausea, blyuvotynnya, dry
mouth. From anamnesis known that 2 2 Alcohol later took those spicy, fatty food. Then there were
constant nausea, blyuvotynnya yidenoyu operizuvalni food and pain in epigastric area. Self
received analgesic drugs, but condition worsened, pain intensified napruzhennist appeared dizzy
and fever up to 38 º C. What is the probable diagnosis can be established patient? And what
methods should be to confirm the diagnosis?
3.Hvora N., 1975 delivered by ambulance to the medical receiving ward with complaints of
intense pain in the right pidreber'yi, nausea, blyuvotynnya. Complaints appeared after the flaws in
the diet. With every review and covers the sclera icteric. Tongue dry, thickly furred yellowish
plaque, nadymlenyy abdomen, painful to palpation in the right pidreber'yi, positive syndrome
Ortnera and ceramics. What diagnosis can be established patient?
4.Hvoryy 1940 he entered office to the receiving hospital complaining of vomiting lots of bright
red blood, before which were nausea and repeated vomiting without mixture of blood. Vomiting
after eating there were a large number of alcohol and fatty foods on the background of complete
well-being. What is the most likely diagnosis?
5. Patient in 1942 entered the clinic complaining of pain in the epigastric area, which gives the
back and aggravated after eating so that the patient strashytsya eat. Shud last year, 1.5 to 20 kg.
Emptying uncertain character: fix changing diarrhea. Vyporozhnen Microscopy study found no
stravleni myazovi fibers, drops of neutral fat, fatty acid crystals. On abdominal plain film revealed
flatulence by peritoneal kaltsynaty. Your preliminary diagnosis?
VI. Literature.
1. Anohyna GA Абдоминальный yshemycheskyy syndrome / / Current Gastroenterology. - 2005.
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2. PO Box Grigorieva, Yakovenko Э.П. Абдоминальные boly: aetiology, pathogenesis,
diagnosis, vrachebnaya tactics / Praktykuyuschyy doctor. - 2002. - № 1. - S. 39-41.
3. Katerenchuk IP, OO Hutsalenko Диференційний діагноз болю у животі у практиці
терапевта. – К.: Книга плюс, 2003. – 106 с.
4. Комаров Ф.И., Шептулин А.А. Боли в животе // Клиническая медицина. – 2000. – № 1. –
С. 46-50.
5. Крылов А.А., Земляной А.Г., Михайлович В.А., Иванов В.И.
Неотложная гастроэнтерология: Руководство для врачей. – 2-е изд., перераб. и доп. – СПб.:
Питер Паблишинг, 1997. – 512 с.
6. Ллойд М. Найхус, Джозеф М. Вителло, Роберт Э. Конден. Боль в животе: Пер. с англ. –
М.: Бином, 2000. – 320 с.
7. Мерта Дж. Справочник врача общей практики: Пер. с англ. – М.: Практика, 2000. – 1230
с.
8. Передерий В.Г., Викторов А.П., Щербак А.В. Острые абдоминальные синдромы при
сахарном диабете // Клин. med. – 1989. – № 8. – С. 33-38.
9. Фадеенко Г.Д. Абдоминальная боль в терапевтической практике: от патогенеза к лечению
// Doctor. – 2003. – № 4. – С. 72-74.
10. Харченко Н.В., Родонежская У.В. Абдоминальная боль в практике гастроэнтеролога //
Журнал практичного лікаря. – 2003. – № 4. – С. 8-12.
11. Яковенко Э.П. Абдоминальный болевой синдром: этиология, патогенез и вопросы
терапии // Клин. фармакология и терапия. – 2002. – № 3. – С. 1-8.
12. Drossman DA Chronic Functional abdominal pain. Sliesenger & Fordtrans's Gastroentestinal
and Liver Disease. Philadelfia-London-Toronto-Monreal-Sydney-Tokyo. – 2003. – Vol. 1. – P. 9097.
13. Glasgow RT, Mulvihil SJ Abdominal pain, including the acute abdomen. Sliesenger &
Fordtrans's Gastroentestinal and Liver Disease. Philadelfia-London-Toronto-Monreal-SydneyTokyo. – 2003. – Vol. 1. – P. 80-90.
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