Methods of clinical research of the patient. Subjective and objective examination

Subjective and objective examination.

Subjective examination- These are physiological, psychological, social data about the patient.

Subjective examination:

Questioning the patient (anamnessis). Anamnesis - a set of information about the patient and the development of the disease, obtained by questioning the patient himself and those who know him;

Conversation with relatives;

Interview with ambulance workers;

Conversation with neighbors, etc.

Objective examination- This is an examination that determines the status of the patient at the present time.

Examination methods:

Basic;

Additional - studies conducted by other specialists (example: endoscopic examination methods).

The main methods of examination include:

General inspection;

Palpation is one of the main clinical methods of objective examination of the patient using touch;

Percussion - tapping on the surface of the body and assessing the nature of the sounds arising from this; one of the main methods of objective examination of the patient .;

Auscultation - listening to sound phenomena associated with the activity of internal organs; is a method of objective examination.

After that, the nurse prepares the patient for other scheduled examinations.

During a general examination, determine:

1. General condition of the patient:

Extremely heavy;

Medium severity;

Satisfactory;

2. The position of the patient in bed:

Active - this is the position of the patient when the patient is able to independently return, sit down, stand up;

Passive - the position is called when the patient is very weak, emaciated, unconscious, usually in bed and cannot change his position without outside help;

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

3. State of consciousness (five types are distinguished):

Clear - the patient specifically and quickly answers questions;

Gloomy - the patient answers questions correctly, but late;

Stupor (numbness) - a state of stupor, the patient is poorly oriented in the environment, answers questions sluggishly, late, the patient's answers are meaningless .;

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

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

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

4. Facial expression - allows you to judge the internal state of the patient. It can express anxiety, longing, fear. With fever, there is reddening of the cheeks, excitement, gleam of the eyes. A pale, puffy face with drooping eyelids occurs in patients suffering from kidney diseases.

5. General body structure

The normosthenic type is characterized by proportionality in the structure of the body, moderately developed subcutaneous fat, strong muscles, and a cone-shaped chest.

Asthenics are characterized by the predominance of longitudinal dimensions over transverse ones. The neck is long and thin, the shoulders are narrow, the shoulder blades are often separated from the chest, the epigastric angle is sharp, the muscles are poorly developed, the skin is thin and pale. Subcutaneous fat is underdeveloped, the diaphragm is low.

In hypersthenics, transverse dimensions are underlined. They are characterized by a significant development of muscles and subcutaneous fat. The chest is short and wide, the direction of the ribs is horizontal, the epigastric angle is obtuse, the shoulders are wide and straight.

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

Paleness of the skin and mucous membranes can be permanent and temporary. Paleness can be associated with chronic and acute blood loss (uterine bleeding, peptic ulcer).

Abnormal redness (hyperemia) of the skin depends on the expansion and overflow of small vessels with blood (observed during mental arousal).

Cyanosis - a bluish-purple color of the skin and mucous membranes is associated with an excessive increase in carbon dioxide in the blood and insufficient oxygen saturation.

Jaundice is a discoloration of the skin and mucous membranes due to an excess of bile pigments in the blood. This occurs when there is a violation of the normal outflow of bile from the liver to the intestine through the bile duct.

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

Increased pigmentation can cause skin discoloration. Pigmentation is local and general. Sometimes there are limited areas of pigmentation on the skin - freckles, birthmarks. Albinism is the partial or complete absence of pigmentation, the absence of certain areas of the skin is called vitiligo.

Skin rashes and hemorrhages. The most characteristic rashes are found in skin, acute infectious diseases.

In allergic conditions, urticaria can develop, which resembles a rash with a nettle burn and is accompanied by itching.

Skin moisture depends on perspiration. Increased humidity occurs with rheumatism, tuberculosis, Graves' disease. Dryness occurs with myxedema, sugar and non-sugar diabetes, diarrhea, general exhaustion.

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

Examination of the patient. Inquiry. Complaints. Disease history. Life story.

Objective examination of the patient. General inspection. Body temperature. Face examination. Inspection of the skin. Palpation of peripheral lymph nodes. Inspection and palpation of the thyroid gland. Objective research methods. Establishing diagnosis. Forecast

The initial stage of examination of the patient is questioning. A correctly conducted questioning can lead to a diagnosis, and then the objective and instrumental methods of research carried out can finally confirm it. The main examination methods include history taking, examination, percussion, auscultation, palpation, and additional methods include clinical, laboratory, instrumental and other research methods. The main research methods can be objective or physical (examination, palpation, percussion, auscultation) and subjective (questioning).

Questioning, as a rule, is carried out purposefully, taking into account the alleged possible disease. The questioning consists of identifying the patient's complaints and studying the anamnesis (a set of information about the patient). Taking an anamnesis requires from the doctor not only special knowledge, but also psychological preparation, as well as great general erudition to establish a trusting relationship with the patient, psychological contact, and tactful conversation.

Complaints

After clarifying the passport data, the patient's complaints are evaluated. First, the patient is given the opportunity to speak out on his own, based on his subjective feelings, then it is necessary to clarify the complaints with the help of additional questions. When studying complaints of pain, it is necessary to find out their nature (permanent or in the form of an attack), localization, intensity, irradiation, time of their appearance and concomitant circumstances, factors that increase or decrease pain, the effect of physical activity and medications on them. Even if the patient has no complaints and he feels healthy, a thorough study of the history of the disease is necessary.

Medical history

It is important to find out when and how the disease arose, how it developed, that is, the dynamics of the disease. Many patients tend to talk about the last deterioration in well-being as the beginning of the disease (for example, the patient may say that he has yesterday“pressure rose”, there was nausea, vomiting, while in fact the duration of the disease is 15 years).

An important question is how (acutely or gradually) the disease arose. Upon careful questioning of the patient, it may turn out that the so-called general complaints (weight loss, weakness, temperature) have been bothering him for a long time. The course of the disease in different patients, young and old, may be different. It must be remembered that at present the “clinic” of diseases can change, the so-called “masks” of diseases have appeared. All this complicates the assessment of the anamnesis.

The results of previous studies are important from the point of view of the dynamics of the disease (how many worsenings, relapses). It is important to find out how and with what the patient was treated earlier. Treatment methods can be medical, surgical, physiotherapeutic, as well as non-traditional. It is necessary to find out whether the treatment was ineffective due to the fault of the patient (if the patient does not take or takes medicines irregularly). Next, the reason for hospitalization is clarified: deterioration of the condition, planned treatment, accidental detection of pathology, acute development of the disease. In conclusion, they find out how the patient's condition has changed during his stay in the hospital (improvement, deterioration, no dynamics).

Life story

Anamnesis of life (anamnesis vitae) is a medical biography of the patient, which includes information about the place of birth, education, hereditary factors, living conditions in the past and present, financial security, marital status, habits, working and leisure conditions, degree of physical activity and emotional loads. The study of life history allows for an in-depth analysis of the physical, mental and social development of the subject, his lifestyle in order to identify possible risk factors and triggers for deterioration in health or the onset of a disease.

The patient's life history is studied in a certain sequence.

3. A professional (labor) anamnesis allows not only to study the professional route (by whom and where he worked), work experience in the main profession, but also working conditions, taking into account the presence of occupational hazards (for example, when working in a printing house, lead intoxication may develop, and work on a night shift can provoke a crisis in hypertension). Knowledge of the unfavorable role of certain production factors allows you to give the patient specific recommendations.

4. Household anamnesis (material, living conditions). The study of household history includes housing conditions, the composition and number of family members, the average monthly income and family budget, the presence of a subsidiary farm, diet.

5. Past illnesses and injuries. Some of them can provoke the development of various diseases (for example, a fracture of the arm can be complicated by osteomyelitis, which can lead to the development of amyloidosis of the internal organs). You should especially find out from the patient about prolonged febrile conditions, edema of the body, bleeding. Previously transferred multiple sore throats predispose to diseases of the heart, kidneys, joints.

6. Epidemiological history (contact with infectious patients, injections, surgical interventions, being in a certain area that is unfavorable for this infectious disease, previous infectious diseases, blood transfusions).

7. Gynecological history (the nature of menstruation, the course of pregnancy and childbirth, abortion, menopause). It is also necessary to find out about contraceptive measures (long-term use of hormonal drugs can lead to serious complications).

8. Bad habits, including drug use. Smoking is a risk factor for respiratory diseases and cardiovascular systems. Alcohol negatively affects the nervous system, changes the functioning of vital organs, especially the liver.

9. Allergologicalhistory (primarily allergic reactions to drugs and diagnostic drugs.A large part of the population is sensitized to various allergens (dust, food, etc.).

10. Heredity. It is very important to study the hereditary history, that is, information about the state of health of parents and close relatives. First, information is collected about the father and mother, and then about relatives in ascending order (grandparents) and along the lateral lines.

11. Insurance history, the presence of an insurance policy, disability groups (a disability group can be given not for medical, but for social reasons).

When collecting an anamnesis, it is desirable to strive for the most frank conversation with the patient, creating a psychological atmosphere of trust, the patient's confidence in the importance and necessity of therapeutic measures.

Body temperature

Normal body temperature is assumed to be 36.5 - 37 ° C in the armpit (slightly higher in children, and lower in the elderly). The temperature of the mucous membrane of the oral cavity, vagina, rectum is higher than the temperature of the skin in the axillary and inguinal areas by 0.2 - 0.4°C. Normal temperature during the day gives small fluctuations, depending on work or food intake. The temperature can also rise under the influence of intense mental work, but not more than 0.1 - 0.15 ° C. An increase in temperature can occur under the influence of sharp emotions, but in such cases it is short-lived. As a rule, daytime temperatures are higher than nighttime ones. Temperatures are lowest at night and before morning.

There are two maximums: one is in the morning (between 7 and 9 o'clock), the other is in the evening (17-19 o'clock). These intervals are chosen for temperature measurement.

In some cases, in order to identify more accurate fluctuations in daily temperature in some diseases, it is measured every 2-3 hours.

Fever is a complex pathological process that develops as a general reaction of the body to various external, mainly infectious, influences and is expressed in a number of metabolic disorders and functions of all physiological systems of the body. The main symptom in symptom complex fever, is an increase in temperature due to a disorder of thermoregulation. It is generally accepted that the temperature in a healthy person does not exceed 37 ° C.

There are the following degrees of temperature increase: 1) subfebrile temperature (between 37 and 38 ° C); 2) moderately elevated (between 38 and 39°C); 3) high - between 39 and 41 ° C; 4) excessively high, hyperpyretic (over 41°C). The height of the temperature depends on age, nutritional status, fatigue. Depending on the daily fluctuations in temperature, the following types of fevers are distinguished:

1. Constant fever (febris continua): the temperature is usually high, lasts a long time, daily fluctuations are noted within 1 ° C. Occurs with croupous pneumonia, typhus and typhoid fever;

2. Remittent fever, laxative (febris remittens): daily fluctuations within 1 - 1.5 ° C without decreasing to normal (focal pneumonia, suppuration);

3. Debilitating fever ( febris hectica) - long, with daily fluctuations of 4 - 5 ° C and falling to normal and subnormal levels (sepsis, suppurative disease, severe pulmonary tuberculosis);

4. Perverted fever (febris inversa): similar in characteristics to hectic, but the maximum temperature is noted in the morning, and in the evening it can be normal (sepsis, severe);

5. Irregular fever (febris irrigularis): characterized by an indefinite duration with irregular and varied daily fluctuations;

6. Intermittent fever (febris intermittens): alternation during the day of periods of high temperature with periods of normal or low (malaria);

7. Return fever ( febris reccurens): a natural change high fever and fever-free periods lasting several days (relapsing fever);

8. Wavy fever ( febris undulans): characterized by a change in periods of constant temperature increase with periods of normal or elevated temperature (lymphogranulomatosis, brucellosis)(Fig. 5, c).

Subnormal temperature is observed:

a) after a crisis in patients with croupous pneumonia;

b) during collapse, when a sharp drop in temperature is accompanied by a small frequent pulse, severe pallor, general weakness, cold extremities;

c) after severe blood loss;

d) as a temporary phenomenon in chronic diseases of the heart and lungs;

e) in chronic debilitating diseases (cancer of the esophagus);

e) in patients with mental disorders;

g) in case of metabolic disorders (myxedema).

The important point is assessment of physique and type of constitution (asthenic, hypersthenic, normosthenic). This is important to find out, since the location of the internal organs in asthenics and hypersthenics is different. Finally, assessment of posture and gait may indicate the condition of the musculoskeletal system. Thus, it is estimated: 1) the shape of the chest, 2) the presence of edema, which can be local and general (anasarca), 3) the state of the lymph nodes. The study of the lymph nodes is carried out in the same symmetrical areas, starting with the submandibular.

Face examination

First of all, we pay attention to the facial expression, the correctness of the features, their symmetry and proportionality, since there are diseases in which the face can be asymmetrical, for example, paresis of the facial nerve. Then we evaluate the condition of the skin, the presence of edema on the face, its puffiness, for example, with Quincke's edema, treatment with corticosteroid drugs. You can also observe a peculiar face with fever, tuberculosis, Graves' disease, myxedema, the face of a "wax doll" with Addison-Birmer pernicious anemia, the "face of Hippocrates" with peritonitis, the "lion's" face with leprosy.

Patients with nephritis are characterized by a pale, edematous, shapeless face with swollen eyelids and narrow palpebral fissures, while the appearance is often changed beyond recognition. Pale puffiness of the face and eyelids is also observed in patients with trichinosis, severe anemia. A pale yellow, broad, evenly swollen face with smoothed contours, enlarged features, sluggish facial expressions, bag-like swelling of the eyelids, a narrowed palpebral fissure, and a frozen, dull, indifferent look sunken deep into the eyes may indicate the presence of hypothyroidism, especially in women with signs of early wilting. With severe circulatory failure, the face is puffy, flabby, yellowish-pale with a bluish tint, the eyes are dull, sticking together, the mouth is constantly half open, the lips are purplish-blue, somewhat protruding and seem to catch air ( Corvisart's face). Puffiness of the face can be observed in patients with chronic obstructive bronchitis and bronchial asthma, complicated by pulmonary emphysema, or with compression of the lymphatic tract, for example, a massive effusion into the pericardial or pleural cavity. Puffiness and cyanosis of the face in combination with swelling and cyanosis of the neck, upper shoulder girdle, expansion and swelling of the saphenous veins of the upper half of the body are usually caused by thrombosis of the superior vena cava or compression from the outside, for example, an aneurysm of the aortic arch, mediastinal tumor, retrosternal goiter. The sudden development of severe swelling of the face is characteristic of allergic edema ( Quincke's edema). Sometimes it can be noted that the patient looks younger or, on the contrary, older than his years. In particular, patients with thyrotoxicosis look younger, adiposogenital dystrophy, pulmonary tuberculosis. Premature appearance of signs of withering on the face (progeria) is typical for patients with porphyria, hypothyroidism and some other endocrine diseases(Fig. 7).

Ears

First, pay attention to the position, size and shape of the auricles, the condition of the skin covering them. Then they examine and feel the parotid regions in front and behind the auricles.(Fig. 8).With gout on the auricles, it is often possible to detect deposits of crystals of the sodium salt of uric acid ( tophi) in the form of whitish-yellow dense tubercles translucent through the skin. The parotid salivary glands are normally not visible and cannot be palpated. In patients with inflammatory lesions of the parotid salivary glands (parotitis), a noticeable unilateral or bilateral tumor-like swelling appears in front of the auricles, depending on the severity of the process. soft pasty or densely elastic consistency, often painful on palpation. Acute bilateral parotitis is usually of viral origin, and unilateral - bacterial. The cause of chronic parotitis can be salivary duct stones or autoimmune gland damage ( Sjögren's syndrome). Unilateral enlargement of the parotid gland is caused by a tumor lesion. Moderate swelling and soreness of the parotid region in front of the tragus is also observed in arthritis of the temporomandibular joint. Examination of the external auditory canals reveals inflammatory changes in the skin lining them and the presence of discharge. Serous or purulent discharge is observed in patients with inflammation of the middle ear ( mezatympanitis), as well as with a furuncle of the external auditory canal. Bloody discharge from the ears, which appeared after an injury, is an important sign of a fracture of the base of the skull, and may also be a consequence of ear barotrauma.

Nose

Pay attention to the size and shape of the nose, the condition of the skin covering it. After that, palpation and tapping are carried out in the region of the root of the nose, its back, in the places of projection of the maxillary (maxillary) and frontal. Then examine the vestibule of the nose and nasal passages. To do this, the doctor tilts back and fixes the patient’s head with one hand, giving it the necessary position, with the thumb of the other, lifts the tip of the nose up, asks the patient to breathe deeply through the nose and, alternately pressing the finger from the outside on the wings of the nose, determines the degree of patency of the nasal passages (nasal breathing ) according to the noise of the air jet or the amplitude of movements of a cotton wick brought to the open nostril (Fig. 9).

Many pathological processes can lead to a change in the shape and size of the nose, as well as the skin covering it.

When injured, the nose is swollen and purple-blue. A disproportionately large fleshy nose is characteristic of patients with acromegaly. In elderly patients suffering from rosacea and in alcoholics, the nose sometimes increases in size, becomes lobulated and purple-red ("pineal" nose, or rhinophyma). In patients with systemic scleroderma, the nose is narrow, thinned, the skin above it does not fold.

Rhinoscleroma, tuberculosis, recurrent perichondritis lead to deformation of the anterior part of the nose due to wrinkling of its cartilaginous part. Retraction of the back of the nose (saddle nose) is caused by changes in its bone structures due to trauma, syphilis or leprosy.

The presence of mucous or purulent discharge in the nasal passages indicates an inflammatory lesion of the mucous membrane of the nose itself (rhinitis) or its paranasal sinuses (sinusitis). Difficulty in nasal breathing can be caused by many reasons: vasomotor rhinitis, polypous sinusitis, turbinate hypertrophy, adenoids, curvature, hematoma or abscess of the nasal septum, the presence of a foreign body or tumor in the nasal passages. With severe shortness of breath, swelling of the wings of the nose during breathing is often noted.

Eyes

When examining the eyes, first visually determine the width and uniformity of the palpebral fissures, the position of the eyeballs in the orbits ( rice. 10). Pay attention to the shape and mobility (blinking frequency) of the eyelids, the condition of the skin covering them, the safety of eyelashes and eyebrows. Then examine the mucous membrane of the conjunctiva and eyeballs. To do this, the doctor pulls down the lower eyelids with his thumbs and asks the patient to look up. The color of the mucous membrane, the degree of its moisture (shine), the severity of the vascular pattern, the presence of rashes and pathological discharge are noted.

When examining the eyeballs, the condition of the sclera, corneas, irises, the shape, size and uniformity of the pupils are determined. To determine the range of motion of the eyeballs, the doctor places a small object (a neurological hammer or a pen) at a distance of 20-25 cm from the patient's eyes. Having offered the patient, without turning his head, to fix his gaze on this object, he is moved to the right, left, up, down, observing the amplitude of eyeball movements. Gradually removing the object from the patient's eyes, and then bringing it closer, determine the ability of the eyeballs to converge. Bilateral narrowing of the palpebral fissures can be caused by swelling of the eyelids, which is primarily characteristic of kidney diseases. At the same time, the eyelids swell, become watery, their skin becomes thinner. At the same time, the narrowing of the palpebral fissures due to eyelid edema, although less pronounced, is sometimes also observed with myxedema and trichinosis.

Swelling and cyanosis of the eyelids are characteristic of cavernous sinus thrombosis, while puffiness and a peculiar lilac coloration of the eyelids (“heliotrope glasses”) are a typical manifestation of dermatomyositis. Subcutaneous emphysema, caused by a fracture of the bones of the orbit and penetration air from the paranasal sinuses under the skin. On palpation of such a swelling, characteristic crepitus is revealed. One-sided narrowing of the palpebral fissure is observed with swelling of the eyelids due to inflammatory, traumatic or tumor lesions of the eyelids themselves or the orbit, as well as with persistent drooping of the upper eyelid (ptosis) due to a violation of its innervation.

Inspection of the skin

The presence of rashes, skin color, vascular pattern on the skin, areas of depigmentation, i.e. vitiligo, skin elasticity are evaluated. Types of skin rash: erythematous, blistering, hemorrhagic (purpura, for example, in Shenlein-Genoch disease), bullous, for example, in pemphigus. There may be "marble" skin with SLE, tuberculosis. The condition of the hair, nail plates is assessed (for example, brittle nails with iron deficiency anemia, in the form of "watch glasses" - with chronic lung diseases). You can observe the so-called "capillary pulse" with aortic insufficiency.

Palpation of peripheral lymph nodes

Their palpation is performed in the following sequence: occipital, parotid, cervical, submandibular, supraclavicular, axillary, ulnar, inguinal, popliteal.In a healthy person, soft (up to 1 cm), painless, elastic, mobile lymph nodes that are not soldered to each other and surrounding tissues are palpable. (Fig. 11,12).

Establishing diagnosis

When making a diagnosis, take into account:

· Collecting an anamnesis of the disease, an anamnesis of life.

· Objective examination of the patient.

· Instrumental methods of examination.

· Expansion of diagnostic search (additional methods).

· Councils, consultations.

· Live biopsy, diagnostic laparotomy.

· Establishing diagnosis.

Types of diagnostics:

· direct (symptomatic),

· methodical.

The direct type consists in the fact that the doctor, based on a symptom, conducts a series of studies that are relevant to this symptom, for example, when providing emergency care. It can lead to a number of errors due to the one-sidedness of the study. The methodical type is more thorough, since the main complaints, anamnesis are taken into account, all organs are examined.

Forecast

Forecastis a reasonable guess about what will happen to the patient.

Types of prognosis: prognosis for life ( prognosis quoad vitam), prognosis for completeness of recovery ( prognosis quoad valitudinem), for life expectancy ( prognosis quoad decursum morbi), to restore the function of the affected organs ( prognosis quoad functionem), for labor ( prognosis quoad laborem) . And also: good (bona), bad (mala), dubious (dubia), very bad (pessima), portends death (letalis). The possibility of medical error must be taken into account.

Lecture #2

Topic 1.2 "METHODS OF EXAMINATION OF THE PATIENT: SUBJECTIVE, OBJECTIVE DATA"

Subjective examination of the patient: sources of information, sequence and rules for obtaining information.
Objective methods of examination of the patient: examination, palpation, percussion, auscultation. Diagnostic value of these methods.
Features of nursing examination of the patient.
Nursing diagnoses, their classification. The concept of observation and care of the sick.

Symptoms of the disease, on the basis of which it is possible to make a diagnosis, prescribe treatment and evaluate its effectiveness, can be obtained by examining a patient, which includes a subjective and objective examination.

1. Subjective examination of the patient

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

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

During the questioning about the symptoms and the development of the disease itself - the anamnesis of the disease - you need to get accurate answers to the following questions: 1) what the patient is complaining about; 2) when the disease began; 3) how it started; 4) how it went. The study of the main complaints of the patient allows you to make a preliminary conclusion about the nature of the disease. For example, high fever, sudden onset are characteristic of infectious diseases. Complaints of pain in the region of the heart, which arose in connection with physical activity and radiate to the left hand, make one think of angina pectoris. Pain in the abdomen that occurs 1-2 hours after eating or at night, on an empty stomach, suggests a duodenal ulcer. When clarifying the course of the disease, it is often necessary to ask the patient additional questions, specifying which conditions increase the painful symptoms or relieve them; What was the impact of previous treatment? Additional questions include the following: working and living conditions, the environment in which the disease began, the intensification or weakening of symptoms, what kind of treatment was carried out.

Information about the life of the patient - the anamnesis of life - is often of great importance for determining the present disease. It is necessary to find out the working and living conditions at different periods of life, to find out if the patient has bad habits (smoking, alcohol abuse, addiction to drugs), what diseases he had, operations, mental trauma, sexual life, family composition, psychological environment.

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

2. Objective methods of examination of the patient

Objective methods of the patient allows you to get the amount of reliable symptoms necessary in order to establish a diagnosis. An objective examination consists of: 1) examination; 2) feeling (palpation); 3) percussion (percussion); 4) listening (auscultation).

Inspection

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

The position of the patient

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

come back, sit down, stand up.

A position is called passive when the patient is very weak, emaciated, unconscious, usually in bed and cannot change his position without outside help.

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

State of consciousness

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

Stupor (numbness) - a state of stupor, the patient is poorly oriented in the environment, answers questions sluggishly, late, the patient's answers are meaningless.

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

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

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

Facial expression allows you to judge the internal state of the patient. It can express anxiety, longing, fear. With fever, there is reddening of the cheeks, excitement, gleam of the eyes. A pale, puffy face with drooping eyelids occurs in patients suffering from kidney diseases. With tetanus, a facial expression reminiscent of a sarcastic smile is typical.

A fixed gaze directed to one point is found in patients with meningitis. Bulging and glare of the eyes is observed in Graves' disease. In case of poisoning with alcohol, drugs, uremia, constriction of the pupils is observed, and in case of poisoning with atropine, the pupils are dilated. With liver damage, yellowness of the sclera is expressed.

General body structure

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

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

For asthenics the predominance of longitudinal dimensions over transverse ones is characteristic. The neck is long and thin, the shoulders are narrow, the shoulder blades are often separated from the chest, the epigastric angle is sharp, the muscles are poorly developed, the skin is thin and pale. Subcutaneous fat is underdeveloped, the diaphragm is low. In asthenics, blood pressure is lowered, metabolism is increased.

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

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

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

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

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

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

Jaundice - staining of the skin and mucous membranes due to the deposition of bile pigments in them. With jaundice, yellow coloration of the sclera and hard palate is always observed, which distinguishes it from yellowing of another origin (sunburn, the use of quinacrine). The intensity of the icteric color varies from light yellow to olive green. A weak degree of icterus is called subicteric.

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

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

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

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

Skin rashes and hemorrhages. The most characteristic rashes are found in skin, acute infectious diseases.

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

The bumps are easily palpable accumulations of cells in the skin. Such formations are observed in rheumatism.

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

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

Condition of hair and nails. Excessive hair growth in areas free of hair is indicative of endocrine disorders. Hair loss and fragility are characteristic of Graves' disease, alopecia areata - with syphilis. Hair falls out in case of skin diseases - favus, seborrhea. Brittleness and delamination of nails is observed in violation of vitamin metabolism, a disease of the nervous system. With fungal infections, the nails become dull, thickened and crumble.

Decubitus ulcers occur as a result of impaired blood circulation and the integrity of the surface layers in bedridden patients in places of greatest pressure. Pressure ulcers can involve subcutaneous fat and muscle.

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

Stage 1 - obtaining information from the patient, his relatives, health workers, honey. Documentation Subjective data - the patient's opinion about his condition. Objective - these are data obtained as a result of a patient's examination, the opinion of the examiner about the state of the patient. During the examination, we obtain data: about the physical, psychological, social and spiritual problems of the patient

Stage 2 - registration of nursing diagnoses. In c / diagnosis, the patient's real and potential problems are taken into account, indicating the possible cause of their occurrence (headache due to increased blood pressure). When making a s/diagnosis, m/s determines the patient's condition. The patient's condition is considered satisfactory when the symptoms of the disease are moderately pronounced. He is on the floor of bed rest and is fully self-serving. The state of moderate severity - the symptoms of the disease are pronounced, the patient is on bed rest, there are restrictions on self-care.

In heavy able symptoms of the disease are expressed, the patient is on bed or strictly bed rest. Completely lost self care.

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

In a state of moderate severity, the type of c / intervention is partially compensatory, i.e. providing the patient with compensation for the lack of self-care, in addition, training relatives manipulation of care.

In severe condition, the type of intervention is fully compensated, i.e. Caring for the patient in full and teaching relatives the necessary manipulations for care.

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

Drawing up a plan with / interventions:

Independent activity - does not require special instructions.

Dependent - only on prescription.

Interdependent - in interaction with health workers and relatives.

Independent activities include care activities, information to the patient, psychological support, observation of the patient and the results of treatment.

Observation of the patient includes the dynamics of the symptoms of the disease and possible complications. Monitoring of treatment means evaluating the effectiveness and identifying side effects of drugs. Then, based on the data obtained, a c / assistance plan (CAP) is drawn up.

Stage 4 - implementation of the care plan in accordance with the standards.

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

A thorough clarification of complaints and anamnesis is the first stage in the study of the patient and in most cases allows you to immediately develop a diagnostic hypothesis and draw up a plan for further objective research, including a special one.

Complaints a patient with a lung disease usually have a twofold character: some of them reflect changes in the respiratory organs, others - the general reaction of the body to the pathological process. For damage to the respiratory organs, the patient complains of cough, dry or wet, hemoptysis, chest pain, especially associated with breathing, shortness of breath, asthma attacks.

Cough is a common symptom in respiratory infections. It should be remembered, however, that a cough can also be associated with damage to other organs (reflex cough when the branches of the vagus nerve are irritated by a tumor of the mediastinum, aortic aneurysm, enlarged left atrium, etc.). On the other hand, cough may be absent even with obvious damage to the respiratory system, for example, with shallow breathing in elderly debilitated patients. There are two main types of cough - dry and wet. Dry cough is characteristic of the early stage of acute bronchitis, acute pneumonia, etc.

With the appearance of a sufficient amount of bronchial and alveolar secretions, it can be replaced by a wet one. With a wet cough, the characteristic of sputum discharge has a diagnostic value. So, mucous sputum characteristic of the initial period of chronic bronchitis. Mucopurulent sputum occurs in most broncho-pulmonary diseases (bronchitis, pneumonia, etc.). Purulent sputum characteristic of lung abscess, bronchiectasis. The assessment of the amount of sputum discharge is essential. So, expectoration of sputum "full mouth" suggests the emptying of a lung abscess.

The sputum secreted by the patient should be collected in a separate jar with a well-screwed stopper in order to assess its daily amount, appearance, smell, etc. At the same time, three-layer sputum (pus at the bottom of the jar, serous fluid above it, mucus at the top) is characteristic of abscess formation, putrid odor is often indicates gangrene of the lung.

Under hemoptysis usually understand a greater or lesser admixture of blood to sputum. If the amount of simultaneously separated blood exceeds 50-100 ml, we should talk about pulmonary bleeding. Pulmonary bleeding must be differentiated from bleeding from the nasal and oral cavity, esophageal and gastric. With pulmonary bleeding, the blood usually foams, is coughed up, has a bright red color, does not coagulate for a long time, and has an alkaline reaction. However, these signs do not have absolute significance, since blood from the respiratory tract can be involuntarily swallowed and then excreted with vomit, which changes its appearance and reaction. Hemoptysis occurs with lung abscess, bronchiectasis, bronchitis (subatrophic form), fungal infection of the lungs (aspergillosis), heart attack-pneumonia, bronchogenic cancer, etc. Lung injury, foreign bodies of the bronchi, venous plethora of the lungs (with mitral valve defects) can also lead to hemoptysis ).

Chest pain may be superficial or deep. Superficial pain is usually associated with damage to the tissues of the chest wall. For their recognition, careful examination and palpation of the chest are important, in which it is possible to identify pain points or zones. Pain associated with damage to the lungs, as a rule, is deep; they are provoked by breathing and coughing. Most often, these pains are the result of irritation of the parietal pleura, especially its costal and diaphragmatic sheets. With the accumulation of fluid in the pleural cavity that separates the pleural sheets, the pain may subside.

Pleural pain usually appear during inspiration, often spread to the epigastric region and hypochondrium ("pricks in the side"), and with irritation of the diaphragmatic pleura - to the neck or shoulder; they weaken and decrease if you squeeze the chest and thereby reduce its mobility during breathing ( symptom of F. G. Yanovsky). Unlike pain in intercostal neuralgia, which is aggravated by flexion to the affected side, pleural pain is aggravated by flexion to the healthy side, since in this case the conditions for rubbing the inflamed pleural sheets improve. In the presence of pleural pain, Crofton and Douglas (1974) advise asking the patient to indicate the most painful point with a finger and carefully listen to this area for friction noise.

Dyspnea is a common symptom of respiratory diseases. It can only be a subjective feeling of respiratory discomfort in neuropathic patients or be recorded objectively by increased breathing. Clinical experience shows that in most cases, patients begin to feel shortness of breath when the respiratory reserves are already seriously impaired. Dyspnea can be inspiratory, expiratory or mixed. It is also necessary to distinguish between shortness of breath during physical exertion and at rest, which characterizes a different degree of respiratory failure of the patient. We must not forget that shortness of breath may not be associated with damage to the respiratory system and be observed with heart failure, severe anemia, etc.

The extreme degree of shortness of breath is called suffocation, which, like shortness of breath, is inspiratory, expiratory and mixed. Often suffocation is paroxysmal in nature, occurring suddenly. In the practical work of a therapist, suffocation associated with bronchial or cardiac asthma is most often encountered. In severe patients with combined pulmonary and cardiac pathology, asthma is sometimes mixed; phenomena of cardiac (usually left ventricular) insufficiency are combined

with bronchospasm.

Medical history helps to trace the chronological sequence of events in the patient's story. At the same time, attention is paid to: 1) the onset of the disease (when and how did it begin, suddenly or gradually, with what initial manifestations?); 2) the cause of the disease according to the patient (for example, hypothermia, reaction to an unpleasant odor, etc.); 3) the nature of the further course of the disease, in particular the frequency of exacerbations; 4) ongoing treatment and its effectiveness.

It is necessary to identify the presence and severity of various manifestations of allergies (urticaria, Quincke's edema, vasomotor rhinitis, migraine, bronchial asthma) and try to establish what they are associated with (intolerance to certain foods, odors, etc.), occupational hazards (dusty workplace , temperature fluctuations, etc.). Information about individual intolerance to certain medicinal substances (in particular, antibiotics) is important, especially if this is supported by medical documents. However, it is desirable to get acquainted with the documents last, after an opinion about the patient has been formed, since an incorrect previous diagnosis sometimes binds the doctor's clinical thinking.

Anamnesis of life of the patient is extremely important not only for recognizing the nature of a pulmonary disease. It also makes it possible to identify a number of individual characteristics of the sick person, both acquired by him during his life and inherited. Long-term tobacco smoking can contribute to the development of chronic bronchitis or bronchial cancer. The abuse of alcoholic beverages also predisposes to and maintains chronic damage to the bronchi and lungs. The role of hereditary predisposition to allergic reactions in the origin of bronchial asthma, etc. is well known. Work and housing conditions are important (for example, many years of work as a miner, gas welder, foundry worker; living in an apartment with a patient with tuberculosis), chest injuries.

As already mentioned, there are basic and auxiliary (additional) methods of objective examination of patients.

The main methods of objective examination of patients:

inspection - inspectio, palpation - palpatio, percussion - percussio, listening - auscultatio.

Auxiliary (additional) methods:

measuring, laboratory, instrumental, histological, histochemical, immunological, etc.

Let's consider them in more detail.

Examination of the sick

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.

Basic requirements for the inspection

Good illumination of the room, comfortable conditions, compliance with the "technique" of the inspection, strict sequence, regularity of the inspection.

General examination of patients

The sequence of the general examination of patients:

The general condition of the patient.

The patient's state of mind.

Physique and constitution of the patient.

Facial expression, examination of the head and neck.

Examination of the skin and visible mucous membranes.

Character of hair and nails.

The development of the subcutaneous fat layer, the presence of edema.

condition of the lymph nodes.

Assessment of the condition of muscles, bones and joints.

General examination of patients, as a rule, is supplemented by palpation.

General state sick May be extremely severe, severe, moderate 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 the patient, it is traditional to begin with a description of the general condition of the patient.

Consciousness

The word "consciousness" in Russian has several meanings, in particular, in the Ozhegov dictionary, five meanings are indicated, 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).

Speaking about the pathology of consciousness, the second meaning of the term is more often used, i.e. the pathology of the functional state of the brain is considered. When considering alterations in consciousness, there are:

A. Long-term violations:

quantitative forms of violation ( oppression syndromes );

qualitative forms of violation ( confusion syndromes );

B. Paroxysmal disorders :

1) syncope; 2) epileptic seizures (including derealization and depersonalization syndromes.

Altered states of consciousness (hypnosis, trance) are not a pathology, they will be considered in senior courses.

Western neurologists distinguish two components of consciousness (consciousness) - awareness , the content of consciousness (awarness) and activation (arousal). At quantitative violations consciousness (depression of the level of consciousness) suffers mainly activation, and the content, the quality of consciousness is more intact. Sequential degrees of loss of consciousness are called: 1)stun (obtundation ), 2)sopor (corresponding to English. stupor ), 3)coma .

Scales are used to classify and assess the degree of impairment. In the CIS, the most common classification is Konovalov A.N. et al., (1982).

Working classification of disorders of consciousness(with abbreviations)

State of consciousness	Definition	Clinical characteristics	Leading Feature
clear	Complete preservation of consciousness with active wakefulness, equivalent perception of oneself and adequate response to the environment	Awake. The ability to pay attention. Full speech contact. Understanding and answering questions appropriately. Complete and fast execution of commands. Fast and targeted response to any stimulus. Preservation of all types of orientation. Correct behaviour.	Full orientation, wakefulness, quick execution of all instructions
Moderate stun	Partial turning off of consciousness with the preservation of verbal contact against the background of an increase in the threshold of perception of all external stimuli and a decrease in one's own activity	The ability to pay attention is reduced. Speech contact is maintained, but getting complete answers often requires repeating questions. Answers are slow, delayed, often monosyllabic. Commands are executed correctly, but slowly. The reaction of the extremities to pain is active, purposeful. Rapid exhaustion, lethargy. Impoverishment of facial expressions, inactivity, drowsiness. Control over the functions of the pelvic organs is preserved. Orientation in the environment, place and time is incomplete, while orientation in one's own personality is relatively preserved. Pronounced retro- and anterograde amnesia	Partial disorientation in the place of time, situation; moderate drowsiness, slow execution of commands, especially complex ones

Stun Deep		Almost constant state of sleep. Possible motor arousal. Speech contact is difficult and limited; after insistent demands, he can respond in monosyllables to an appeal of the “yes - no” type. Often with perseverations, he can report his name, surname and some other data. Responds slowly to commands. Able to perform elementary tasks (open eyes, raise a hand, etc.), but is "depleted" almost instantly. Quite often it only tries to do this by performing the initial act of movement. To establish even a short-term contact, repeated appeals are necessary, a loud call is often combined with the use of painful stimuli. The coordinated protective reaction to pain is preserved; reaction to other types of stimuli is changed. Control over the functions of the pelvic organs is weakened. Disorientation in the environment, place, time, persons, etc., often with the preservation of orientation elements in one's own personality.	Complete disorientation, deep drowsiness; execution of only simple commands is slow
Sopor	Turning off consciousness with the absence of verbal contact with the preservation of coordinated defensive reactions to painful stimuli	Speech and mimic-manual contact is impossible. No commands are executed. Immobility or reflex movements. When painful stimuli are applied, defensive hand movements directed to the source of irritation, turning over to the other side, and suffering grimaces on the face appear. May moan, make inarticulate sounds. Sometimes mindlessly opens his eyes to pain, a sharp sound. Sphincter control is broken. Vital functions are preserved or there are non-threatening disorders in one or two parameters.	Total failure to execute commands; localization ability (coordinated defensive movements)
Coma moderate ( I)	Complete shutdown of consciousness with a total loss of perception of the environment and oneself, with neurological and vegetative disorders. The severity of coma depends on the severity and duration of neurological and autonomic disorders.	"Unawakened". Lack of reactions to any external stimuli, except for strong pain. In response to painful stimuli, extensor or flexion movements in the limbs, tonic convulsions may appear. Sometimes the facial expressions of suffering. Unlike stupor, protective motor reactions are not coordinated and are not aimed at eliminating the stimulus. Eyes do not open to pain. Pupillary and corneal reflexes are preserved. There are reflexes of oral automatism and pathological foot reflexes. Swallowing is severely difficult. Protective reflexes are relatively preserved. Sphincter control is broken. Respiration and cardiovascular activity are stable, without sharp deviations.	"Unawakened"; no ability to localize pain (uncoordinated defensive movements)
Coma deep ( II )		The absence of any reactions to any external stimuli, including severe pain. Complete absence of spontaneous movements. A variety of changes in muscle tone ranging from decerebrate rigidity to muscle hypotension. Hyporeflexia or areflexia without bilateral mydriasis. Preservation of spontaneous respiration and cardiovascular activity in severe disorders	"Unawakened"; lack of protective movements for pain

Coma beyond ( 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.	Catastrophic state of vital functions

Etiologically isolated cerebral, hyperglycemic, hypoglycemic, uremic, renal, hepatic, hypoxic, anemic, intoxication, hypochloremic and other coma. In addition, there are also pseudo-comatose states, which will be discussed in the course of neurology.

Prolonged qualitative disturbances of consciousness

Qualitative disorders 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.).

According to the classification of Morozov G.V., they distinguish delirium, oneiroid ,amentia and twilight consciousness .

Delirium (delirium) hallucinatory stupefaction with a predominance of true visual hallucinations and illusions, figurative delirium, changeable affect, in which fear and motor excitation predominate. 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 phenomena of incoherence of 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) various types of 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;

4) full or partial amnesia of the period of stupefaction.

Paroxysmal disorders of consciousness will be considered in senior courses.

Patient position:

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 shortness of breath decreases due to the additional connection of the muscles of the shoulder girdle to exhalation.

Sitting with legs down, head thrown back, with heart failure ( orthopnea ): the stagnation of blood in the lungs decreases, the pulmonary circulation is unloaded, and thus shortness of breath decreases (Fig. 1).

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 diseased side with suppurative lung diseases (bronchiectasis, abscess, gangrene): cough decreases, excretion of foul-smelling sputum.

Fig.1. The position of a patient with chronic heart failure

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”).

Body type- this is a combination of morphological features (height, weight, body shape, muscle development, degree of fatness, skeletal structure) and proportionality (harmony) of physical development.

Patient growth 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 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.

The degree of 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 is a set of morphological and functional features of the organism, 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;

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 supraclavicular 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 hyperfunction of the thyroid gland, and lowered sex glands. 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. In these individuals, the function of the sex glands is slightly increased and the function of the thyroid gland is reduced. More often, a violation of lipid metabolism, a tendency to arterial hypertension and coronary artery disease, cholelithiasis and urolithiasis are detected.

Facial expression - a mirror of the mental and physical state of the patient. Facial expression is an important diagnostic feature in a number of diseases.

Fig.2. Exophthalmos at Rice. 3. Type of patient

thyrotoxicosis myxedema

"Hippocratic face" - typical for patients with peritonitis (inflammation of the peritoneum) or in an agonal state: pale with a bluish tinge, cheekbones and nose are pointed, sunken eyes, an expression of pain, 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 (faciesfthisica): pale, thin face with a bright blush on the cheeks, eyes shining, consumptive blush of a tuberculous patient.

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.

Color (colour) of skin and mucous membranes, depends on: vascular development; conditions of peripheral circulation; melanin pigment content; skin thickness and translucency. Healthy people have flesh-colored, pale pink skin.

Pathological coloration of the skin:

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, pallor of the skin can also occur 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 air temperature, fevers, alcohol intake, carbon monoxide poisoning; with hypertension (on the face); with erythremia (increased levels of red blood cells and hemoglobin in the blood)

bluish coloration (cyanosis). cyanosis happens diffuse (common) 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. 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). At the same time, reduced hemoglobin accumulates in the tissues, giving a blue color to the skin and mucous membranes. Mixed cyanosis carries the features of the central and peripheral.

jaundice . Allocate true Andfalse jaundice. True jaundice is caused by a violation of bilirubin metabolism. According to the mechanism of occurrence, true jaundice is: a) suprahepatic(hemolytic) due to increased breakdown of red blood cells; b) hepatic(with liver damage); V) subhepatic(mechanical) due to blockage of the bile ducts. False jaundice is the result of taking large doses of certain drugs (acrikhin, 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 coloring - Adrenal insufficiency (Addison's disease).

Vitiligo - 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).

Herpetic rash (blistering rash) with influenza, lobar pneumonia, malaria, immunodeficiency states.

Skin scars: 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.

Skin moisture determined by touch. 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).

Dry skin is noted with the loss of a large amount of fluid (with indomitable vomiting, diarrhea, vomiting of pregnant women, diabetes and diabetes insipidus, myxedema, scleroderma, chronic nephritis).

Hair. Violation of hair growth most often indicates a pathology of the function of the sex 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 on the pubis; with syphilis - nested or total alopecia. Male-pattern hair growth (hirsutism) is observed in women with Itsenko-Cushing's disease, tumors of the adrenal glands.

Nails Normally smooth, pink. Thin, brittle, exfoliating nails, spoon-shaped impressions ( kaylonychia), transverse and longitudinal striation on them are observed with iron deficiency anemia, vitamin B12 deficiency, hypo- and hyperfunction of the thyroid gland. In chronic suppurative diseases of the lungs (abscesses, bronchiectasis, tuberculosis), nails appear in the form of "watch glasses".

The development of subcutaneous fat layer can be normal, elevated or reduced. The fat layer can be distributed evenly or its deposition can occur 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.) (Fig. 4). Underdevelopment of subcutaneous fat

Fig.4. Above - alimentary obesity,

below - cancer cachexia

can be due to the constitutional features of the body (asthenic type), malnutrition, dysfunction of the digestive system. Extreme exhaustion is called cachexia (Fig. 4). 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 body mass index (See chapter "Obesity").

Edema- pathological accumulation of fluid in soft tissues, organs and cavities. Distinguished by origin: 1)are common 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 .

Edema is diagnosed using:

examination - the edematous limb is enlarged, its contours are smoothed, the skin is stretched, shiny;

palpation - when pressing with the thumb in the area of the tibia, sacrum, rear of the foot, a hole forms on the skin (Fig. 5);

Fig.5. Palpation diagnosis of edema on the lower leg and sacrum

control weighing of the body in dynamics;

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;

measuring the circumference of the abdomen and limbs in dynamics;

determination of fluid in cavities by palpation, percussion, instrumental (X-ray, ultrasound) methods;

determination of tissue hydrophilicity (tendency to edema) using a sample McClure-Aldrich : 0.1-0.2 ml of physiological sodium chloride solution is injected intradermally in the forearm. The resulting papule should normally resolve no earlier than after 45-50 minutes, and with a tendency to edema - faster.

Table 1 presents data on the most common differential diagnostic signs of cardiac and renal edema.