Первый слайд презентации: Lecture № 1-2
Topic: Introduction to clinical medicine. General conception about diseases of internal organs & tasks of internal medicine. Principles of general visual inspection of a patient: assessment of conscious, position, skin & subcutaneous fat, musculoskeletal system. Lecture № 1-2
Слайд 2: Plan
Introduction to clinical medicine. General conception about diseases of internal organs Tasks of internal medicine. Bases of medical deontology. General visual inspection of a patient.
Internal medicine is one of the majority parts of theoretical & practical medicine, which researches the recognition of internal diseases in there different clinical forms, emerging causes, its pathogenesis, prophylaxis & therapy.
Term “Propaedeutics” means “introduction” or “provisional studying”. The main purposes of the Discipline are To learn how to examine the patient and to interpret its results. To know the diagnostics of symptoms and syndromes. To learn clinical characteristics of some diseases. To know how to write the case report.
Clinical medicine, besides the modern natural scientific base & brilliant cover, has also ancient, often invisible, but powerful the life-giving root — centuries-old, unlimited in volume & variable practice, experience of doctors generation, among them were really talented watchers & genial thinker.
Matvey Yacovlevich Mudrov ( 1776-1831). His contributions to medicine were : He assumed that disease is a result of exposure of man to unfavorable effects of the environment; He was the first to interrogate the patient in order to substantiate the anamnestic method; He developed a planned clinical examination & recording case histories; He followed the principle of individual approach & claimed that the patient should be treated rather than his disease; He also accentuated the great importance of hygiene.
Sergei Petrovich Botkin ( 1832-1889) His contributions to medicine were : He widely introduced the physiological & instrumental investigation in clinical practice; He worked out the theory of disease development, in which the first role was given to the nervous system; He described the series of clinical features in cardiac diseases; He believed that the main task of practical medicine is disease prevention; He was the first to organize out-patient & then hospital treatment free of charge.
Gregory Antonovich Zakharyin (1829-1897) His contributions to medicine were : He worked out in detail the anamnestic method of diagnostics; He worked at the diagnostics of tuberculosis & its classification; He described zones of hypersensitivity of the skin in diseases of internal organs; According to his clinical opinion, the therapy of disease should include hygienic procedures, climate therapy, dietary treatment & medicamentous treatment; Also he proposed treatment with koumiss & mineral water.
Aleksey Alexandrovich Ostroumov ( 1844-1908) His contributions to medicine were : He fought for the connection of theory with practical medicine; He worked out the main principles of the theory of reflex disorders in various organs due to affection of the nervous system; He accentuated the importance of the relationships between man & the environment; He worked out in details the clinic of early tuberculosis; According his opinion individual therapy should be combined with specific treatment of patients.
Vasily Parmernovich Obraztsov (1849-1920) His contributions to medicine were : He developed & improved methods for clinical investigation of patients; In collaboration he worked out criteria of thrombosis of the coronary arteries & proved the possibility of its intravital diagnostics.
Слайд 11: Tasks of the discipline “Introduction to clinical medicine”
Teaching the students of the clinical methods examination. Studying the symptoms, found out by the clinical methods examination — semiotics. Forming the diagnostic conclusions according to data of observation — diagnosis methodic. Studying the private questions of internal diseases — classic current of exact disease. The basic principles of treatment of internal diseases. Admitting to clinical medicine.
Слайд 12: Conception “disease”, “etiology”, “pathogenesis”
Disease ( morbus ) is pathological condition of an organism, connected with damage of organs & tissues by pathogenic factors, i.e. disease is a response of the body to its damage. Etiology ( aetia — «cause» + logos — «studying») is a science about causes of development of diseases.
Слайд 13: Conception “disease”, “etiology”, “pathogenesis”
Pathogenesis ( pathos — «hurt» + genesis — «emerging») is a science about mechanisms of development of diseases & pathological processes. Mainly pathogenesis depends of etiologic factors, which appear the trigger mechanism, but sometimes have determinant meaning during whole the disease.
Subjective & objective symptoms of a disease. Stages of a current disease. Every disease is characterized by symptoms & syndromes typical for it. Symptom ( symptoma — «sign») is a clinical sign of a disease found out by clinical diagnostics. All symptoms are divided on subjective (pathological signs in a patient are felt just by himself) & objective (changes are identified by doctor during examination). There are early & late symptoms according to term of development.
Subjective & objective symptoms of a disease. Stages of a current disease. Syndrome (syndrome — «collection») is a complex of symptoms with the same pathogenesis. In our days there more than 1500 syndromes are known. Concept «syndrome» & «symptom» is not the same with determination of disease as a nosological unit. But often term «syndrome» included to a name of varying nosological units.
Generally, following stages of a disease can be determined : 1. Asymptomatic is preclinical period of a disease. The moment emerging of a disease is couldn’t be fixed for majority of diseases. To a large degree it connected with compensatory-adaptive reactions in an organism & low efficiency of modern laboratory diagnostics ;
Generally, following stages of a disease can be determined : 2. Prodromal is period with the first clinical manifestations. This stage of a disease is not frequently emphasized. Two described stages are the most typical for whole series of diseases, for example, atherosclerosis, and oncologic diseases.
Generally, following stages of a disease can be determined : 3. Period of full clinical-&-anatomic manifestations (Latin - manifestatio - display). Great changes in structure & functions of organs & tissues are noted in that stage.
These periods can be finished by -recovery (get better), -death of an organism -transformation to chronic form.
There characteristics of chronic disease: 1. Getting down is remission (Latin - remissio — «decreasing, reduction») — temporary decreasing of clinical signs; 2. Acute stage is recurrence ( от лат. recidivus — «returning») — return of a disease after evident complete recovery or becoming against the background of relative clinical well-being.
Слайд 21: Concept “ anamnesis ”, “ diagnosis ”
Anamnesis (Greek - anamnesis — «remember») is information taken from a patient or persons surrounding him, about him & development of his disease. There are two types of anamnesis: history of disease (anamnesis morbi ) & history of life (anamnesis vitae).
Слайд 22: Concept “ anamnesis ”, “ diagnosis ”
Diagnosis (Greek - diagnosis — «recognition, definition») is determination of character & essence of a disease on base of patient exanimation. Medical conclusion (diagnosis) is given for disease, physiologic condition (pregnancy) or death cause.
Слайд 23: Concept “ anamnesis ”, “ diagnosis ”
Clinical diagnosis is written to medical card of out-patient or in-patient appears the base for carrying out the treatment. Formulation of diagnosis can be complicated & consists of name of main disease, complication & accompanying pathology.
Слайд 24: METHODS OF CLINICAL EXAMINATION OF A PATIENT
Interviewing the patient Investigation of a patient starts from an interviewing. Interviewing method has name «taking the anamnesis» Interviewing scheme is : Passport data ; Patient’s complaints ( main & additional ) History of disease (anamnesis morbi ); History of life (anamnesis vitae).
Слайд 25: Complaints
Doctor has to ask a patient about his complaints, which makes him to address for medical help. Doctor is a leader in an interview & asks a patient according to special diagnostic algorithms. He finds out complaints & tries to define main complaints, to discover its character. Main complaints are directly connected with damage of some system.
Слайд 26: Complaints
Additional complaints Patient must be asked on special system (Status functionalis ) about change of general condition (loss of body weight, fever, edema etc.), that not to omit any symptom & discover condition of functions of all organs. Condition of each system must be determined:
Слайд 27: Complaints
Respiratory system (cough, dyspnea, chest pain, hemoptysis etc.); Cardiovascular system (chest pain, dyspnea, palpitation, arrhythmia etc.); Digestive system (appetite, nausea, vomiting, sense of burning, pains, diarrhea, constipation etc.); Urinary system (frequent, painful or blocked urination, blood or pathological mixture to urine etc.); Nervous system (sleeping, dizziness, headache, irritability, memory etc.); Sense organs (hearing, vision etc.)
Слайд 28: History of disease (anamnesis morbi )
Have to ask a patient about: When did it start ; How has it started ; How is it developing ; What investigations have done & its results; What treatment has done & its efficiency.
Слайд 29: History of disease (anamnesis morbi )
General conception about disease is formed due to interviewing. Having found out character of its manifestations, first of all necessary to know beginning of a disease: is it acute or gradual, & has a patient have the similar symptoms before. It is necessary to understand causes & conditions of emergence of a disease, its connection with cold or contact with an infected sick. Occupational conditions, regime of work & rest, feeding features are discovered. Different medical manipulations in the past, such as tooth extraction, injections etc., using of medicines have great importance. If patient addresses with these symptoms first time, his action to decrease its manifestations will be found out.
Слайд 30: History of life (anamnesis vitae)
Information about patient’s life must be collected according to special plan: General biographic data : Birth place (some diseases are spread to definite placement, for example, goiter); Age of his parents at the moment of his birthday; Character of pregnancy current (risk of abortion, infective diseases, taking medicines etc.).
Слайд 31: History of life (anamnesis vitae)
Labor (term, full-term degree, what pregnancy & labor was finished by birth of this person); Feeding of newborn (lactation or artificial feeding); General conditions of childhood & juvenility Features of physical & mental development; Puberty period ;
Слайд 32: History of life (anamnesis vitae)
Data about suffered infections : Infective diseases of childhood, degree, complications; Frequent respiratory infections (cold, flu etc.), character of its manifestations, complications. Congenital infective diseases. Trips to Africa, Asia, and South America are defined.
Слайд 33: History of life (anamnesis vitae)
Data about occupational harm: chemical (poisons, pesticides etc.), radiation etc. Data about bad habits: alcoholism, narcotics, smoking, toxicomania. Family & hereditary anamnesis lets give health assessment of relatives & helps to determine the disease in a patient. Allergic anamnesis : Definition immunologic reaction for different pathogenic factor (medicine, meal, dust, specific pollutant). Feedback can be different too: easy vasomotor rhinitis, urticaria, Quince’s edema, and anaphylaxis.
Слайд 34: Conception about objective investigation of a patient
Clinical, or objective, investigation of a patient lets view about general condition of an organism & its separate organs or systems. It includes general visual inspection of a patient; palpation; percussion; auscultation. Other investigative methods to study condition of an organism (respiratory, cardiovascular, digestive, urinary, lymphatic, endocrine, nervous, musculoskeletal systems) are carried out too. The objective methods of investigations are laboratory diagnostics, different functional tests, X-ray, ECG, ultrasound investigation & others.
Слайд 35: Conception about objective investigation of a patient
General visual inspection (Latin - inspectio — «examination, review») is method of objective examination of a patient, which is done generally & according to special plan. Palpation (Latin - palpatio — «touch») is method of examination of patient’s organs by fingers touching. Percussion (Latin - percussio — «tap») is tapping of a patient (by finger or hammer) for determination of internal organs condition of character of percussion sound. Auscultation (Latin - auscultatio — «hearing») is method of examination of patient’s organs (lungs, heart) by hearing of sounds, which appear due to work of those organs.
Слайд 36: General visual inspection
It has to be done only in day lights (natural or artificial). Step by step, patient’s body must be naked & inspected in direct& side lighting. General inspection helps to find out position of a patient, his behavior, condition of skin & visible mucous. Orthopnea is forced sitting position of a person because of great dyspnea in cardiac asthma, for example. If patient suffers of dry pleuritis, he will lie on the damaged side to relieve his pain. If patient suffers of pericardial effusion, he will sit a little flexed forward to relieve his pain too.
Слайд 37: General visual inspection
If patient’s health lets, examination of body & thorax will be executed in vertical position of a patient, & abdomen – in vertical & horizontal position. First of all, general visual inspection has to be effected, then is local: head, face, neck, body, extremities, skin, bones, joints, mucous, hair. General condition is estimated by consciousness, psychological characteristic, position & constitution.
Слайд 38: PATIENT’S CONSCIOUSNESS
Patient’s consciousness can be clear or disturbed. There are follow types of disturbed consciousness: Stupor is condition of stun. Patient orients to environment badly, & answers on questions with delay; Sopor is condition of sleep. Patient goes out of sleep just when somebody shouts or shakes him. Reflexes are kept; Coma is unconsciousness condition, when reactions to a stimulus, reflexes are absent, disorder of important vital functions is great.
Слайд 39: PATIENT’S CONSCIOUSNESS
There are lots of types of coma: Alcoholic coma appears due to alcoholic intoxication; Apoplectic coma is in hemorrhagic stroke; Hypo- & hyperglycemic coma is in disturbance of a pancreas (diabetes mellitus) Hepatic coma is in great dystrophy of a liver (cirrhosis, for example); Uremic coma is in acute toxic damage of kidneys; Epileptic coma is in epileptic attack. Irritative disturbances of consciousness (hallucination, delirium) sometimes appear in mental & infective diseases.
Слайд 40: Position of a patient
There are three types of possible position of a patient: active, passive & forced. Active position is possibility of a patient to spine in a bed & walk. Passive position has an immobile patient without any reaction on environmental events. Forced position takes a patient to relieve his pain (or other problems).
Слайд 41: Constitution of a patient
Estimating the constitution (Latin - habitus — «appearance»), define the constitution, body weight, height of a patient, also their relation (weight/height indexes). There are three main types of constitution: Asthenic is characterized the dominance of the height over the weight. Hypersthenic is characterized the dominance of weight over height. Normosthenic is characterized of proportionality & takes the medium place between asthenic & hypersthenic.
Characteristics of mental development Deformations & anomaly of skull & brain are reflected to mental development. So, oligophrenia (congenital mental retardation), depending of severity divided into three forms : debility ( easy degree ); imbecility ( moderate degree ); idiocy ( severe degree ).
Inspection of a face, its «masks» pronounced asymmetry of a face; micrognathia ( underdevelopment of mandibula ); macrognathia ( overdevelopment of mandibula ); high « gothic » palate ; the splitting of an upper jaw (cleft palate & cleft lip); dysplastic growth of teeth ; malocclusion ; expanded and flattened nasal bridge; hypertelorism (increased distance between the orbits).
Слайд 45: Face can be changed in endocrine diseases:
Acromegaly - enlargement of prominent parts (nose, chin, cheekbone); Myxedema – this face shows decreased function of thyroid gland. It is puffy, because mucous edema, eyes are narrowed, face bars are smoothed, short brows, roses on chicks like in a doll; Bazedov’s face is in a patient with hyperthyroidism; it is mobile, with extended eye gaps, increased bright of eyes, exophthalmia, it is like expression of fear; Moon-face is red, shiny with beard & moustache in a female. It is specific for Cushing’s syndrome.
There are lots of “masks”, which characterize special disease or condition: « Corvizart’s face» in cardiac incompetence (puffy, yellowish-pale, cyanotic, mouth is always opened, lackluster eyes); « Lion face » in leprosy «Parkinson’s mask» is face with poor mimicry in a patient with encephalitis; «Hippocratic face» is in a patient with severe problems of abdominal organs. Specific signs are: concave eyes, peaked nose; skin of face is pallid with bluish tone & covered with drops of a cold sweat.
Further consequentially eyes, eyelids & nose must be inspected; aberration is indicated to create the complete clinical picture of a disease. Inspection of a mouth has to be started from assessment of its form (symmetry of angles), color of lips, rash etc. Then it is necessary to estimate mucous of oral cavity, gingivae, teeth, including caries as source of infection.
Tongue has features in series diseases: Clean, red & wet is in ulcer disease of a stomach; crimson is in scarlet fever; Dry, covered with rifts & dark brown fur is in severe intoxication & infection; its center & root are covered by fur, but margins of tip are clear — in typhoid fever; polished tongue (papillae smoothed) is in pernicious (Addison’s) anemia;
Слайд 59: Inspection of a neck
Pulsation of carotids (aortic incompetence). Swelling & pulsation of jugular veins(tricuspid incompetence) Enlargement of lymph nodes Enlargement of thyroid gland
Слайд 63: Inspection of skin
Color, elasticity, rash, scars etc. Hyperemia can be observed in fever or erythremia. Cyanosis is caused by hypoxia of tissues Rugosity is caused by loss of skin elasticity.
Слайд 68: Layer of subcutaneous fat
It can be increased or decreased. Increased calls obesity. Marginal degree of thinning is cachexia.
Слайд 70: Edema
Develop when fluid goes out of vessels through capillary walls & its accumulation to tissues. There are general & local edema
Слайд 71: Inspection of lymph nodes
It not palpable in norm. Its size changes depending pathologic process from peas till apple
Слайд 72: Inspection of musculoskeletal system
Development of muscular system, different defects of bones (twist, bulging, & others), rickets changes. Configuration of joints must be determined Varicose disease of low limbs, “clubbing finger”, saber-shape of legs & others can be found out too.
Последний слайд презентации: Lecture № 1-2
So, either concept about condition of patient’s organism & determination of correct diagnosis «by first view» can be realized by general visual inspection. Pathological signs, discovered in inspection, give great help in taking of anamnesis & further investigation.