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KHARKIV NATIONAL MEDICAL UNIVERSITY
DEPARTMENT OF PROPEDEUTICS OF INTERNAL MEDICINE N1
PRACTICUMin Propedeutics of Internal Medicine
for 3rd year students of 6th medical faculty
Part 1:
“Main methods of the patient’s examination in internal medicine”
Student ______________________
Group ________
Teacher ______________________
_____________________________
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Practicum in Propedeutics of Internal Medicine. Part 1: “Main methods of the patient’sexamination in internal medicine”: Меthod. instr. for students / Authors. Т.V. Ashcheulova,O.N. Kovalyova, G.V. Demydenko, S.O. Shapovalova, O.A. Kochubiei, O.V. Honchar, S.V.Ivanchenko, A.V. Kozhemyaka, M.A. Vizir. – Kharkiv: KhNMU, 2017. – 63 с.
Authors: Т.V. Ashcheulova O. N. Kovalyova A.V. Demydenko O.A. Kochubiei O.V. Honchar S.V. Ivanchenko A.V. Kozhemyaka M.A. Vizir
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THEMATIC PRACTICAL CLASSES PLAN of Propedeutics to Internal Medicine
Part 1: “Main methods of the patients examination in internal diseases clinics”
Content 1. Introduction to internal medicine. Main rules of inquiry and inspection of the
patients
1. Case history scheme. Inquiry of the patient: patient’s complaints, their detailed
description, questioning on organs and systems.
2. Anamnesis morbi. Anamnesis vitae.
3. General inspection of the patients. Diagnostic significance of symptoms revealed during
patient inspection.
4. Inspection of separate body parts: head, neck, trunk, extremities.
Content 2. Physical and instrumental examination methods of the broncho-pulmonary
system
5. Main complaints and general inspection of the patients with respiratory organs pathology.
Palpation of the chest.
6. Percussion as method of physical examination of the lungs. Comparative percussion of the
lungs technique. Topographic percussion of the lungs.
7. Auscultation as method of physical examination of the lungs. Auscultation of the lungs
technique. The main respiratory sounds.
8. Auscultation of the lungs: additional respiratory sounds (rales, crepitation, pleural friction
sound). Laboratory sputum and pleural fluid analysis. Instrumental methods of respiratory
organs examination.
Content 3. Physical methods of cardiovascular system examination
9. Physical methods of cardiovascular system examination. Inquiry and general inspection of
the patients with cardiovascular pathology. Inspection and palpation of precordial area.
10. Percussion of the heart.
11. Auscultation of the heart. Normal heart sounds, reduplication of the sounds, additional
sounds (triple rhythm, gallop rhythm). Auscultation of the heart: organic and functional heart
murmurs.
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12. Study of arterial pulse and blood pressure.
Content 4. Instrumental methods of cardiovascular system examination
13. Electrocardiographic method of cardiac function examination. Technique of ECG registration
and reading.
14. ECG signs of hypertrophy of heart atriums and ventricles.
15. The main ECG syndromes of the myocardium damage (ischemia, injury, necrosis). ECG in
myocardial infarction.
16. Electrocardiographic examination of patients with automaticity and excitability function
alterations.
17. Electrocardiographic examination of patients with conductivity function alterations.
Content 5. Main examination methods of digestive organs and kidneys.
18. Inquiry and inspection of the patients with digestive organs diseases. Inspection and
superficial palpation of the abdomen.
19. Deep, sliding, methodic palpation of intestines and stomach.Deep, sliding, methodic
palpation of liver, spleen. Liver percussion.
20. Inquiry and inspection of the patients with renal diseases. Instrumental and laboratory
methods of examination of urinary system.
21. Analysis of urine
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Part 1:
“Main methods of the patients examination in internal diseases clinics”
Content 1. Introduction to internal medicine. Main rules of inquiry and inspection.
Topic 1. Case history scheme. Inquiring of the patient
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Propedeutics (Gk propos – introduction) to internal diseases is_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Diagnostics (Gk dia – through, gnosis – knowledge) is___________________________________________________________________________________________________________________________
Diagnosis is____________________________________________________________________________________________________________________________________________________________Preliminary diagnosis is based on_______________________________________________________________________________________________________________________________________________Clinical diagnosis is based on__________________________________________________________________________________________________________________________________________________Final diagnosis is based on____________________________________________________________________________________________________________________________________________________
Diagnosis has the following structure:1. ______________________________________________________________________2. ______________________________________________________________________3. ______________________________________________________________________
Symptom___________________________________________________________________________Subjective and objective symptoms are differentiated.
Subjective symptoms are those that_____________________________________________________________________________________________________________________________________________Objective symptoms are those that______________________________________________________________________________________________________________________________________________
The symptoms are divided into pathological symptoms (pain, elevated temperature) andcompensatory symptoms (tachycardia, tachypnoea, hypertrophy).
According significance symptoms can be ______________________________________________. According to time symptoms are _____________________________________________________According to prognosis symptoms are _________________________________________________.
Syndrome is defined as_________________________________________________________________________________________________________________________________________________Symptomocomlex is defined as____________________________________________________
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_____________________________________________________________________________________
CASE HISTORYA. SUBJECTIVE EXAMINATION1) __________________________________________________________________________________2) __________________________________________________________________________________3) __________________________________________________________________________________4) __________________________________________________________________________________5) __________________________________________________________________________________6) __________________________________________________________________________________B. OBJECTIVE EXAMINATION1) ___________________________________________________________________________________2) ___________________________________________________________________________________3) ___________________________________________________________________________________4) ___________________________________________________________________________________5) ___________________________________________________________________________________C. BACKGROUND FOR THE PRELIMINARY DIAGNOSISD. PATIENT’S ADDITIONAL EXAMINATION PLAN AND ANALYSIS RESULTSE. BACKGROUND AND STATEMENT OF CLINICAL DIAGNOSIS
Passport part 1. ______________________________________________________2. ______________________________________________________3. ______________________________________________________4. ______________________________________________________5. ______________________________________________________6. ______________________________________________________7. ______________________________________________________
Patient’s present complains
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Questions about general condition
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Questions on organs and systems
1. CENTRAL NERVOUS SYSTEM_______________________________________________________________________________________________________________________________________________________
2. RESPIRATORY SYSTEM________________________________________________________________________________________________________________________________________________________
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Questions on organs and systems
3. CENTRAL NERVOUS SYSTEM____________________________________________________________________________________________________________________________________________
4. RESPIRATORY SYSTEM________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. CARDIOVASCULAR SYSTEM__________________________________________________________________________________________________________________________________________________________________________________________________________________
4. DIGESTIVE SYSTEM__________________________________________________________________________________________________________________________________________________________________________________________________________________
5. URINARY SYSTEM____________________________________________________________________________________________________________________________________________
8. LOCOMOTOR SYSTEM____________________________________________________________________________________________________________________________________________
Topic 2. Anamnesis morbi. Anamnesis vitae.
Anamnesis morbi
1. _______________________________________________________________________________________________________________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnesis vitae
1) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________
2) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________
3) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________
4) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Topic 3-4.General inspection of the patients.
GENERAL INSPECTION
Status praesens is:__________________________________________________________________________________________________________________________The criteria of patient’s condition are ________________________________________________________________________________________________________________________________________________________________________________Good patient’s condition is characterized______________________________________________________________________________________________________________________________________________________________________________Satisfactory patient’s condition (status morboacili) is characterized:__________________________________________________________________________________________________________________________________________________________Moderate condition (status ingravescens) is characterized:________________________________________________________________________________________________________________________________________________________________Severe condition (status morbogravi) is characterized:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Extremely Severe condition (status gravissimus) is characterized:________________________________________________________________________________________________________________________________________________________________________________________________________________________________Consciousness (sensorium) may be:________________________________________The deranged consciousness is divided into____________________________________________________________________________________________________________________________________________________________________________Possible causes of deranged consciousness are:___________________________________________________________________________________________________The forms of excited consciousness:________________________________________Twilight state is characterized:__________________________________________________________________________________________________________________Delirium is characterized:______________________________________________________________________________________________________________________The forms of excited consciousness are:__________________________________________________________________________________________________________Complete the following table:
The forms of depressed consciousnessForms Definition State
Cloudiness
Stupor
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GENERAL INSPECTION
Sopor
Coma
What kinds of coma do you know? Give examples.____________________________________________________________________________________________________________________________________________________________________
Define and mark the type of forced posture for each patient
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
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______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
GENERAL INSPECTION
Gait. Gait is________________________________________________________________________________________________________________________________Spastic gait is characterized:________________________________________________________________________________________________________________________________________________________________________________________Paretic gait is characterized:_______________________________________________________________________________________________________________________________________________________________________________________Hemiplegic/circumductive gait is characterized:____________________________________________________________________________________________________Doll’s/puppet gait is characterized:___________________________________________________________________________________________________________________________________________________________________________________Peroneal gait is characterized:_______________________________________________________________________________________________________________________________________________________________________________________Cerebellar gait (wobbly/tottering/reeling gait) is characterized:_________________________________________________________________________________________Describe the face in patients with diseases of respiratory system:_________________facies pneumonica___________________________________________________________________________________________________________________________facies tuberculous___________________________________________________________________________________________________________________________facies asthmatica____________________________________________________________________________________________________________________________facies adenoidea_______________________________________________________
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GENERAL INSPECTION
_____________________________________________________________________Describe the face in patients with diseases of cardiovascular system:______________facies aortale__________________________________________________________facies mitrale_________________________________________________________________________________________________________________________facies Corvisari_____________________________________________________________________________________________________________________________facies plethorica_____________________________________________________________________________________________________________________________Describe the face in patients with endocrine disorders:__________________________facies acromegalica____________________________________________________________________________________________________________________facies in patients with Cushing’s syndrome__________________________________________________________________________________________________facies myxoedemica___________________________________________________________________________________________________________________facies basedovica____________________________________________________________________________________________________________________Describe the face in patients with diseases of kidney:___________________________facies nefritica______________________________________________________________________________________________________________________________Describe the face in patients with diseases of digestive system:__________________facies Hyppocratica_______________________________________________________________________________________________________________________________________________________________________________________________Describe the face in patients with diseases of nervous system:___________________facies amimica________________________________________________________risus sardonicus_____________________________________________________________________________________________________________________________facies asymmetrica_____________________________________________________Describe the face in patients with infectious disease:___________________________facies fibrilis________________________________________________________________________________________________________________________________facies in patients with parotitis:_________________________________________________________________________________________________________________Describe the face in patients with diseases of blood system:_____________________facies anemic_______________________________________________________________________________________________________________________________facies as a “wax-doll”____________________________________________________
Define and mark a facies in patients with different diseases
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GENERAL INSPECTION
____________________________________________________________________________________________________________________________Color of the skin. Give examples of diseases which are characterized by the followingchanges in skin color:Pale color of the skin (cutis pallida)___________________________________________________________________________________________________________________________________________________________________________________Red color of the skin (cutis rubra, erythema)______________________________________________________________________________________________________Cyanosis (cutis cyanotica)_____________________________________________________________________________________________________________________Yellow skin and mucosa (cutis icterica, s. icterus)___________________________________________________________________________________________________Brown or bronze skin__________________________________________________________________________________________________________________Eruption of the skin. Herpetic lesions (herpes) is_______________________________________________________________________________________________________________________________________________________________________Hemorrhage lesions are of different forms:___________________________________Hematoma is_______________________________________________________________________________________________________________________________Erythema_____________________________________________________________Teleangioectasia is__________________________________________________________________________________________________________________________Ulcer (ulcus) is______________________________________________________________________________________________________________________________Abscess is_________________________________________________________________________________________________________________________________Scars is___________________________________________________________________________________________________________________________________Turgor and elasticity of the skin.Turgor (turgor) of the tissue depends on__________________________________________________________________________________________________________
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GENERAL INSPECTION
_____________________________________________________________________Moisture of skin: the reasons of alteration (dryness / swetness)____________________________________________________________________________________The skin derivates. The following pathological changes of nails are of great diagnosticmeaning:_____________________________________________________________Nails in a form of “watch glass” are characterized___________________________________________________________________________________________________Hair. Abnormally excessive hair growth may be present:_____________________________________________________________________Deficient hair growth is characteristic of:__________________________________________________________________________________________________________Subcutaneous fat. Where to measure:__________________________________________________________________________________________________________In normosthenic person thickness of skinfold_________________________________Ginoid type of obesity is characterized___________________________________________________________________________________________________________Android type of obesity is characterized__________________________________________________________________________________________________________Edema. According to the pathogenic and location factors, edema may be:_______________________________________________________________________________The main reasons of general edema are:_________________________________________________________________________________________________________General edema is characterized:________________________________________________________________________________________________________________The main reasons of local edema are:____________________________________________________________________________________________________________
Identify and write the possible cause of edema in pictures
__________________________________________________________________________________________________________________________________________
_____________________________________________________________________
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_____________________________________________________________________Lymph nodes. Groups of regional lymph nodes include:_____________________________________________________________________________________________The examination of lymph nodes in definite order:______________________________________________________________________________________________________________________________________________________________________The main causes of enlargement of the lymph nodes:________________________________________________________________________________________
Diagnostic meaning of enlarged lymph nodes localization.
Localization DiseasesOccipital
Submandibular
Axillary
Inguinal
Cubital (local)
Thyroid gland. Inspection_______________________________________________Palpation__________________________________________________________________________________________________________________________________Muscular system. _____________________________________________________Development__________________________________________________________sex and age correspondence_____________________________________________tenderness____________________________________________________________muscular tone_________________________________________________________Muscular dystrophy is_______________________________________________________________________________________________________________________Causes of muscular weakness are______________________________________________________________________________________________________________Cramps (spasmus) is_________________________________________________________________________________________________________________________Paralysis is________________________________________________________________________________________________________________________________Bones and joints system. Symmetry of joints, shape; Configuration (normal, deformed, edema);Hyperemia of skin and local hyperthermia; Movements (active, passive, free or limited); Palpable tenderness related to passive movements (indicate joints);Crackles, fluctuation._________________________________________________________________________________________________________________________________
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GENERAL INSPECTION
Content 2. Physical and instrumental examination methods of the broncho-pulmonarysystem Topic 5-8.
Inquiring___________________________________________________________________The main complaints of the patients with disease of the respiratory system are: ______________________________________________________________________________________________________________________________________Additional complaints: _______________________________________________________________________________________________________________________________________________________________________________________Dyspnoea: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Conditions causing dyspnoea classified by rate of onset№ Categories Causes 1. Dramatically sudden: over
minutes
2. Acute:over hours
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3. Subacute:over weeks
4. Chronic:over month or years
5. Intermittent:Episodic breathlessness
Cough_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Haemoptysis__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Chest pain____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INSPECTIONOF THE CHEST
Position of the patient: ______________________________________________________________________________________________________________________________________________________________________________________Sputum analysis:
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INSPECTIONOF THE CHEST
________________________________________________________________________________________________________________________Complete the anatomy points of the chest wall. Anterior view
Complete the anatomy points of the chest wall. Posterior view
Write down topographical lines:Anterioir surface: 1
2
3
4
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Lateral surface:1
2
3
INSPECTIONOF THE CHEST
Posterior surface:1
2
3
Point apex of the lung and lobes
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Write down regions: ______________ region – above clavicles;
_______________region – below clavicle;
______________ region – above scapulae;
_________ region – between the scapulae;
_____ _________ region – below scapular;
____________________the lowerst points;
________________________ lungs fields.
Static inspection
Static inspection includes:____________________________________________________________________________________________________________________________________________________________________________________The shape of the chest is described in that order:____________________________1._________________________________________________________________2. ________________________________________________________________3. ________________________________________________________________4. ________________________________________________________________5. ________________________________________________________________6.
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________________________________________________________________7.
Physiological shapes of the chest: 1________________________________________________________________________________________________________________________________________________________________________________________________________2______________________________________________________________________________________________
_______________________________________ 3_____________________________________________________________________________________________________________________________________________________________________________________________________Pathological shapes of the chest __________________________________________________________________________________________________________
Static inspection
Name and describe the shapes of the chest____________________________________
___________________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Types of spine deformities are distinguished:Scoliosis – _________________________________________________________.Kyphosis – _________________________________________________________.Lordosis – _________________________________________________________.Kyphoscoliosis – ___________________________________________________._________________________________________________________________________________________________________________________________________________________________________________________________________The symmetry of the chest. ________________________________________________________________________________________________________________Enlarged volume of one half of the chest ____________________________________________________________________________________________________________
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__________________________Decreased volume of the one part of the chest ______________________________________________________________________________________________________________________________________
Dynamic inspection of the chest
Dynamic inspection of the chest
Dynamic inspection includes____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Types of respiration: _____________________________________________________________________________________________________________________Normal breathing rate:____________________________________________________________________________________________________________________Specify the breathing type______________________________________________
__________________________________________________________________
__________________________________________________________________
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PALPATION OF THE CHEST
PERCUSSION OF THE LUNGS
Describe type of breathing and pathological state, when it observed
_________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________
PALPATION OF THE CHESTPalpation of the chest has four potential uses:
1. ______________________________________________________;
2. ______________________________________________________;
3. ______________________________________________________;
4. ______________________________________________________.
Vocal fremitus is increased____________________________________________
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PERCUSSION OF THE LUNGS
______________________________________________________________________________________________________________________________________Vocal fremitus is decreased______________________________________________________________________________________________________________Vocal fremitus can be absent_____________________________________________________________________________________________________________
PERCUSSION OF THE LUNGSThe task of comparative percussion is _______________________________________________________________________________________________________Numerate the order of comparative percussion in anterior, lateral, posterior view.
Anterior view Posterior view Lateral view
Comparative percussion helps to determine whether theunderlying tissues are air-filled, fluid-filled, or solid. The commoncause of percussion changes include: ______________________________________________________
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______________________________________________________________________________________________________________________________________________________________________________________________________________________
Characteristics of the percussion soundsSound Relative
intensityRelative
pitchRelativeduration
Examplelocation
Pathologicalexamples
Clearpulmonary(resonance)
Loud Low LongNormallungs
---
Intermediate
Higher
Bandbox(hyper-resonance)
Longer
Dullness Soft (Medium)
High (Medium)
Tympany
Metallic
Cracked-pot
Intermediate pulmonary sound causes include:1. ________________________________________
__________________;2. ________________________________________
__________________;3. ________________________________________
__________________;4. ________________________________________
__________________;5. ________________________________________
__________________;Dullness appear when solid tissue replaces air-containing lungs inconditions as:
1. ____________________________________________________________;
2. ____________________________________________________________;
3. ____________________________________________________________;
4. ____________________________________________________________.Bandbox sound____________________________________________________.
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Tympany suggests __________________________________________________
Topographic percussion of the lungs: _____________________________________________________
_______; _____________________________________________________
_______; _____________________________________________________
_______.Lower borders of the lungs in normosthenic persons.
Topographic lines Right lung Left lungParasternal Midclavicular Anterior axillaryMidaxillary 8th interspacePosterior axillaryScapular Paraspinal
AUSCULTATION OF THE LUNGS
AUSCULTATION OF THE LUNGSAuscultation includes:
1.
____________________________________________________________;2.
____________________________________________________________.
Lung sounds
Main respiratory (breath) sounds Adventitious (added) sounds
Specify the type of breathing and its changes.
Pathologically decreased vesicular breathing observes in:I. abnormal generation of breath sounds occurs in:
______________________________________________________
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AUSCULTATION OF THE LUNGS
____________________________________________________________________________________________________________
__________________________________II. abnormal transmission of breath sounds results
from:
______________________________________________________________________________________________________________________________________
Pathologically increased vesicular breathingoccurs______________________
__________________________________________________________________
Specify the breathing and conditions when it observed ____________________________________________________________________________________________________________________________________________________________________________________________________________________
Specify the breathing, points of auscultation, origin ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pathological bronchial breathing is observed in consolidation of the pulmonary tissue in:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________;in formation of an empty cavity in the lung communicated with alarge bronchus:_________________________________________________________________________________________________________________________________________________________________________________________________________Amphoric respiration is heard in the presence
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AUSCULTATION OF THE LUNGS
of_________________________________________________________________________________________________________________________________________________________________Bronchovesicular or mixed breathing___________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sound Duration Intensity ofthe
expiratorysound
Pitch ofthe
expiratory sound
Examplelocation
Pathologicexample
Vesicular
Inspiratory soundslastlongerthanexpiratory one
Soft Low
Over mostof bothlungs
Decreased
vesicular
Increased
vesicular
Cogwheel
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SPUTUM ANALYSIS
Bronchial
Broncho-vesicular
Adventitious (added) sounds are:____________________________________________________________________________________________________________________________________________________________________________Differential diagnosis of adventitious sounds
Signs ……..rales ……..rales Crepitation
Relation to therespiratory
phases
Best heardduring expiration
Change duringcough
Pressure withthe stethoscope
Without changes
Breathing movement with close nose and mouth
Absent
SPUTUM ANALYSISClinical sputum analysis includes: _________________________________________________________________________________________________________In macroscopic study assessed __________________________________________
Sputum revealed in macroscopic examination
Character
Consistency
Color Odor Layerness
Disease
Mucous Glass-like
Muco-purulent
Odorless
Puro-mucous Purulent
Mucous Absent
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bloody
Muco-purulentbloodyBloody Liquid,
foamyOdorless Absent Pulmonary
hemorrhage: in tuberculosis, wounds, lung tumor
Serous Transpa-rentyellowish
Odorless
Absent Pulmonary edema
Sputum elements in microscopic study
Cellular elements Fibrous elements Crystal elements
Bacterioscopic study______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Disease Sputumamount
Sputumcharacter
Macroscopic study
Microscopic study
Acutebronchitis
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STUDY OF THE PLEURAL FLUID
STUDY OF THE PLEURAL FLUID
Chronicbronchitis
Various Leucocytes – large amount; erythrocytes, macrophages
Bronchi-ectasis
Bronchialasthma
Mucous
Lobarpneumoni
a
Fibrin clots, changed blood
Pulmonary abscess
Pulmonary
tuberculosis
Broncho-pulmonary tumor
STUDY OF THE PLEURAL FLUIDMacroscopic
study:______________________________________________________________________________________________
______________________________________________________________
_____________Character. _____________________________________________________________________________________________________________________________Transudates____________________________________________________________________________________________________________________________Exudates_______________________________________________________________________________________________________________________________Transparency__________________________________________
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________________________________________________________________________________Color____________________________________________________________________________________________________________________________________________________________________________________________________Consistency______________________________________________________________________________________________________________________________________________________________________________________________
Odor__________________________________________________________________________________________________________________________________Relative density________________________________________________________________________________________________________________________
Chemical study Protein level____________________________________________________________________________________________________________________________Rivalt’s reaction_______________________________________________________________________________________________________________________Lucaerini test._________________________________________________________________________________________________________________________
Microscopic studyErythrocytes______________________________________________________
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_____________________________________________________________________Leucocytes___________________________________________________________________________________________________________________________Mesothelium cells______________________________________________________________________________________________________________________Tumor cells.__________________________________________________________________________________________________________________________
Cytology Neutrophils____________________________________________________________________________________________________________________________Lymphocytes__________________________________________________________________________________________________________________________Eosinophils___________________________________________________________________________________________________________________________Macrophages__________________________________________________________________________________________________________________________Mesothelial cells______________________________________________________________________________________________________________________Malignant cells.________________________________________________________________________________________________________________________
Bacterioscopic studyTransudates______________________________________________________
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_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Exudates_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Content 3. Physical methods of cardiovascular system examination. Topic 9-12.
INQUIRY The main complaints of the patients with cardiovascular pathology are:____________________________________________________________________________________________________________________________________________________________________________________________________________________Additional complaints: _______________________________________________________________________________________________________________________________________________________________________________________Pain in the heart region___________________________________________________________________________________________________________________Typical anginal pain:______________________________________________________________________________________________________________________Atypical anginal pain:_____________________________________________________________________________________________________________________Non-anginal pain:________________________________________________________________________________________________________________________Intermissions____________________________________________________________________________________________________________________________Palpitation______________________________________________________________________________________________________________________________Dyspnea_______________________________________________________________________________________________________________________________Asphyxia_______________________________________________________________________________________________________________________________Cough______________________________________________________________
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___________________________________________________________________Hemoptysis_____________________________________________________________________________________________________________________________Edema________________________________________________________________________________________________________________________________Syncope_______________________________________________________________________________________________________________________________
GENERAL INSPECTION
Position of the patient:______________________________________________________________________________________________________________________________________________________________________________________Coloration of the skin:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Specific signs:________________________________________________________Facies mitrale___________________________________________________________________________________________________________________________Facies Corvisarti:________________________________________________________________________________________________________________________Stokes’ collar:___________________________________________________________________________________________________________________________
Edema________________________________________________________________________________________________________________________________
Cardiac edema Renal edemaTypical location
Palpatory characteristicsSkin in edematous areaTime of appearence
INSPECTION OF PRECORDIAL REGION
Cardiac hump___________________________________________________________________________________________________________________________Cardiac beat____________________________________________________________________________________________________________________________Apex beat______________________________________________________________________________________________________________________________Visible pathological pulsations_________________________________________________________________________________________________________________________________________________________________________________
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___________________________________________________________________
PALPATION OF PRECORDIAL REGION
Apex beat______________________________________________________________________________________________________________________________
1 - left midclavicular line; 2 – left anterior axillary line; 3 – line of displacement.Sign the variants of AB location and describe their diagnostical significance:A:____________________________________________________________________________________________________________________________________B:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________D:_______________________________________________________________________________________________________________________________________________________________________________________________________ Area of the AB: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Height of the AB: ________________________________________________________________________________________________________________________
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______________________________________________________________________________________________________________________________________Strength of the AB: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Cat’s purr symptom: ___________________________________________________
Systolic DiastolicApex of the heart
2nd right intercostal space
2nd left intercostal space
Lower right sternal edge
PERCUSSION OF THE HEART
Mark the areas of different percussion sounds:1 - ___________________________________________________________________2 - ___________________________________________________________________3 - ___________________________________________________________________
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RELATIVE CARDIAC DULLNESS
Fill in the normal borders position:
Dislocation of relative cardiac dullness borders:To the right: ________________________________________________________________________________________________________________________________________________________________________________________________________To the right and upward: _________________________________________________________________________________________________________________________________________________________________________________________________________To the right and upward: ________________________________________________________________________________________________________________________________________________________________________________________________________To the left: ________________________________________________________________________________________________________________________________________________________________________________________________To the left and downward: _________________________________________________________________________________________________________________________________________________________________________________________________________To all sides: _________________________________________________________________________________________________________________________________________________________________________________________________________
Mark the structures forming the cardiac contour:1 - ______________________________2 - ______________________________3 - ______________________________4 - ______________________________5 - ______________________________6 - ______________________________7 - ______________________________8 - ______________________________
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Waist of the heart: ______________________________________________________________________________________________________________________________________Sign the variants of cardiac contour and their diagnostical significance:
_________________________________________________________________________________________________________________________________________________________________________________________________________
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HEART SOUNDS
Sign the components of normal heart sounds:
Sign the heart valves projections and points of optimal auscultation:1 - ________________________ ________________________2 - ________________________ ________________________3 - ________________________ ________________________4 - ________________________ ________________________5 - ________________________ ________________________
1 - __________________________2 - __________________________3 - __________________________4 - __________________________5 - __________________________6 - __________________________7 - __________________________8 - __________________________
1 - __________________________2 - __________________________3 - __________________________4 - __________________________
S1
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HEART MURMURS
Sign the components of auscultation patterns with additional heart sounds and their diagnostical significance:
____________________________ _______________________________
____________________________ _______________________________
S2
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Mark the variants of heart murmurs in relation to cardiac cycle:
____________________________________________________________________________________________
____________________________________________________________________________________________
Sign the diastolic significance of main variants of cardiac murmurs:
Auscultatoryareas
Murmur Heart valvular disease
Heart apex
Systolic
Diastolic
________________________
________________________
Second intercostal space at the right sternal edge
Systolic
Diastolic
________________________
________________________
Second intercostal space at the left sternal edge
Systolic
Diastolic
________________________
________________________
Base of the xiphoid
Systolic
Diastolic
________________________
________________________
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ARTERIAL PULSE
Fill in the table – define the charachteristics that are evaluated during arterial pulse study, describe the normal findings and possible pathology:
Examinationsequence
Factors thatcause pulse
characteristicsNorm Pathology
Symmetry
Rhythm
Rate (PR)
Relation between PR and HR
Tension
Volume
Size
Speed
Shape
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BLOOD PRESSURE
Describe the technique of blood pressure measurement, mark (with the arrows) the points of SBP and DBP detection ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Finish the classification of blood pressure according to WHO (fill in the table):
Level of blood pressure SBP (mmHg) DBP (mmHg)
< 120 < 80
< 130 < 85
130-139 85-89
Hypertension:
I grade (________________________________)
Subgroup: _____________________________
II grade (_______________________________)
III grade (______________________________)
_______________________________________
Subgroup: _____________________________
140-159
140-149
160-179
≥ 180
≥ 140
140-149
90-99
90-94
100-109
≥110
≤ 90
< 90
Content 4. Instrumental methods of cardiovascular system examination. ECG. Topic 13-17.
ECG is___________________________________________________________________________________________________________________________________________________________________________________________________Fillthe parts of the conduction pathways by numbers
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1_________________________________________________2_________________________________________________3_________________________________________________4________________________________________________5____________________________________________________________________________6______________________________________________________________________________________________________________________________Automacity_________________________________________________________________________________________________________________________________________________Conductivity___________________________________________________________________Refractoriness ________________________________________________________________________________Depolarization____________________________________________________________________________________________________________Repolarization____________________________________________________________________________________________________________
ECG Registration 12 leads:3______________________________________________________________________________________________3______________________________________________________________________________________________6_____________________________________________________________________________________________________________________________________________
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________________________________________V1__________________________________________________________________________________V2_____________________________________________________________________________________V3_____________________________________________________________________________________V4_______________________________________________________________________________V5______________________________________________________________________V6______________________________________________________________________________________________________________________________________________________________________________________________________________________Normal ECG
_________Right leads______________________________Left leads_______________________________________________________________________________________________________________________________________________________________________________________________________________________
Speed of ECG recording______________________________________________
Specify the ESC recording speed________________________________________
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___________50 mm/sec________25 mm/secECG
Wright down all the waves, intervals, segments on ECG
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________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________
P wave
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PQ segment -______________________________
______________________________________________________________________________________PQ interval_________________________________________________________________________________________________________________________________________________________________
QRS complex -_______________________________________________________________________________________________________________QRSinterval________________________________________________________________________
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__________________________________________________________________________________
STsegment_______________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Twave__________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Interpretation of the ECG1.___________________________________________________________________________2. ___________________________________________________________________________3. ___________________________________________________________________________4.___________________________________________________________________________5.___________________________________________________________________________6.___________________________________________________________________________7.___________________________________________________________________________8.___________________________________________________________________________
Determine regularity of the rhythm
_____________________________________________________________________________
Sinus rhythm criteria
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_______________________________________________________________________________________________________________________________________Nonsinus rhythm (possible types)_-_____________________________________________________________________________________________________________________________Measurement of the ECG Amplitude (voltage)____________________________________________________________________________________________________________________
Determine the amplitude._left________________________right_______________________Specify electrical axis of the hearta)_______________________b)________________________c)______________________
P-mitrale-___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
P-pulmonale-_______________________________________________________________________________
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__________________________________________________________________________________________________________________________________________
P-cardiale-_______________________________________________________________________________________________________________________________________________Common signs of ventricular hypertrophy_________________________________________________________________________________________________________________________________________________________Left Ventricular Hypertrophy
LV Hypertrophy criteria_________________________________________________________________________________________________________________________________________________________________________________________________________________Right Ventricular Hypertrophy
RV Hypertrophy criteria_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Coronary Artery DiseaseStages of MI: ischemia, injury, necrosisMyocardial infarction: what, when, where
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Ischemiasigns________________________________________________________________Injurysigns___________________________________________________________________Necrosissigns_________________________________________________________________Stages of the myocardial infarction:Acute________________________________________________________________Evolutionary__________________________________________________________Recovery_____________________________________________________________Stabilized_____________________________________________________________Location of the myocardial infarction:Anterior______________________________________________________________Septal________________________________________________________________Posterior_____________________________________________________________Apical________________________________________________________________Lateral_______________________________________________________________Diafragmal____________________________________________________________
Cardiac ArrhythmiasNormal Sinus Rhythm Cardiac Arrhythmias
1. The SA node is pacemaker. Heartrate: _______beats per minute.
1.
2. Regular cardiac rhythm: 2. ____________ cardiac rhythm: the R-R intervals ________________________
3. The P waves originate from 3. The P waves originate from
4. The relationship of the P wave andthe QRS complex:
4.
5. The conduction to the ventricles is1:1 (equal amount).
5.
6. Constant and normal duration ofP_________________________________________
6.
Abnormalities of the Impulse Formation
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A. Altered Automaticity of the Sinoatrial Node (NomotopicArrhythmias).
• 1.__________________________________________________________________
• 2.__________________________________________________________________
• 3.__________________________________________________________________
• 4.__________________________________________________________________
B. Increased Automaticity of an Ectopic Pacemaker• 1._____________________________________________________
_____________• 2._____________________________________________________
_____________• 3._____________________________________________________
_____________• 4._____________________________________________________
_____________C. Ectopic (heterotopic) Arrhythmias caused by increasedexcitability of the myocardium
• __________________________________________________________________• __________________________________________________________________• __________________________________________________________________
II. Abnormalities of Conduction• 1._____________________________________________________
___________• 2._____________________________________________________
___________• 3.
_______________________________________________________________• 4.
_______________________________________________________________:• ________________________________________
______________• ________________________________________
______________
Altered Automaticity of the Sinoatrial Node (NomotopicArrhythmias)Sinus Tachycardia
• 1.________________________________________________________________________
• 2.________________________________________________________________________
• 3._______________________________________________________________________
• 4._______________________________________________________________________
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Sinus Bradycardia
• 1.________________________________________________________________________
• 2.________________________________________________________________________
• 3._______________________________________________________________________
• 4._______________________________________________________________________
Sinus Arrhythmia
• 1.________________________________________________________________________
• 2.________________________________________________________________________
• 3._______________________________________________________________________
• 4._______________________________________________________________________
Sick Sinus Syndrome• 1._____________________________________________________
___________________• 2._____________________________________________________
___________________• 3.
_______________________________________________________________________• 4.
_______________________________________________________________________
Increased Automaticity of an Ectopic PacemakerAtrial Rhythm• 1._____________________________________________________
___________________• 2._____________________________________________________
___________________• 3.
_______________________________________________________________________• 4.
____________________________________________________________________________________________________________________________________________________
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Junctional (AV) Rhythm
• 1.________________________________________________________________________
• 2.________________________________________________________________________
• 3._______________________________________________________________________
• 4._______________________________________________________________________
_____________________________________________________________________________Ventricular or Idioventricular Rhythm
• 1.________________________________________________________________________
• 2.________________________________________________________________________
• 3._______________________________________________________________________
• 4._______________________________________________________________________
_____________________________________________________________________________Wandering Pacemaker• 1._____________________________________________________
___________________• 2._____________________________________________________
___________________• 3.
_______________________________________________________________________• 4.
_______________________________________________________________________
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Ectopic (heterotopic) Arrhythmias caused by increasedexcitability of the myocardium
Re-entry mechanism________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Premature Atrial Contraction______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Junctional Premature Contractions_____________________________________
____________________________________________________________________________________________________________________________________________________Ventricular Premature Contractions____________________________________
________________________________________________________________________________________________________________________________________________
Unifocal PVC__________________________________________________________________________________________________________________________________________________________Multifocal PVC__________________________________________________________________________________________________________________________________________________________Ventricular bigeminy_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ventricular Trigeminy_____________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________Group Ventricular Premature Contractions_______________________________________________________________________________________________________________________
-_________________________________________________________________________________________________________________________________________________________________________________________________________________
Paroxysmal Tachycardia1____________________________________________________________________________2____________________________________________________________________________3____________________________________________________________________________Write down what kind of paroxysmal tachycardia is that&_____________________________________________________________________________
Ventricular Flutter and Fibrillation
1___________________________________2___________________________________3_______________________________________________________________________Atrial Flutter1____________________________________________________________________________2____________________________________________________________________________3____________________________________________________________________________
Atrial fibrillation1____________________________________________________________________________2____________________________________________________________________________3____________________________________________________________________________
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Abnormalities of the Impulse ConductionHeart block________________________________________________________________________________________________________________________________________________________Incomplete block________________________________________________________________________________________________________________________________________________________Complete heart block________________________________________________________________________________________________________________________________________________________Sinoatrial Block
________________________________________________________________________________________________________________________________________________________Atrioventricular Block________________________________________________________________________________________________________________________________________________________The First-Degree AV Block _____________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
Second-Degree AV Block________________________________________________________________________________________________________________________________________________________Mobitz (Wenchenbach) typeI.__________________________________________________
____________________________________________________________________________________________________________________________________________________________
Mobitz type II_______________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
Type III second-degree AV block or incomplete AV
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block______________________________________________________________
_____________________________________________________________________________________________________________________________
Third-Degree AV block or complete AVblock_____________________________________
__________________________________________________________________________________________________________________________________________________________________________________________Bundle-branch block
_______________________________________________________________________________________________________________________________ Right BBBLeft BBB___________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Find outRight BBBAndLeft BBB←
Differences between Bundle branch block and ventricular rhythm________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ventricular PreexcitationSyndromes_____________________________________________ECG signs of CLC syndrome____________________________________________________________________________________________________________________________________________________ECG signs of WPW syndrome____________________________________________________________________________________________________________________________________________________The long QT-syndrome__________________________________________________________________________
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__________________________________________________________________________
Give a conclusion about ECG
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Content 5. Main examination methods of digestive organs and kidneys.
The most common complaintsof the patients with the diseases of digestive organs are:
1.___________________________________________________________________________2.___________________________________________________________________________3.___________________________________________________________________________4.___________________________________________________________________________5.___________________________________________________________________________6.___________________________________________________________________________7.___________________________________________________________________________8.___________________________________________________________________________9.___________________________________________________________________________10.__________________________________________________________________________
Overview of approach to patients with common gastrointestinal disorders
Site of disorder Common symptoms Possible physical signs
EsophagusDysphagia Odynophagia Heartburn, chest painHematemesis/melena
Stomach
PancreasMass Jaundice
Duodenum
Jejunum
Ileum
Colon
Rectum
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Dysphagia_______________________________________________________________________________________________________________________________________________________Aphagia_________________________________________________________________________________________________________________________________________________________Odynophagia_________________________________________________________________________________________________________________________________________________________Globus pharyngeous_________________________________________________________________________________________________________________________________________________________Misdirection of food_________________________________________________________________________________________________________________________________________________________Phagophobia
Dysphagia
Process and Problem
Timing Factors that Aggravate Factors that Relieve AssociatedSymptoms andConditions
Transfer Dysphagia, due to motor disorders affectingthe pharyngeal muscles
Esophageal DysphagiaMechanical Narrowing
Mucosal rings and webs
Esophageal stricture
Esophageal cancer
Motor disorders
Diffuse esophagealspasm
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Scleroderma
Achalasia
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Regurgitation
Causes of nausea
Vomiting
Heartburn____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Regurgitation____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
By air
(eructation)
By food or by gas
(regurgitatio)
Cause Motor dysfunction of the stomach with increased formation of gas due to abnormal
or
Odour
Disease
Nausea__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nausea can be due to
Vomiting____________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vomiting etiology
Central Peripheral (of visceral etiology,
Hematogenic and toxic
Other causes-
-
-
-
Gastric diseases
-
-
-
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Topic 20-21. Inquiry and inspection of the patients with renal diseases. Instrumental and laboratory methods of examination of urinary system.
FUNCTIONALAND
CLINICALANATOMY
Kidney anatomy
The functional units of the kidney are the nephronsThe formation of urine :1)__________________________________
____________________________________2)__________________________________________________________________________________________________________3)__________________________________________________________________________________________________________4)__________________________________________________________________________________________________________________________________________________________________________________
The primary urinary system functions____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Inquiring The most common complaints of the patients with renal diseases are: ____________________________________________________________________________________
Pain in selected urinary diseases.Disease Location
RadiationCharacter
Nephrolithiasis
Pyelonephritis
Renal abscess
Renal infarction
Nephroptosis (movable kidney)
Acute glomerulonephritis
Congestive kidney
Cystitis
Urethritis
Healthy person excretes approximately ____ liters of urine in 24 hours; urination rate is ______ times a 24 hours; ratio of daily and nightly amount of excreted urine is ____ accordingly. Urination is free and painless.
Deranged urination:Term Definition Causes
1 2 3Polyuria Oliguria
Anuria
Ishuria
Nocturia
Pollakiuria Ollakiuria Enuresis
Dysuria
Isuria Stranguria
Edema (varying degrees) is the common symptom, Local: edema of face (facial edema), edema around eyes (periorbital swelling), in lower extremities Generalized (__________),
70
edema of penis and scrotum
General inspection
General condition _________________________________________________________Consciousness ____________________________________________________________Posture _________________________________________________________________Skin __________________________________________________________________Facies nephritica _____________________________________________________________________________________________________________________________
Palpation
Palpation of the kidneys according to Obraztsov-Strazhesko
Palpation of the kidneys according to S. Botkin
Palpation is used to diagnose ptosis of the kidneys. Three degrees of the nephroptosis are differentiated I degree – palpable kidney (Ren palpabilis): __________________________________________________________________________________II degree – movable kidney (Ren mobilis): __________________________________________________________________________________
71
III degree – wandering kidney (Ren migrans) __________________________________________________________________________________
Palpation of the urine bladderIn palpation you can detect following tenderness points:1.________________________ point – the site of kidney projection, is placed in the anglebetween the 12th rib and the longissimus thoracis muscles;2._________________________point is placed at the lateral edge of the rectus abdominal muscle at the umbilicus level;3.___________________ is placed at the intersection of linea biiliaca with the vertical line passing the spina ossis pubis (pubic tubercle).
Percussion Pasternatsky’s symptom.
Pain with percussion in the costovertebral angle suggests ______________________________________________ ______________________________________________ _______________________________________________
Laboratory methods
Collection of the urine_________________________________________________________________________________________________________________________________________________________________________________________________Macroscopic study includes assessment of physical properties of the urine: ________________________________________________________________________________Clinical significance of urine color changes.
Color Pathological condition CauseDark yellow
Pale, water-like
Dark
Dark, almost black
Red
Appearance of“meat wastes”
Greenish-brown
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(beer-like)Greenish-yellow
Whitish
Milky
Cloudiness of the urine. _______________________________________________________________________________________________________________________________________________________________________________________________Smell of the urine. _________________________________________________________________________________________________________________________________________________________________________________________________Specific gravity of the urine is ___________________________________________________________________________________________________________________________________________________________________________________________Zimnitsky’s test______________________________________________________________________________________________________________________________________________________________________________________________________Isosthenuria is ________________________________________________________________________________________________________________________________Hyposthenuria is_______________________________________________________________________________________________________________________________
Chemical study includes assessment of reaction of the urine (urine pH),protein, glucose, ketone bodies, and bile pigments.
Clinical significance of urine pH changes.Urine reaction
Acid NeutralFeebly acid
Alkaline
Physiological conditions:
Pathological conditions: diabetes
Norm Physiological conditions:
Pathological conditions:
Proteinuria _____________________________________________________________________________________________________________________________________Selective proteinuria ______________________________________________________________________________________________________________________________Depend on protein- amount in the urine, ___________________-– 30-300 mg/24h, and proteinuria (_________________________) – more than 300 mg/24h are distinguished.
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Functional proteinuria ____________________________________________________________________________________________________________________________Organic proteinuria ______________________________________________________________________________________________________________________________Glycosuria____________________________________________________________________________________________________________________________________________________________________________________________________________Ketone bodies (acetone, acetoacetic and β2-oxybutyric acid) _____________________________________________________________________________________________________________________________________________________________________Bilirubin. _____________________________________________________________________________________________________________________________________Urobilinoids: ____________________________________________________________________________________________________________________________________Macroscopic studyThe presence of erythrocytes in the urine is called ____________________. Microhaematuria_________________________________________________________________________________________________________________________________Macrohaematuria________________________________________________________________________________________________________________________________Leucocyturia ____________________________________________________________________________________________________________________________________Epithelium cellsTubular (renal) epithelium cells ___________________________________________________________________________________________________________________________________________________________________________________________Squamous epithelium cells ________________________________________________________________________________________________________________________Cylinders (casts). _______________________________________________________________________________________________________________________________________________________________________________________________________Nechiporenko’s method allows counting formed elements in 1 ml of urine, normally:o Leucocytes – __________;o Erythrocytes –__________;o Casts – ___________. Crystals. _____________________________________________________________________________________________________________________________________Mucus. ______________________________________________________________Bacterioscopic studyBacteriuria_____________________________________________________________________________________________________________________________________
Instrumental methods
Plain radiography of the urinary tract_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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_______________________________________________________________________Excretion urography (synonyms: intravenous pyelography; IVP; IVU) __________________________________________________________________________________________________________________________________________________________Retrograde pyelography/ureterography__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Renal arteriography. ___________________________________________________________________________________________________________________________________________________________________________________________________Renal venography______________________________________________________________________________________________________________________________________________________________________________________________________Computed tomography (CT scanning) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ultrasonography. _________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________Nuclear renal imaging__________________________________________________________________________________________________________________________________________________________________________________________________