INSPECTION OF THE PATIENT - a complex of the researches conducted purposefully for detection of specific features of the patient, establishment of the diagnosis of a disease, selection of rational treatment, overseeing by the course of a disease, definition of the forecast.
The volume of researches at O. depends on the purposes of inspection (establishment of the diagnosis, dispensary observation, control of efficiency of treatment etc.) and on a type of a disease, apropos to-rogo it it is carried out. At the diseases which are within the competence of certain medical specialists, napr at urological, gynecologic, dental, eye and other diseases, O. includes special techniques, to-rye can be decisive for recognition of this type of a disease, but have no diagnostic value and usually would not be applied at O. with other diseases. These techniques are described in articles devoted to a specific nosology (e.g., Dislocations, Fractures, the Craniocereberal injury, etc.). At the same time at any disease it is necessary an all-wedge. the inspection directed to receiving complete idea of the patient and establishment or an exception of communication of defeat of separate bodies (e.g., organs of sight, hearing etc.) with pathology of other systems of an organism. All-wedge. Lake. is important most in diagnosis internal and endocrine a disease and for assessment of possible volume to lay down. the help, especially in the presence of indications to operational treatment.
The plan and necessary volume of researches at O. are chosen not only depending on the offered type of pathology, but also with the obligatory accounting of features of the personality inspected at observance/^онтологических requirements (see. Deontology medical ).
- 1 All-clinical inspection of the patient and inspection at internal and endocrine diseases
- 1.1 Inspection of the patient with diseases of cardiovascular system
- 1.2 Inspection of the patient with diseases of system of breath
- 1.3 Inspection of the patient with diseases of the digestive system
- 1.4 Inspection of the patient with diseases of kidneys
- 1.5 Inspection of the patient with diseases of system of blood
- 1.6 Inspection of the patient with diseases of endocrine system
- 2 Inspection of the surgical patient
- 3 Inspection of the infectious patient
- 4 Inspection mentally sick
- 5 Dermatovenerologichesky inspection
- 6 Neurologic inspection
- 7 Otorhinolaryngological inspection
- 8 Ophthalmologic inspection
- 9 Dental inspection
- 10 Urological inspection
- 11 Features of inspection of children
- 12 Kliniko-genealogichesky examination
All-clinical inspection of the patient and inspection at internal and endocrine diseases
Obshcheklin. Lake. assumes obtaining the summarized information on the state of health inspected according to posistemny diagnostic inspection, including using techniques of a research of a state and function nervous, endocrine, cardiovascular, respiratory, digestive, sexual, secretory and other systems.
For O. numerous methods of a research are used, to-rye divide into the main and additional. The main methods — collecting anamnesis (see), survey of the patient (see), palpation (see), percussion (see), auscultation (see); additional — the numerous laboratory, tool, X-ray inspections, functional diagnostic tests and other methods necessary for the obtaining information on the state of health inspected and establishments of the diagnosis of a disease (see. Diagnosis , Diagnosis ).
Development of the main methods O. any wedge, specialties is obligatory for the doctor; these methods remain high-significant owing to the high informational content, availability, simplicity of execution and full harmlessness for the patient. Any laboratory and tool methods of a research, are as if perfect they were, the main diagnostic receptions often sufficient for detection of a disease and establishment of the nosological diagnosis of a disease which are not able to replace. At the same time full clinical O. assumes use as the main, and additional methods of a research.
Domestic scientists M. Ya. Mudroye, G. A. Zakharyin, S. P. Botkin, V.P. Obraztsov and their schools considerably would improve system O. Development of methods of a tool and laboratory research, their constant and bystry improvement considerably explain progress modern a wedge, medicine. Functional laboratory diagnosis was deeply implemented into a wedge, thinking of the modern doctor, without having forced out, however, the main receptions of a research of the patient and traditional system of diagnosis. The last is improved by integral assessment of all information obtained through the main and additional methods of a research. Implementation in a wedge, medicine of the mathematical methods allowing to algoritmirovat and automate processes of diagnosis and forecasting of various diseases showed that the best results turn out during the use of a combination of the high-informative signs received by means of poll and survey, and these adequately picked up tool and laboratory methods of a research (see. Diagnosis machine ).
Inquiry besides that he allows to be guided in character a crust, diseases and according to it step by step to use other adequate methods of a research, has a number of obvious advantages. With its help establish the specific features of the patient which are shown in the course of all previous life, value of heredity, character of the environment surrounding the patient, including social. The role of inquiry in recognition of a preclinical stage of a disease, as well as its first signs is invaluable. Nek-ry early displays of a disease can be established only by means of skillfully collected anamnesis.
Survey is the first stage of the general objective research and allows to estimate weight of a state, forcedness of position of the patient, a look, coloring of integuments, a constitution and the constitution, a condition of food and to reveal a number patol, signs.
The palpation — palpation of skin, a musculoskeletal system, number of internals — gives an idea of local temperature, painful points, a tone of muscles, a configuration, the sizes, a consistence of bodies, character of pulse etc.
Percussion allows to reveal disturbances in topography of bodies, changes of their density, existence of additional environments under the explored place (consolidation and depression of fabric, lightness, availability of liquid etc.).
Auscultation gives the chance to judge activity of a number of bodies (heart, vessels, lungs, a stomach, intestines) and patol, changes in them on the basis of listening of characteristic sounds.
All additional methods applied at O. with diseases of internals, it is possible to divide into methods of the general and special research of separate bodies and systems.
It is necessary to refer various measurements to methods of the general character. Determination of growth and weight matters di-agnosticheskse at the diseases of endocrine system which are followed by disturbances of food. At O. it is important to establish dimensional defects of separate parts of a body and bodies from norm. The thermometry of a body is obligatory for all patients, at the same time matters both the absolute value of temperature, and its daily fluctuations and character of a daily temperature curve (see. Thermometry ).
One of universal methods of a research of an organism is radiological, applied as one of the general methods O. and a number of specialized techniques including at the same time, especially thanks to improvement of the x-ray equipment, implementation of electron-optical amplifiers, X-ray cinematography, the various equipment of pictures, a wide choice of contrast agents and, at last, a possibility of a computer tomography (see. X-ray inspection ).
Radio isotope research (see) it would be applied to clinical O. more and more widely. Use of the perfect equipment, new isotopes, automation of processes of a research and a kompyyutirovaniye of the received results expands positions of this method in diagnostic testing of patients with various diseases.
All informativny also becomes more available ultrasonic diagnosis of diseases, napr, in cardiology, gastroenterology, urology (see. Ultrasonic diagnosis). Increase in resolving power and technical improvement of this method in combination with use of electronic computers creates perspective conditions for its development.
The electrocardiography (see) on the frequency of use would approach the general methods of additional O., though, certainly, is a special method, as well as other eurysynusic methods elektrofiziol. diagnoses — reografiya, an electromyography, elektrogastrografiya, an electroencephalography. It is applied also to monitoring (see. Monitor observation) and telemetry (see. Teleelektrokardiografiya ).
Endoscopic methods of a research began to be used especially widely in connection with transition from rigid metal devices to flexible optical wave guides with a fiber optics (see. Endoscopy ). There was a possibility of visual studying of departments of bronchial tubes, hardly accessible for a research, went. - kish. path.
Laboratory diagnosis (see) provides an extensive range of the conducted researches — from all-clinical (bulk analyses of blood, urine, a phlegm, a calla etc.) to the most difficult biochemical, tsitomorfo-logical, including a research of bioptat (see. Biopsy ), and other types of researches. Methodical receptions and the modern equipment are based on the last achievements of chemistry, physics, electronics, optics etc. Thanks to implementation in practice autoanalyzers (see) and machining of the received results the accuracy and productivity of laboratory methods increases. The understanding of many patol, processes is helped by studying of enzymes, hormones, including and neurohormones, their metabolites and other biologically active agents, researches of electrolytes, acid-base equilibrium, indicators of coagulant and anticoagulative systems of blood. Etiol, diagnosis inf. diseases the broad range of researches bacterial, the laboratories working in close connection with diversified medical institutions promotes. Actively various forms immunol, and .allergol develop. diagnostic testings at patients with diseases of various systems and bodies.
Except listed, at O. a number of specific methods is applied functional diagnosis (see), the dysfunctions of separate systems and assessment of treatment used for researches.
Progress of medicine and health care is connected substantially with the level of armament the diagnostic equipment and therefore requirements to quality of information obtained with its help are very high: the greatest possible reliability of the received results of a research, harmlessness for patients, wide availability of a technique of a research on technology of performance. Technical and economic validity of designing, a possibility of production and implementation of the equipment in medical practice — an important condition for its universal use.
Various methods O. help the doctor to reveal a number of reliable and probable symptoms of a disease. At the same time the probability of signs can be various, and during the carrying out an additional research nek-ry of them become reliable, and another, not found confirmations — doubtful or are at all discarded. The medical conclusion, as a rule, is based on reliable signs; therefore double or triple ensuring reliability of the main symptoms of a disease is preferable to justification of the diagnosis. It is possible at the correct combination of the main and additional methods of a research. In O. coherence of the revealed signs with each other, lack of a contradiction in results of a research of the patient with various methods is represented important. Skillful group received at O. the facts and their correct assessment promote the qualified their generalization and a certain conclusion.
General plan of O. would assume, with rare exception, carrying out additional researches after O. by the main methods and on the basis of the data obtained with their help.
In the beginning as a result of carefully thought over and correctly carried out inquiry obtain anamnestic data, then conduct the general objective research with the subsequent studying of changes on bodies and systems. After that pass to necessary laboratory and tool researches. In such sequence the general plan of O. would be under construction. with obligatory broad detailing of separate links in each case.
The doctor builds the diagnostic inference step by step. At acquaintance to the main complaints and history of development of the real disease the doctor comes to certain hypotheses of the nature of a disease, then on the basis of additional inquiry of the patient specifies a hypothesis and would check the assumptions at further physical O. (survey, a palpation, percussion, auscultation), a cut introduces a large number of new data. On set of results of primary inspection the doctor concretizes the conclusion about a condition of the patient and about a disease and would make further O.'s plan. Use of additional methods of a research confirms or specifies primary idea of the patient and does it to more capacious. However there are diseases or stages of a course of a disease, recognition to-rykh perhaps only by means of the corresponding laboratory and tool researches.
Despite existence of the uniform scheme O., the doctor individualizes it in relation to the specific patient. Focus in history taking, use of the main and use of additional methods of a research provides timely statement and adequate accuracy of the diagnosis of a disease. Such focus forms as a result of versatile medical knowledge of various diseases and patol, processes, about the existing variety of diagnostic methods O. and their comparative value, and also on mastering of O.'s features by the doctor., defined type of initially estimated pathology, i.e. features of inspection at diseases cardiovascular, respiratory, digestive and other systems.
In the conditions of accrescence of technical means O. many scientists pay attention to danger of replacement of medical thinking with thoughtless hobby tekhnitsiz-MOhM, a possibility of the wrong orientation of the doctor in approach to use of laboratory and tool methods of a research with belief in their absolute infallibility. Undoubtedly such danger exists, it should be considered and in pedagogical process, in daily education of thinking of doctors, constantly to bring up students and young doctors in the spirit of the best clinical schools.
Inspection of the patient with diseases of cardiovascular system
Inquiry of the patient can have crucial diagnostic importance. From burdensome feelings at patients with diseases of cardiovascular system it is necessary to allocate pains in heart, heartbeat, feeling of interruptions of heart, a pulsation in various parts of a body, an asthma, existence of hypostases, a nocturia. Due to the prevalence and special relevance of coronary heart disease establishment of nature of pains in heart, time and conditions of their emergence and termination, duration, efficiency of pharmaceuticals is extremely important. Similar detailing is made at assessment of complaints to heartbeat and interruption of heart. At complaints to an asthma and suffocation it is necessary to specify their features under what circumstances they arise, remembering that the origin of an asthma can be a miscellaneous (see. Asthma ).
At survey it is possible to reveal typical symptoms of heart diseases and vessels: a characteristic look at the time of an attack stenocardias (see), a forced sitting position at heart failure, cyanosis (see), a marble shade of skin, a pulsation of various vessels, a cordial hump, features of an apical beat, existence of hypostases (see. Swelled ), etc.
The palpation gives the chance to estimate features pulse (see), an apical beat to establish patol. trembling of a thorax, skin temperature of extremities.
Auscultation allows to estimate cardiac sounds (see) and cordial noise (see) to reveal vascular noise (see) that is of great importance in diagnosis of the inborn and acquired heart diseases. It is informative at shunts, an aortic aneurysm, a pericardis, arrhythmias of heart; with its help the ABP across Korotkov is measured.
Tool methods of a research of cardiovascular system are diverse. With the help electrocardiography (see) reveal a position of heart, signs of a hypertrophy of its departments, disturbance of exchange processes in a myocardium, including at the expense of ischemia, the centers of a necrosis, specify the nature of various disturbances of a rhythm, define a heart block, estimate changes of functions of automatism, excitability and conductivity of heart on changes of an ECG under the influence of load and pharmakol, tests. If necessary data of an ECG are specified with the help vektorkardiografiya (see), giving information on a hypertrophy of auricles and ventricles, blockade of legs of an atrioventricular band (ventriculonector), localization of a myocardial infarction and so forth.
Elektrokimografiya (see) allows to register and study the movements and a pulsation of any site of heart and vessels therefore its use is shown for diagnosis of hems and aneurisms of a myocardium, a pericardis, diffusion damage of a myocardium, nek-ry heart diseases.
Rentgenol, methods of a research at diseases of cardiovascular system are appointed in different volume almost in each case. They have special value in diagnosis of inborn defects of large vessels, the inborn and acquired heart diseases, and also for assessment of hemodynamic disturbances in a small circle of blood circulation.
Fonokardiografiya (see) it is applied to specification of changes of tones and the nature of noise of heart for diagnosis of various damages of heart and vessels.
Studying of parameters of the central hemodynamics is carried out by numerous invasive and noninvasive methods. Among the last are most informative tetra-lolyarny reokardiografiya (see), mechanocardiography (see) and kinds of a dilution method of the indicator (dye, radioisotope, temperature of liquid). About mechanical action of the heart judge by data of a cardiography (see), dinamokardiografiya (see), ballistokardiografiya (see), study phase structure of a cardial cycle with the help polycardiography (see).
Sounding of the main vessels and cameras of heart catheters with special technical devices (see. Catheterization of heart ) allows to receive the most authentic data on pressure in cardial cavities and vessels and other hemodynamic parameters, gas composition of blood; with its help researches are conducted nek-ry X-ray contrast and additional elektrofiziol. If necessary (generally at the serious illness of heart which is not distinguished by means of other methods O., the biopsy of a myocardium with gistomorfo in l is applied. research of a bioptat.
In a research of structural changes, dysfunctions of a myocardium, the valve device, the sizes of cameras of heart, a condition of a hemodynamics ultrasonic diagnosis has special value, in particular Echocardiography (see). The last would be applied to O. in diagnostically hard cases of a cardiomyopathy, nek-ry heart diseases, and also at patients with a pericardis, coronary heart disease, etc.
Radio isotope diagnosis (see) is used for studying of both the central, and peripheral hemodynamics, but it has the greatest diagnostic value in assessment regional, in particular cerebral and coronary, blood circulations, and also microcirculation of a myocardium.
Apply a pletizmografiya to assessment of a condition of vessels and a local blood-groove (see), a reografiya (see), a flebografiya (see), a sfigmografiya (see), thermovision, a X-ray contrast angiography (see), including coronary angiography (see).
In nek-ry cases the kapillyaroskopiya did not lose the value (see). Measurement of venous pressure (see. Blood pressure ) urgent at diseases of venous system, damages of a liver, a pericardium, the squeezing processes in a mediastinum. For specification of the nature of hemodynamic frustration, their dynamics under the influence of treatment and for the purpose of identification funkts, reserves of cardiovascular system apply various loading tests — exercise tolerance tests, orthostatic tests (see), pharmakol, tests, etc. In diagnosis of a myocardial infarction widely apply researches of enzymes in blood. Research of hormones, neurohormones, their predecessors, inhibitors, metabolites, biologically active agents (catecholamines, steroid hormones, Aldosteronum, antidiuretic hormone, serotonin, renin, angiotensin, etc.) carry out as in the diagnostic purposes (arterial hypertension, cordial not sufficiency), and for control of the carried-out treatment.
Bakteriol, and immunol, researches, definition of proteins and belkovouglevodny complexes make at inflammatory processes in heart. At atherosclerosis for diagnosis and rational treatment investigate fats, proteinaceous and fatty complexes in blood serum, nek-ry factors of coagulant and anticoagulative system.
In some cases, in particular at patients with acute and hron, a circulatory unefficiency, at cardiogenic shock define indicators of acid-base equilibrium, water and electrolytic balance. Are of interest and nek-ry data characterizing other systems (breath, allocation), to-rye are naturally involved in patol, process at heart diseases and development of a circulatory unefficiency.
Inspection of the patient with diseases of system of breath
At assessment of complaints of the patient existence and the nature of cough, a phlegm, pneumorrhagia, thorax pains pay attention to unpleasant feelings in a nasopharynx; conditions of emergence and the nature of short wind, attacks of suffocation (if they are available). In the course of history taking specify interdependence of complaints whether there are contacts with in the fever and coughing patients, bronchopulmonary diseases at relatives; the special attention is paid allergol. to the anamnesis.
Cough (see) — one of specific characters of a disease of respiratory system, but it is necessary to consider a possibility of its emergence and at other diseases. Diagnostic value has the nature of cough: constant, periodic, pristupoobrazny, dry, wet. Phlegm (see), its nature, time and conditions of allocation, quantity, color also began to smell also valuable diagnostic indicators. The thorax pains connected with a disease of respiratory system are generally caused by damage of a pleura. To distinguish them from pains at heart diseases, a mediastinum and other bodies, it is necessary to establish the nature of pains, their communication with breath and cough, duration, time and conditions, at to-rykh they arise. Asthma (see), as well as attacks of suffocation — a sign not only diseases of respiratory system, but also the blood circulatory system; in this regard it is especially important to estimate feeling the patient of the complicated breath or exhalation (inspiratory and expiratory asthma), time and conditions of developing of short wind, communication with cough, etc.
At survey of the patient estimate color of integuments and mucous membranes (for detection of diffusion cyanosis, crimson tsnanotichnoy colourings of skin at a polycythemia etc.), a nabukhlost of cervical veins and its dynamics on phases of breath, a respiration rate, a ratio of time of a breath and an exhalation, change of a thorax (barrel-shaped, flat, pear-shaped, rachitic, funneled, carinate, kyphotic, lordotic, scoliotic), symmetry of its participation in breath.
The palpation of a thorax allows to reveal painful points, kostnokhryashchevy defects of a thorax, the nature of voice trembling (see), to-ry depends on a look and density of the carrying-out environment.
Topographical percussion gives an idea of changes of borders of lungs, mobility of pulmonary edges. Comparative percussion reveal character of a percussion sound (clear pulmonary, stupid or dulled, tympanic), density dependent the subject environment. At auscultation of a thorax establish the nature of breath (weakened, strengthened, vesicular, bronchial) and define patol, respiratory noise (dry and wet rattles, crepitation, a pleural rub), estimate a ratio of cardiac sounds over an aorta and a pulmonary artery.
In all to lay down. institutions for all patients with an obligatory method of a research of system of breath is radiological — X-ray analysis (see), roentgenoscopy (see). For profound studying of pathology in a pulmonary parenchyma, in a bronchial tree, in vessels of lungs use special methods: an angiopuljmonografiya (see), a bronchography (see), a rentgenokimografiya (see), a tomography (see), etc.
Great diagnostic value has bronkhoskopiya (see), with the help the cut is specified character patol, process in a bronchial tree and the biopsy of the changed fabrics can be made. The biopsy can be carried also out in the transthoracic way (a puncture by a needle, an open biopsy of pulmonary fabric, a trial thoracotomy). In need of a number of cases the biopsy of a parietal pleura and regional limf, nodes is carried out.
For etiol, the diagnosis of inflammatory diseases of bronchial tubes and lungs produce bacterial, a research of a phlegm and rinsing waters of bronchial tubes, and sometimes and a stomach, smears from a throat, crops of blood and urine, carry out serological tests. Bakteriol. diagnosis is supplemented significantly by definition of in vitro of degree of order to antibiotics of the grown-up cultures. For identification etiol, roles of nek-ry activators (viruses, rickettsiae, fungi, parasites) use special receptions, including immunol, skin tests (e.g., Kasoni's test at an echinococcosis), RSK, infection of an experimental animal (e.g., at a toxoplasmosis), etc.
Tsitol. a research of a phlegm, pleural exudate very urgent at a number of diseases, especially oncological. At O. with bronchopulmonary diseases the methods of a research informing on existence, type and degree of respiratory insufficiency, used also for assessment of efficiency of the carried-out treatment and for examination of professional working capacity are of great importance funkts. Are eurysynusic, in particular, spirometry and spirography (see) for determination of size and structure of vital capacity of lungs, identification of nek-ry disturbances of ventilation; pneumotachometry and Votchala — Tiffno test (see) for diagnosis of an obstructive syndrome; various methods of assessment of diffusion of gases through alveolocapillary membranes, gas composition of blood; diagnostic methods of hypertensia of a small circle of blood circulation (see) and a pulmonary heart (see).
Valuable information is given by the radiological methods of a research of external respiration allowing to gain an impression at the same time about ventilation, diffusion, a pulmonary blood-groove and nek-ry indicators of a hemodynamics (see. Lungs, radio isotope research ).
Inspection of the patient with diseases of the digestive system
Inquiry at diseases went. - kish. a path in some cases exerts decisive impact on formation of the medical conclusion (a peptic ulcer, a coloenteritis etc.). Such complaints as pains, a raspiraniye and weight in a stomach, disturbance are carefully detailed and analyzed appetite (see), hypersalivation, changes of taste in a mouth, disturbance of swallowing (see), heartburn (see), nausea (see), vomiting (see), abdominal distention, disturbance of the act of defecation (see). Conditions and provocative circumstances for noted symptoms, time of their emergence, communication with meal and its character, intensity, duration and other features can serve as starting points for diagnosis of a peptic ulcer, cholecystitis etc. The chair and the act of defecation can change differently at diseases of a stomach, intestines, pancreas. The doctor shall learn about outward, a consistence and a form calla (see), its amount, color, a smell, impurity of slime, pus, blood, about presence in it of worms, the remains of undigested food etc. It is necessary to inquire about existence of hemorrhoidal nodes, bleedings from them, an itch in an anus.
The physical methods of a research applied at diseases went. - kish. a path, are carried out at horizontal and vertical provisions of the patient. By means of survey reveal the general displays of a disease, change of a shape of a stomach, a front abdominal wall. The palpation of a stomach is especially informative (see) and bodies of a brkshshy cavity, classically developed V. P. Exemplary and its school. The palpation, superficial or orienting, allows to reveal characteristic painful points, muscular protection, defects of an abdominal wall, hernia etc. The deep, topographical palpation supplements the above-stated data with idea of an arrangement and the sizes of digestive organs, their surface, a tone of a stomach and an intestinal tube, availability of infiltrates or tumors etc. At percussion availability of liquid in an abdominal cavity, sometimes borders of body is defined (a stomach, a liver). Auscultation represents also much valuable data for the characteristic of the intestinal noise connected with a peristaltics or nek-ry patol, processes. Lack of these auskultativny phenomena at impassability of intestines is extremely characteristic, e.g. Listen to also deglutitory noise (see), capotements in a stomach and in intestines.
The plan of tool and laboratory researches is dictated by results of the main methods of a research.
The research of a gullet is conducted radiological and endoscopic by methods (see Ezofagoskopiya), apply an ezofagokimografiya (see), endoradio sounding (see), measurement in a gullet of temperature, pH, pressure. Study gistomorfol. features of bioptat (see. Biopsy ).
Various methods allow to conduct in the various ways researches of function of a stomach (excretory and vsasyvatelny, acid-forming, peptic, allocation of krupiomolekulyariy connections, chlorides, hemopoietic, motor etc.). These functions quite often define using food irritants and a row pharmakol, tests. Similar approach is used also at researches of other bodies of a digestive tract. By the most frequent methods of a research of a stomach at primary O. are definition of secretory function of a stomach, rentgenol, diagnosis, gastroscopy (see) with carrying out in need of a biopsy.
The research of intestines provides studying of secretory function, absorption of carbohydrates and fats, enzymatic activity. Researches of excrements and a wide range rentgenol, methods are most widespread and available laboratory (microscopic, chemical, bacteriological, parasitological, etc.). Valuable diagnostic methods of diseases of intestines are an intestinoskopiya (see), a rektoromanoskopiya (see) and kolonoskopiya (see).
The aspiration biopsy of a small and large intestine gives the chance to receive a gistomorfologichesky and cytoenzymatic picture of a mucous membrane of intestines. Methods of endoradio sounding and radio isotope researches deepen data on dysfunctions went. - kish. path.
Function of a pancreas is studied on a nek-eye to properties of contents of a duodenum (carbonate alkalinity, enzymatic activity and so forth) and to the content in blood and urine of enzymes of a pancreas (amylase, elastase, trypsin, a lipase, a phospholipase And).
In studying of functions of a liver methods are of great importance biochemical. From tests on lability of serum proteins gained distribution of Veltmann's reaction, Takat — the Macaw and timolovy. Participation of a liver in carbohydrate metabolism decides on the help of loading by a galactose. Researches of pigmental exchange are valuable (see. Jaundice ), studying of content in blood of iron and copper, especially at a gematokhromato-za (sharp increase in content of iron), hepatocerebral dystrophy (decrease in a copper content), hepatitis (increase in coefficient of Fe/Cu) etc. Studying of the neutralizing function of a liver (a one-stage prothrombin time test — Pytelya), excretory function is widely available and productive (tests with loading bilirubin, bromsulfaleinovy, etc.). For diagnosis of inflammatory processes in a liver studying of enzymatic activity of aminotransferases, zymohexases, phosphohexaisomerases, lactate dehydrogenases, sorbitdegidrogenaz, an alkaline phosphatase has special value. In some cases it is reasonable to investigate exchange of a histamine and serotonin, a condition of kallikrein of ininny system.
Immunol, researches acquired relevance in connection with detection of participation of factors of humoral and cellular immunity at hron, diseases of a liver. Definition of the Australian antigen (see) became widespread in inspection of the patient with hepatitis.
Gives valuable information on zhelchevydelitelny function duodenal sounding (see). The portions of bile received at the same time investigate microscopically (number of leukocytes, existence of lyambliya), bacteriological (crops) and biochemical (reaction, specific weight, content of bilirubin, bilious to - t, cholesterol).
Methods of studying of a liver and bilious ways are various rentgenol: a survey, aim, layer-by-layer X-ray analysis (see. Holangiografiya , Holegrafiya ). The same researches are conducted in the conditions of a pneumoperitoneum (size discrimination, forms, contours of a liver and spleen). Roentgenoscopy of a stomach and gullet (identification of expanded veins), an angiography of system of a portal vein (see. Portografiya ), splenoportografiya) (see) apply to identification of the intra hepatic and ekstrapechenochny block.
Widely use radio-gramophones, methods of a research of function, structure and blood supply of a liver with the help clearance method (see. Clearance ). Computer data processing of a stsintigrafiya (see) much increased effectiveness of this method. Krovenapolneniye of a liver is defined also by other noninvasive method — a reogepatografiya (see). Ultrasonic diagnosis of damage of a gall bladder and liver is applied in specialized institutions.
At pathology of a liver a laparoscopy (see. Peritopeoskopiya ) did not lose the diagnostic value. In many cases a biopsy of a liver, gistol., tsitomorfol. researches are decisive for diagnosis of a disease.
Inspection of the patient with diseases of kidneys
At inquiry it is necessary to pay attention to the complaints rather specific to diseases of uric system — pains in a waist, an oliguria or an anury (see), a polyuria (see), a pollakiuria (see), I am eager (see), hypostases, etc., against the background of to-rykh estimate complaints of the general character — on a headache, fatigue, weakness, disturbance of sweating, a fever etc. Reduction of a daily urine and urezheny mocheotdeleniye are observed in certain phases of a current acute and hron, nephrite, during education or strengthening of hypostases of any origin. At a convergence of hypostases, and also at patients with pyelonephritis the polyuria is observed. The dysuric phenomena, pains, a pollakiuria are more characteristic for the Urals, diseases.
From physical methods of a research use survey, a palpation, is more rare — percussion and auscultation.
Survey allows to reveal such important signs as characteristic pallor, puffiness of the person, hypostases, hemorrhages, raschesa, asymmetry of lumbar area (as a result of protrusion of the relevant party at tumors or pararenal suppurations), increase in a stomach (at a polycystosis of kidneys) etc.
The palpation of nights is carried out in horizontal position of the patient (on spin, on one side) and costing (topography, the sizes, a consistence) — see the section Urological inspection.
Auscultation of renal arteries can reveal noise over area of a stenosis of one of them. Besides, by means of auscultation reveal a friction murmur of serous covers (a pleura, a pericardium) at uraemia. Measurement of the ABP since many diseases of kidneys are followed by arterial hypertension, often diastolic is important.
Additional methods of a research at diseases to urine of secretory system play a crucial role in definition of nature of damage of kidneys and disturbances of their function.
Water secretory and concentration function of kidneys is studied by measurement of specific weight of urine and a daily urine at tests with cultivation, xerophagia, Zimnitsky's test, etc. (see. Kidneys, methods of a research ).
Glomerular filtering, a canalicular reabsorption, excretion and secretion are defined by assessment of clearance of various substances, and also radio isotope and methods. The last apply also to a research of structural changes of kidneys — scanning (see), stsintigrafiya (see). Studying of water and electrolytic balance and acid-base equilibrium is extremely important at various diseases of kidneys, especially at a renal failure and its treatment. Disturbance azo that secretory function of kidneys is followed by increase in content in blood of residual nitrogen and its main components (an urea nitrogen, creatinine, uric to - you, ammonia of an indican). Consider that increase in content in blood of creatinine reflects degree of a renal failure.
Bakteriol, and immunol, researches are important for differentiation of damages of kidneys of different genesis (collagenose, an infection, etc.) and for definition of tactics of treatment at acute and hron, a glomerulonephritis, pyelonephritis, at transplantation of kidneys etc.
A biopsy of kidneys with tsitomorfol. a research of a bioptat it is used by nephrologists for specification of nature of damage of kidneys in not clear cases when it is necessary to define therapeutic tactics.
Rentgenol, would belong to methods one of the main places in O. with a disease of bodies of uric system — survey pictures, excretory, infusional urography (see), etc. Especially the survey and selection renal angiography (see) in diagnosis of tumors, cystous diseases of kidneys, and also renovascular hypertensia is important. In recognition of the nature of the last the blood analysis on the maintenance of a renin can play a role (see) and Aldosteronum (see).
Inspection of the patient with diseases of system of blood
not always reveals Inquiry accurate patol, symptoms of diseases of the hemopoietic system, however allows to receive the wide data which are indirectly characterizing a disease, its beginning, a current. At anemias pay attention to the complaints concerning changes of flavoring feelings to fragility of nails, paresthesias, heartbeat, etc. In the anamnesis pay attention to bleedings, hron, influence of poisons, radiation, existence in the past of jaundice and its repetitions, diseases of a nervous system, a stomach, intestines, a helminthic invasion and onkol, diseases that allows to differentiate character of an anemia and respectively to draw up the plan of additional researches. At erythremias cases of the address in connection with the vascular diseases (a brain, heart, etc.) caused by thrombosis are frequent. At leukoses, an agranulocytosis the first complaints are quite often caused by quinsy. It is necessary to pay attention to long fever, the expressed perspiration, a skin itch which are observed at a lymphogranulomatosis. It is important to establish character of hemorrhagic purpuras and their communication with other diseases, poisonings.
By survey reveal discolorations of integuments and visible mucous membranes, valuable to diagnosis, at different anemias (pallor, yellowness), at an erythremia (purple-red color), hemorrhagic diathesis and leukoses (petechias, ecchymomas, hemorrhages). At anemias and leukoses from an oral cavity and a pharynx such changes as a glossitis, small knots of a lymphatic and myeloid metaplasia, hemorrhage in mucous membranes, necrotic quinsy etc. can be observed.
The palpation allows to reveal increase limf, nodes, napr, at leukoses, a lymphogranulomatosis, a lymphosarcoma, morbidity of bones at pathological processes in the hemopoietic system. Gepato-and a splenomegaly meet at nek-ry forms of anemias, an erythremia, hron, leukoses and a lymphogranulomatosis.
From additional methods O. are most valuable in diagnosis gematol. diseases laboratory blood analyses (see). The wedge, blood test is orienting. In addition to morfol, structure of blood cells, activity is studied them funkts. Cytochemical, researches have big diagnostic and especially predictive value. The research of marrow is conducted by means of a number of methods: cytologic, histologic (see. Sternal puncture, Trepanobiopsiya ), radiological (studying of an erythrogenesis), cultivation of cells on mediums (see. Cultures of cells and fabrics ).
Limf, nodes and a spleen are studied also cytologic (punctate), histologically (bioptat); if necessary carry out limfografiya (see), special radio-gramophones, a research of function of a spleen. For studying of red blood and recognition of nature of anemia conduct a number of researches depending on the estimated diagnosis: investigate, in particular, exchange of iron, porphyrine, haemo education, concentration of vitamin B 12 in blood, enzymes of erythrocytes, concentration and synthesis of hemoglobin and a methemoglobin, intensity of hemolysis (various ways). In diagnosis of leukoses and anemias use immunol. researches, methods of leucio-concentration, study inhibitors and stimulators of a hemogenesis, define enzymes. Special genetic researches have not only the scientific importance, but also applied value. Versatile studying of antibodies is very essential at various cytopenias.
Humoral factors of formation of uniform elements can be studied by various ways of definition erythropoietic leukopoietic and thrombopoietic activity of blood serum and urine. Definition of proteins of serum, their fractions (electrophoresis, immunoforez, ultracentrifuging etc.) important for diagnosis of a number of diseases, especially paraproteinemic reticuloses. At hemorrhagic syndromes of a different origin and fibrinferments researches of separate links of coagulant and anticoagulative system of blood are necessary, Elementary requirements to carried out to all to lay down. institutions to hemotransfusions are definition of group accessory of blood (see. Blood groups ) and a Rhesus factor (see).
Inspection of the patient with diseases of endocrine system
At many patients with pathology of endocrine system the anamnesis is characterized by polymorphism of complaints, an originality of development and the course of a disease. Complaints to headaches, fatigue, sleep disorders can be observed at the most various diseases — a thyrotoxicosis, an acromegalia, Itsenko's disease — Cushing, a pheochromocytoma etc. At the same diseases also signs of disturbance from cardiovascular system can come to light (heartbeat, pains in heart, an asthma). Spasms happen at a hypoparathyrosis, Conn's syndrome. Anorexia is characteristic of patients with an addisonovy disease, Simmonds's disease, the increased appetite — of patients with an acromegalia, Itsenko's disease — Cushing, a diabetes mellitus. At nek-ry diseases disturbances from c are possible. N of page, change of mentality, frustration of the sexual sphere or feature of its development.
Collecting the anamnesis of patients with diseases of endocrine system shall be especially careful and systematic owing to a variety of etiological and «starting» factors (mental, traumatic, infectious, toxic, tumoral, hereditary etc.).
Survey allows to reveal many general and a number of characteristic external symptoms of diseases of endocrine system: changes of size and shape of a body, ratio of its separate parts, features primary and secondary sexual characteristics, food, skeletogeny, visible changes of skin, indumentum. For one diseases obesity (an adiposagenital syndrome, Itsenko's disease — Cushing), is characteristic of others — weight loss (Simmonds's disease, not diabetes mellitus). Changes of growth are connected with damage of a hypophysis (an acromegalia, dwarfism). At survey of the head, neck, trunk, extremities it is possible to find many lines inherent to diseases of endocrine system: so-called eye symptoms, a craw at a thyrotoxicosis, a crescent-shaped face at Itsenko's disease — Cushing, a thickening of a nose, language, lips at an acromegalia, a cataract, a pyorrhea, stomatitis at a diabetes mellitus etc.
The palpation of closed glands can give an idea of size, a form, consistence of a thyroid gland, large tumors of adrenal glands, a pancreas, a condition of ovaries and testicles (tumors, an aplasia, etc.).
Percussion in very exceptional cases allows to receive nek-ry data on the sizes of tumors of a number of endocrine organs.
Auscultation at diagnosis directly of diseases of endocrine system is not of great importance, however with its help establish noise over a thyroid gland at a thyrotoxicosis, use it for a research of the cardiovascular system involved in patol, process under the influence of changes of neurohormonal regulation (a pheochromocytoma, a diffusion toxic craw, etc.).
Special anthropometrical measurements have essential value as the general, and. Disturbances of ossification according to age (have diagnostic value at a hyperparathyreosis, a hypopituitarism, etc.), an order of pro-cutting of teeth etc. The thermometry is important owing to disturbance of thermal control at damages of a hypophysis, thyroid gland, ovary, at a diabetic coma, etc.
Important for quantitative and quality standard of function department of iy glands are biochemical, researches, especially definition of activity of separate hormones. At O. use chemical, tracer and biological techniques. Disturbances of endocrine regulation change chemical structure of fluid mediums of an organism, including and the most available to laboratory researches — blood, urine, an ejaculate, vulval separated etc. Assessment of a condition of mineral and water exchange, acid-base equilibrium, oxidizing processes in an organism, neuromuscular excitability matters. Disturbances of water and electrolytic exchange are connected more often with dysfunction of bark of adrenal glands, exchange of calcium — with pathology of epithelial bodies, exchange of iodine — with dysfunction of a thyroid gland; exchange of inorganic phosphorus in many respects depends on exchange of calcium. Judgments of carbohydrate metabolism are based on the basis not only single-step definition of a sugar content in blood and in urine, but also according to the characteristic of various sugar curves, data load and pharmakol, tests., in particular adrenalinic test (see).
Quantitative and qualitative test of the majority of hormones is, as a rule, carried out by special laboratories. At diseases of reproductive endocrine system study gonadotropic hormones — follicle-stimulating hormone (see), luteinizing hormone (see), Prolaktin (see) and cosecreted under their influence follicular hormone (see. Is oestrogenic ), progesterone (see), and also testosterone (see).
In diagnosis of diseases of a hypophysis, thyroid gland and adrenal glands the important place is taken by a research of adrenocorticotropic hormone (see), and also mineralokortikoid, glucocorticoids and other corticosteroids (see).
Definition of somatotropic hormone (see) has diagnostic value at an acromegalia, a pituitary nanism. Establishment of activity of posterior pituitary hormones — vasopressin (see), oxytocin (see) it is also used at diseases of a hypophysis. Decrease in content in blood of vasopressin is noted at not diabetes mellitus.
At a research of a thyroid gland (see) and studying of its hormones (thyroxine and its fractions) in blood preference is given to tracer techniques of in vitro.
The research of function of cortical substance of adrenal glands (see) is conducted by quantitative definition of Aldosteronum in urine and blood (a hromatografichesky, radio immune method), by researches of glucocorticoid and androgenic function (17 oxycorticosteroids and their fractions in urine, 17 ketosteroids in urine).
Researches of function of marrow of adrenal glands are conducted by definition of adrenaline and noradrenaline and their predecessors and metabolites. Studying of catecholamines serves in blood and urine not only for differentiation of arterial hypertension, but also for rational selection of antihypertensives and dynamic overseeing as the course of treatment.
Gisto-and tsitomorfol. researches in endokrinol, practice are used also widely, in particular for studying of a sex chromatin, semen, slime of the channel of a neck of uterus, a research of bioptat of various fabrics. The endometrial biopsy has special value. Also the diagnostic role of a biopsy of a small egg, a thyroid gland is not lost.
Radiodiagnosis serves for identification of a number of characteristic changes of internals, a skeleton and structural changes of a number of hemadens (adrenal glands, a pancreas, a hypophysis, a thyroid gland). The big place is allocated to radio isotope researches of closed glands (in particular, a thyroid gland, a pancreas) by means of scanning, a stsintigrafiya.
Ultrasonic diagnosis is used for a research of a hypophysis, a pancreas, generative organs etc. At O. neuroendocrinal diseases the researches of different bodies and systems conducted by the corresponding specialists (the neuropathologist, the psychiatrist, the ophthalmologist, the therapist etc.) are of particular importance.
Inspection of the surgical patient
At inspection of the surgical patient implementation of the main requirements of a medical deontology is important especially. In relation to the patient the surgeon shall be the most humane, being guided by the rule «do not do to the patient of what would not make to himself or the relatives under the same conditions». Haste and aspiration to quickly make the diagnosis quite often would lead to disturbance of the necessary sequence of O. (collecting anamnesis, survey, palpation, percussion, auscultation, datas of laboratory, data rentgenol. inspections, etc.), to disturbance of the deontological principles and diagnostic errors — underestimation of one and revaluation of other data. The diagnosis shall be result of detailed discussion, the analysis of all facts got at full O.
Inquiry is begun with clarification of complaints, their character, time of emergence, duration etc., then the patient is asked on development of this disease and passed to acquaintance with the conditions of his life and work which are earlier postponed diseases, heredity. The value and reliability of the received data depend not only on the cultural level, observation and frankness of the patient, but also from ability of the doctor it is correct to conduct inquiry that to a great extent is defined by degree of its medical literacy.
It is important to establish the main, leading complaint of the patient, napr, on pain and to carefully find out everything belonging to them. Sharpness, frequency and specificity of pains, and also other features of painful frustration can be so characteristic that already during the collecting the anamnesis allow to make certain diagnostic assumptions. Than more unexpected, more sharply, «besprichinny» also is more short-term an attack of pains, subjects of a high probability that it carries funkts, character (neuralgia, a spasm of smooth muscles etc.). The attacks of pains lasting for hours after acute or gradual emergence more often in the basis have not functional, but organic character. Temperature increase gives the grounds to think of existence of inflammatory process.
The data on prescription and the course of a disease obtained from the anamnesis allow to make assumptions not only of the nature of process (an injury, an inflammation, a new growth), but also of a look it (chronic, acute, high-quality, malignant etc.).
Survey of the patient begins from the moment of the first contact with it. The habit view of the patient, expression of his face, gait, position of a body, a condition of eyes and pupils, skin color, scleras, mucous membranes, existence of rashes and bruises on them are estimated; in process of inquiry of the patient character of his speech comes to light.
Only full survey of the patient is full (see), to-ry recommend to carry out in the following order: at first examine the head, a face and open parts of a body, then at inspection of bodies of a thorax examine an upper part of a trunk and after the patient puts on a shirt, inspect a stomach, a waist, then the lower extremities.
At limited purulent process (a furuncle, a felon, etc.) or at an injury (a bruise, a burn, a fracture, etc.) in full survey of the patient, apparently, there is no special need. However and full survey allows to find in these cases sometimes, e.g., the reason of frequent repetition of a felon or ease of receiving a change and so forth. So, numerous hems suggest an idea of a myelosyringosis, and detection of a tumor allows to assume existence patol. a change because of metastasises that quite often would be confirmed by further O.
At survey of skin pay attention to pallor it or reddening, cyanosis, pigmentation, yellowness, their prevalence and the nature of transition of the changed skin to healthy. E.g., the diffuse redness of a certain site of skin indicates an inflammation it or the subject fabrics, and the bright redness with sharp, uneven borders speaks about an erysipelatous inflammation. Note spotty brown-brown sites of skin (more often on a stomach) — a trace of prolonged use of hot-water bottles in connection with the pains disturbing the patient. Signs of the hypodermic hemorrhages caused by diseases of blood or connected with an injury can be noted. Survey allows to be guided in prescription of such hypodermic hemorrhages (the yellowish-greenish shade speaks about their rassasyvaniye). Wrinkling, flabbiness of skin or its tension, gloss need also to be noted at survey. By survey define existence and extent of changes of a form and size of body, area, a part of a body, to-rye can be inborn and acquired. So, not fusion of an upper lip (labium leporium) — inborn change, and cicatricial disfigurations of a lip — acquired as a result of a mechanical injury or a burn. Changes of a form and size of body or a body part are connected with excess formation of fabrics, accumulation patol, products or the shift of body. Their designation as «swelling» or «tumor» conditionally since it does not reflect gistol, entities of changes. The inflammation, a new growth, hernias, disturbances krovo-and lymphokineses happen the reasons of such changes most often. Other type of changes of a form of bodies is connected with the degrowth of fabrics not always caused by their atrophy as often designate these changes (there can be an inborn underdevelopment, traumatic defect of fabrics etc.). Many changes are very characteristic of certain diseases, napr, changes of contours of inguinal area and a scrotum at inguinoscrotal hernia. From inborn changes of a musculoskeletal system easily come to light at survey congenital dislocation in a hip joint, a clubfoot and a wryneck. Often changes of situation and a shape of a body or extremities are connected with damages of bones. They are sometimes very characteristic as, e.g., a kyphoscoliosis of a backbone at its tubercular defeat, the Au-shaped and H-shaped curvature of the lower extremities at rickets. Also shifts of fragments of bones at changes of various localization are characteristic. At dislocations, except change of position of an extremity, tension, an immovability, absence active and almost utter impossibility of passive movements in an affected joint is noted.
Disturbances of movements originally are defined by survey. They can be a consequence of disturbance of an integrity of a bone, muscles, defeats of the central and peripheral nervous system (paresis, paralyzes). Survey often allows to define a symptom of so-called abnormal mobility, i.e. existence of mobility of an extremity throughout a bone that meets at changes, formation of a nearthrosis. This sign defined by simple survey in attempt of the patient to make the active movement allows to establish disturbance of an integrity of a bone in a certain place.
By survey define type of breath (chest, belly), its disturbances, restriction of movements of a thorax at fractures of edges, damages of bodies of a thorax, pleurisy etc. These restrictions of movements of a thorax are explained by a protective reflex owing to pain more often. The chest type of breath at men is quite often observed at inflammatory or any other diseases of abdominal organs.
At the weakened, thinned abdominal wall it is possible to reveal contours of a large tumor of abdominal organs, edges it is quite often displaced during respiratory movements. Sometimes it is possible to see a peristaltics of an expanded stomach at a stenosis of a peloric part and reduction of a wall of a gut at impassability (wavy reductions).
A palpation — one of the most important methods of inspection of the surgical patient. Palpation needs to be made carefully, carefully, warm hands, aiming not to cause unpleasant feelings and severe pains at the patient. Carry out it by different ways (see. Palpation ).
Having tentative data about Localization patol, process, it is possible to begin palpation with area of defeat then to pass to inspection of other areas of a body in the accepted sequence. However in these cases it is better to begin palpation with areas, boundary with an affected area. So, at pains in the right inguinal area palpation is begun with the left inguinal area, then passed to inspection nadchrevya and in conclusion — the right inguinal area. Palpation gives the chance to establish: 1) existence of morbidity in various areas of a body; 2) rate of strain of muscles over the struck area; 3) local increase or fall of temperature; 4) existence any patol, educations; 5) localization, a form, size, a consistence of a new growth, and also its relation to surrounding bodies, mobility, a smeshchayemost at the respiratory movements, sensitivity at a palpation and the movements, changes of a form and size at palpation, compression etc.
Existence of pains at palpation most often indicates the inflammatory nature of a disease that it can be confirmed with results of other researches. Intensity and the nature of pains happen various. It is necessary to remember that the feeling of pain substantially is defined by individual sensitivity of the patient and his psychological state. Cases when the patient with diffuse peritonitis owing to perforation of stomach ulcer or a worm-shaped shoot, to-ry usually is followed by the most severe pains are known, on foot came in to lay down. institutions and vice versa, mild pains at gastritis were presented to other patients intolerable.
Extremely important symptom — a muscle tension, determined by a palpation, is explained by defense neuroreflex reaction of a sick organism. Existence tells it about inflammatory process or an injury of fabrics, bodies. To define initial phases of a muscle tension, especially careful comparative palpation giving the chance to reveal even the earliest phases of process (see is required. Muscular protection symptom ).
The local increase or fall of temperature defined at palpation also has essential value. Local temperature increase is observed in a zone of inflammatory process, over sites of excess arterialization of a blood-groove (arteriovenous aneurisms, an eritromelalgiya). Fall of temperature of covers is usually connected with local disturbance of inflow of an arterial blood (a spasm, thrombosis, an embolism of the main artery). The bilateral disorders of blood supply of extremities leading to their cold snap can be connected with the expressed cardiovascular insufficiency, including at shock.
By a palpation it is possible to find patol, education, to define its localization, depth of an arrangement and the relation to the next bodies. Educations the active muscle tension happens an obstacle for detection patol, a cut sometimes easily is eliminated with change of position of a body, extremity. So, at a palpation patol, the education located under muscles of a back surface of a hip, the patient shall bend a leg in a knee joint, at palpation of a neck — to incline the head in the sick party etc. Carefully feeling patol. education from all directions, define its form, size and a consistence. For definition of degree and the nature of mobility of education he is carefully captured or displaced fingers of the investigating hand. At palpation patol. formations of an abdominal cavity use the shift of bodies of a stomach at diaphragmal respiration. Carefully at the weakened abdominal wall investigating puts a hand below patol, educations and suggests the patient to breathe «stomach», i.e. to reduce a diaphragm. The respiratory movement as if pushes out the investigating hand from depth of a stomach, and fingers feel it edge displaced patol, educations. The same reception, giving a vozkhmozh-nost to feel internals (a liver, a spleen, kidneys, etc.), allows to gain an impression about the relation patol, educations to surrounding bodies. During a palpation change of a form and size patol is possible, educations, it quite often decreases or completely disappears. So, during the tightening of hernial protrusion it is set in an abdominal cavity (if there is no strangulation of a hernia); hemangiomas or varicose nodes at a palpation decrease owing to reduction of amount of blood in them, and sometimes for this purpose it is enough to give extremities sublime situation. At palpation it is possible to establish fluctuation when in the studied education there is a liquid. Also establish by a palpation balloting of a patella at accumulation of liquid in a knee joint. This symptom the easiest is defined if the patient lies with the extended leg, and the doctor covers both palms and squeezes a knee joint from sides and thumbs tolchkoobrazno presses on a patella (see. Balloting ).
At O. concerning an injury very important symptom defined at a palpation is local crepitation (see). It occurs at fractures of bones, at hypodermic emphysema, at patients with injury of a lung, at gas gangrene, etc. At hypodermic emphysema there is a gentle crunch felt by the hand making pressure upon the struck area. This crunch is caused by movement of gases in hypodermic cellulose.
The palpation of a stomach demands special softness of receptions and respect for methodicalness of a research. Bowel emptying and a bladder before a palpation of a stomach is very desirable condition since sometimes even experienced doctors take the crowded bladder for the increased uterus, and the loops of guts overflowed with fecal masses — for a tumor or infiltrate. The palpation of a stomach is made in the following provisions of the patient:
1) lying on spin on a plain dense surface with the extended legs;
2) lying on spin with the legs bent in knees;
3) lying on one side about a nek-eye an inclination of a stomach to a surface of a table;
4) on ginekol, a chair;
5) standing with a considerable inclination of a trunk forward (investigating is located behind the patient).
All these provisions, in essence, are necessary for the maximum relaxation of muscles of a prelum abdominale. Investigating usually sits down on the right side from the patient and, having put a hand on his stomach during an exhalation, carefully immerses a hand in depth of an abdominal cavity. The hand shall adjoin as if an abdominal wall and in such situation to follow it during the act of breath. During a breath in connection with reduction of a diaphragm internals move up, during an exhalation — down, and the hand lying on an abdominal wall feels their surfaces especially well during an exhalation when bodies fall down.
The palpation is used also for a research a finger through a rectum (see. Rectal research) or a vagina (see. Gynecologic research ). It in many cases helps to find a tumor of a rectum, a tumor of a bladder and prostate in men, patol, process in a uterus and its appendages at women, abscesses of a small pelvis, retroperitoneal hematomas.
Determine by percussion accumulation of liquid or gas in a cavity at injuries and various diseases. At injury of a thorax and an injury of a stomach the defined dullness indicates accumulation of blood and, therefore, an internal injury (a lung, a liver, a spleen, etc.). Detection at percussion of a thorax of a tympanic sound instead of pulmonary can indicate pheumothorax, smoothing of hepatic dullness and a tympanic sound under a diaphragm allow to suspect a traumatic rupture or perforation of an ulcer of hollow body (a stomach, a gut). Big help is given by percussion at diagnosis of subphrenic abscess, for to-rogo at percussion the shift of a liver or spleen, dome-shaped distribution of obtusion up with a high-pitched tympanic sound at top is characteristic.
Character of a percussion sound over the probed tumor helps to define its nature and the relation to hollow bodies. Percussion at differential diagnosis of gryzhepodobny protrusion with a hydrocele is especially important or a seed cord, a tumor, lymphadenitis and so forth. The tympanic sound over hernial protrusion speaks about existence in it of an intestinal loop.
Auscultation is a valuable method for diagnosis of nek-ry surgical diseases. Weakening of breath at purulent pleurisy, lack of peristaltic noise at peritonitises, vascular noise at aneurisms and other data obtained by listening promote statement of the correct diagnosis.
Additional methods of inspection of the surgical patient are chosen depending on the diagnosis assumed according to O. by the main methods. At defeat of a musculoskeletal system measurements of different parts of a body are of great importance (see. Anthropometry ); the thermometry of a body is almost obligatory; in many cases laboratory, radiological, endoscopic methods, etc. are necessary.
Laboratory methods are traditionally used for inspection of the surgical patient. Klien, blood test allows to confirm the assumption of existence of acute purulent process (a leukocytosis, a deviation to the left, toxic granularity of leukocytes, acceleration of ROE) or internal bleeding (decrease in amount of hemoglobin, the loudspeaker of a hematocrit). Differential diagnosis of surgical and urological diseases is promoted by the general and special researches urine (see). In diagnosis of acute pancreatitis researches of amylase and other enzymes of a pancreas in blood and diastases in urine are of great importance. The modern laboratory has a considerable arsenal a wedge., mikrobiol, and biochemical, the methods of a research considerably facilitating and specifying diagnosis.
Rentgenol, methods (roentgenoscopy, a X-ray analysis, a tomography, a kimografiya, a bronchography, angiocardiography, Fistulografiya and other special techniques) help to collect the additional facts for establishment of the diagnosis at injuries of bones, pheumothorax, acute abscesses of lungs, a gap and a perforation of hollow abdominal organs, at tumors, a vascular embolism, etc.
Endoscopy (see) with use of endoscopes with a fiber optics, especially in combination with a biopsy (see) and gistol, a research of the taken fabrics, allows to improve considerably early diagnosis at diseases of internals. Use of endoscopic methods of a research at bleedings from internals not only allows to define a source and intensity of bleeding (that defines tactics of surgical treatment), but quite often and to stop it. Even more often apply a torakoskopiya to specification of the diagnosis (see) and a laparoscopy (see. Peritoneoskopiya ), to-rye much facilitate recognition of a disease in hard cases. New technical means O.
would receive the increasing use. — a termografiya (see), ultrasound (see), laser (see).
Special value in O. at modern development of surgery and anesthesiology functional diagnosis gets (see), a comprehensive investigation funkts, conditions of vitals and systems of the patient at various stages of development patol, process, studying the compensator and y x opportunities.
If recently the problem of preoperative inspection of the surgical patient was limited to diagnosis and definition of so-called technical operability, then in modern conditions there is a need for definition of so-called functional operability. Achievements of science and technology were a basis for creation of a large number of the new medical diagnostic devices allowing to define at patients necessary for surgeons fiziol, indicators. For simplification of a difficult task of the choice of methods of a research necessary for the patient it is necessary to know possibilities of each of them, a measure of reliability of the received results, and also technical specifications on use of these methods, to-rye can be contraindicated to patients with nek-ry forms of pathology.
Follows from the analysis of the reasons of diagnostic mistakes that they are quite often connected with insufficient use of the existing diagnostic methods or with underestimation of the received results. At the same time, despite progress in development of diagnostic methods, sometimes on the basis of these methods it is not possible to make a wedge, the diagnosis. In these cases apply a diagnostic chrevosecheniye to specification of the diagnosis or volume of possible operational treatment (see. Laparotomy ), a thoracotomy (see).
Inspection of the infectious patient
O. inf. by a disease it is carried out always urgently and has system and complex character. Its purpose — obtaining the fullest data about assumed inf. diseases for bystreyshy establishment of the diagnosis, appointment to lay down. - professional, and protivoepid, actions.
O.'s feature. inf. a disease consists in need of care of the state of health not only this patient, but also surrounding his faces, especially if the patient arrived from collective. For this reason it always has kliniko-epidemiol. the orientation, and to inspection can be exposed not only this patient, but also externally healthy faces which were with it in contact among to-rykh can appear carriers of the activator, the infected persons in an incubation interval of a disease or obviously sick.
Lake. inf. a disease conditionally consists of clinical, epidemiological and tool and laboratory stages. Examination can be conducted in special facilities (provisional hospital) according to instructions and depending on a nosological form of a disease, degree of its contageousness, epid, situations.
Many inf. diseases proceed cyclically, is quite often erased with lack of important symptoms therefore examination is conducted in dynamics repeatedly for specification of the diagnosis of a disease, its form, character of a current, efficiency of the carried-out treatment at different stages of a disease, forecasting of possible complications, a possibility of the emergence mixed inf. process, outcome of the disease. According to it repeated inspection can change on the volume, content and a set of methods.
To O. inf. a disease the differentiated approach since in nek-ry cases the doctor-infektsi-onistu and the epidemiologist should make urgent decisions is necessary.
Primary inspection inf. sick or suspicious on inf. the disease begins with collecting the general anamnesis, and also epidemiol, the anamnesis (see) serving the purposes of clarification of a source of an infection, obtaining data on the inoculations which are carried out earlier postponed inf. diseases, their prescription, the carried-out treatment and so forth. In cases of the darkened consciousness of the patient (e.g., at the typhus status) or its absence (a coma, shock), and also at a disease of small children interview the persons accompanying the patient, acquaintances, relatives. The received data consider on degree of their importance, analyze and would use at the subsequent O.'s carrying out.
At survey at a bed of the patient pay attention to position of the diseased (active, passive, forced), a look. Survey of skin and visible mucous membranes (a mouth, a pharynx) carry out in the warm room at good lighting (better day) from top to down, t, e. from head to foot. The patient shall be completely naked at the same time. Note existence of spasms, paresis, paralyzes, their localization, character. At survey of skin and mucous membranes any site since only single elements of the rash characteristic for inf are possible shall not be passed. diseases, or separate enantema on mucous membranes. Note existence of possible traces of a sting insects, mites, existence of primary affect (see. Affect primary ), skin and mucous membranes ulcers, coloring and turgor of skin, fragility of vessels of skin, existence of hemorrhages on skin and mucous membranes.
Great opportunities for identification of the centers of a hyperemia, elements of rash hidden for an eye, enanty open special researches by means of the infrared equipment, napr, thermovision. Infrared beams are capable to get into deep layers of fabric, and at their registration by devices it is possible to reveal patol, the centers in the earliest terms of their formation.
Rash at inf. diseases can be the most various character (a roseola, a petechia, a papule, a vesicle, a pustule, etc.) and to be localized or diffuzno but to all body, or to concentrate in its certain sites. Sometimes she is quite characteristic and is a pathognomonic sign (e.g., at measles, scarlet fever, a natural pla to chicken pox, a meningococcemia). Existence on mucous membranes of a mouth of spots of Velsky — Filatova — Koplika, plaques of necrotic type on almonds allows to assume measles, diphtheria or an infectious mononucleosis. Survey of language of the patient is of great importance. At a typhoid it is thickened, edematous, laid over by a white plaque, on it prints of teeth are visible. At a sapropyra language dry, is not thickened, at protrusion deviates (deviation) tolchkoobrazno aside, but not further foreteeth (Govorov's symptom — Godelye). These signs are noted almost at all patients with a sapropyra, even at easy disease, a thicket in its heat, and do not meet (except for encephalitis) at any another inf. diseases. Also other signs are known, to-rye are basic in diagnosis inf. diseases at O.
Increase limf, nodes, seen sometimes at survey, is specified a palpation, defining their consistence, mobility, morbidity, a preferential arrangement on these or those body parts. At parotitis, a tularemia increase separate limf, nodes, at an infectious mononucleosis, a brucellosis — many. At subacute and hron, a brucellosis at palpation of skin and hypodermic cellulose cellulitises, fibrosites are found, at palpation of joints — a bursitis.
Inspection of various systems of an organism of the patient (cardiovascular, respiratory, nervous, etc.) it is carried out according to the same scheme, as at the therapeutic patient. At many inf. the diseases proceeding with generalization of process, intoxication the cardiovascular system (dullness of cardiac sounds, tachycardia, or, on the contrary, bradycardia with a dicrotism of pulse — is surprised at a typhoid, decrease in the ABP, etc.). At an ornithosis, the Q fever pulmonary fabric (intersticial pneumonia) often is surprised. At inspection of a nervous system pay attention to existence of paresis, paralyzes, meningeal symptoms (poliomyelitis, a brucellosis, a meningococcal infection, botulism, etc.); at a research of abdominal organs — on abdominal distention, rumbling, a dullness in the right ileal area — at a typhoid, in left — at dysentery (a symptom of Pa-dalkp), morbidity, a spasm of a sigmoid gut, existence gepatolpe-nalyyugo a syndrome. Establish borders of bodies, their consistence, a form of edges, morbidity (a viral hepatitis, malaria, leyshmanioza, etc.).
Existence of a complex of symptoms, syndrome (e.g., intoxications, dehydration of an organism as a result of a diarrhea and vomiting at cholera) allows to make the preliminary diagnosis already at survey of the patient. At assessment of symptoms consider degree of their importance, specificity, a patognomonichnost for this or that inf. diseases. However row inf. diseases has similar symptoms therefore only complex: the accounting of all signs at O., their analysis in comparison to data of the anamnesis, epid, situations, the subsequent tool and laboratory methods of inspection in course of disease allows to put correct (etiological and pathogenetic) the diagnosis of a disease, to foresee the forecast. It is necessary to consider that many inf. diseases can proceed atypically, abortally pl subclinically. Special difficulties would be presented by O. with latent, slow infections, various fevers of the virus nature. In these cases the final diagnosis of a disease is extremely difficult without confirmation by laboratory methods.
Experience of many generations of infectiologists shows that existence at the patient of fever in combination with symptoms of intoxication, as a rule, demonstrates existence at it some inf. diseases. In the past considered that already one type of a temperature curve (e.g., like a trapeze at a typhoid) is sufficient for diagnosis inf. diseases. However many factors therefore at the majority inf exert impact on character of a temperature curve. the diseases proceeding with fever it is possible to meet any types it. At the same time at a row inf. diseases alternation of fever with days of standard temperature of a body remains still specific sign (malaria, typhinias, etc.).
The special attention is required by such state, a caret the infectious and toxic shock which is found at many inf. the diseases caused by bacteria. Such patients need urgent survey, observation and treatment in intensive care units inf. BC. From the correct assessment of results of O., purposes of a timely intensive care life of the patient can depend.
Inf. diseases at the beginning of epidemic have more characteristic signs, than at the end of epidemic when there are atypical, erased forms of a disease more often. It would involve need of expanded volume of O., including wider use tool (endoscopy, roentgenoscopy) and laboratory methods — bacteriological techniques (see), virologic researches (see), serological researches (see) etc.
For early laboratory diagnosis inf. diseases apply express methods (see), napr, definition of specific toxins, antigens in biol, substrates from an organism of patients, in foodstuff, in objects of the environment, immunoallergological tests (see the Immunodiagnosis), biol, tests (see the Bioassey), a research of bioptat of fabrics, etc. Remain important and an all-wedge, methods of a blood analysis, urine, a calla, biochemical, researches of various environments of an organism. The increasing value would get complex O. with the rational choice of the most necessary laboratory and tool methods throughout everything inf. process and even after its termination for judgment of degree a wedge, recovery, release from the activator, recovery of working capacity. Napr, persons who had a viral hepatitis are subject to observation and inspection within 6 months and more in offices inf. diseases, to active patronage.
Special difficulties would arise at the doctor at O., at to-rogo two are at the same time or consistently noted or three inf. diseases (mikst-infection), in case of a combination inf. diseases with injuries, burns, etc., and also at a disease seldom meeting in the USSR inf. diseases.
Inspection mentally sick
Psychiatric O. it is directed to recognition of a disease and scheduling of treatment. Depending on a situation, in a cut the patient is inspected, completeness of his inspection happens various, however always takes the main place inquiry of the most sick and persons close to it.
A special role at inspection of mentally sick is played by collecting of the individual and family anamnesis. The subjective anamnesis is collected by purposeful inquiry, in process to-rogo also features of the mental status of the patient (disturbance of consciousness or dementia, hallucinations or crazy frustration, negativism or a tendency to dissimulation, etc.) can be revealed, on the Crimea it is possible to judge completeness and reliability of the anamnesis.
At inquiry receive data on a family of the patient and hereditary burdeness, physical and mental development, a personal warehouse, a way of life, work and social adaptation, family life, the attitude towards other people, a focus of interest and habits, about existence of somatopathies, appetite, fiziol, departures, a menstrual cycle at women and hl. obr. about features of the beginning, development and the nature of a mental disorder, apropos to-rogo the patient it is inspected. The objective anamnestic data received from the family, acquaintances, colleagues or from medical and other documentation concern the same questions and are important means for confirmation or correction of the subjective anamnesis.
Inquiry of the patient is the main reception of psychiatric inspection. Only by means of inquiry the doctor learns and can judge existence, expressiveness and features of such subjective disturbances of mental activity as persistence, an adynamy, a depression, nonsense, hallucinations, mental avtomatizm, etc. Inquiry demands from the doctor of the skillful management of a conversation, the attentive, impartial and sensitive attitude towards the patient as P. B. Gannushkin spoke, «thoughtfulness, truthfulness and simplicity».
Using inquiry, the doctor naturally addresses data of introspection of the patient since many manifestations of mental diseases are purely subjective and only in introspection they become available to inspection as painful symptoms, i.e. turn into objective signs of disorder of mental activity.
Inquiry would be combined with overseeing by his behavior, a look, intonation of a voice and features of the speech, gestures, a pose and motility. By such observation, a cut, except the doctor, carries usually out also paramedical staff, establish I.Q., disturbances of consciousness, existence and expressiveness of hallucinatory and crazy frustration, reveal depth and the nature of affective disturbances. A certain value at inspection of mentally sick has also studying of his letters to the family and personnel-tsy or art creativity.
Full inspection of the patient is impossible without overseeing by dynamics of a mental disorder. At the examination conducted with tselyo diagnosis of a disease, the doctor establishes first of all separate signs, i.e. subjective and objective symptoms. However the separate symptom, or «sign», always is in interrelation with other symptoms, i.e. within a syndrome. The syndrome contains important information on weight and qualitative features of mental disturbances. In it are shown positive (patholologically productive) and negative (partially reversible, partially irreversible — deficiental) types of a mental disorder. The scale patholologically productive syndromes reflecting severity of disturbance of mental activity is developed for practice of inspection mentally sick: asthenic, affective, neurotic, paranoiac, hallucinatory, hallucinatory paranoid, paraphrenic, catatonic, oneiric syndromes, syndromes of stupefaction, convulsive and psychoorganic. For the nosological diagnosis of a mental disease carry out at first the analysis of positive and negative symptoms in their syndromal manifestations, and then the analysis of consecutive change of syndromes because the circle of frustration inherent to it is inherent in each disease.
Mentally sick enters problems of inspection as well careful studying of somatic and neurologic disturbances. Data of somatic inspection promote recognition of those mental disorders, the origin to-rykh is connected with somatic pathology. Full nevrol, inspection is necessary for establishment of bonds of a mental disorder with focal and diffusion organic lesions of a brain. For this purpose by means of the corresponding techniques reveal disturbances of the speech (aphasia), readings and letters (an alexia and agraphia), accounts (acalculia), deystvovaniye (apraxia), etc.
The @-tamnestichesky data received in different terms (see. Catamnesis ) reflect patterns of a current and an outcome of the disease and play an important role at inspection of mentally sick. They are also based on subjective and objective data. The condition of the patient established at katamnestiches-whom survey is compared with data of the previous inspection that allows to judge existence and quality of remission, possible residual frustration, existence or lack of a progrediyentnost of a disease. According to katamnestichesky data estimate degree and character appeared (as a result of personal changes) disturbances of working capacity and a way of life of the patient. Only the catamnesis allows to determine consistent patterns of a course of a disease (continuous progre-diyentnoye, pristupoobrazno-progre-diyentnoye, recurrent, phase, regreduated etc.). The individual catamnesis is carried out by means of inquiry and, whenever possible, comprehensive inspection of the patient, and by mass katamnesti-chesky inspections of certain groups of patients — but to the unified method by means of the standardized cards.
At comprehensive inspection mentally would use also specially developed experimental and psychological methods playing a supporting role at identification various psikhopatol. frustration in controlled conditions, including weakness of attention, increased fatigue and delay of rate of mental work (correctional test, the account on Krepelin, search of numbers, etc.), disturbances of memory (learning of words, retelling, etc.), features of thinking (transfer of sense of proverbs, comparison of concepts, classification of objects, etc.), and also personal features (so-called about-zhektivnye tests).
Registration of bioelectric activity of a brain (see. Elektroentsefalografiya ) would matter at O., the c having mental disorders against the background of organic diseases. N of page (epilepsy, vascular, atrophic and tumoral processes); it is less informative at funkts, mental disturbances.
Rentgenol, methods of inspection are shown to patients with mental disturbances at organic lesions of a brain. Find, e.g., changes in a kraniogramma and a pneumoencephalogram at intracranial tumors, hydrocephaly, atrophic processes.
Laboratory researches make an obligatory part of somatic inspection mentally sick. Morfol, a blood analysis shows characteristic changes at various symptomatic psychoses and at pshertoks and chesky schizophrenia (see). The research of cerebrospinal liquid (see) at patients with a pathopsyhosis is of great importance. So, discoloration of cerebrospinal liquid is observed at vascular and tumoral diseases, opacification — at meningitis, a cytosis and strengthening of protein — at a general paralysis, neurosyphilis and other organic processes. Nek-roye diagnostic value has also determination of content of a number of organic and inorganic matters in cerebrospinal liquid. Serol. researches — Wasserman reaction (see), Legislative Assembly — Vitebsk reaction (see), and also reaction of an immobilization of treponemas (see. Nelson — Meyer reaction ), etc. are important for diagnosis of a general paralysis and other forms of neurosyphilis.
Dermatovenerologichesky inspection is begun with the analysis of complaints of the patient then perform careful inspection and a research of an integument and visible mucous membranes.
Considering special informational content of survey of visible changes of skin, to begin O. from the anamnesis does not follow since the story of the patient before survey of skin can inspire in the doctor prejudiced opinion on the nature of a disease. Survey of the patient conducted on the course of survey is purposeful that to a large extent promotes establishment of the correct diagnosis.
At survey of skin and visible mucous membranes find out character primary morfol, elements of rash (see) and their evolution in secondary cells; define localization and interposition of separate elements of rash.
On the course of survey find out terms of emergence of elements of rash, the sequence of their emergence, communication of their emergence with season, days, and also character of subjective feelings (paresthesia, an itch, burning, pain, feeling of tension or tightening of skin) and opinion of the patient on the reasons of emergence sygsh (contact with the sick person, with a sick animal, drug intake, the disturbance of food previous or an associated disease, influence of beam energy, chemical irritants in life or on production etc.). At the same time consider close connection of diseases of skin with pathology of internals, a nervous system, a metabolism, heredity that helps to find out an etiology and a pathogeny Dermatolum, diseases and to appoint rational therapy. Define a consistence of primary element of rash by a palpation (dense, dense and elastic, pasty), its sensitivity to a touch, pressure.
Special methods of inspection Dermatolum, the patient are the poskablivaniye and imposing of an adhesive plaster for definition of character of a peeling (scaly, lamellar, follicular), sounding for definition of a consistence, a depth of an element of rash, and also a vitropressiya (see Dermoskopiya) for assessment of changes of his coloring.
Treat special diagnostic methods also so-called. skin tests (see), serving for detection of hypersensitivity of an organism to chemical substances, medicines and bacterial antigens. With the same purpose apply various methods of an immunodiagnosis (see) — studying serol, and tsitol, reactions.
If necessary apply additional laboratory researches. Apply methods of identification of an infestant in pathological material to diagnosis of infectious skin and venereal diseases (a scale, a tire of bubbles, hair, nails, a discharge of ulcers, erosion, urethras, vaginas, etc.) by microscopic methods of a research (see) native or stained preparation, research of cultures of activators on mediums, and also researches of skin and a hair in beams of a lamp of Wood. In doubtful cases conduct patogistol, a research of cuts of biopsirovanny pieces of the affected skin, tsitol, a research of smears prints. Laboratory researches at diagnosis of veins have special value. diseases: detection of a pale treponema in various syphilides, punctate limf, nodes at infectious forms of syphilis, a gonokokk in the separated from an urethra and other material at gonorrhea, a streptobacillus — at a venereal ulcer, serol, reactions to syphilis (Wassermann reaction, reaction of an immobilization of pale treponemas, reaction of an immunofluorescence, reaction of immune sticking of pale treponemas).
For simplification of diagnosis of venereal diseases use inspection of an estimated source of a disease.
Neurologic inspection gives the chance to reveal disturbances of functions of a nervous system, to define their nature and localization of defeat. In combination with additional methods of a research it allows to make a wedge, the diagnosis. Nevrol. Lake. begins with the analysis of complaints. Pay attention to character nevrol, disturbances, their localization, intensity, duration, find out influence of these disturbances on different types of activity of the patient (work, self-service etc.).
During the collecting the anamnesis use not only the data received from the patient but also results of poll of relatives. Many diseases of a nervous system have the hereditary nature therefore carefully study data of the family anamnesis, considering at the same time not only direct symptoms of a disease at relatives, but also states, close to a disease (e.g., at epilepsy — alcoholism, night enuresis, migraine, stutter). For establishment of existence hron, the diseases of a nervous system connected with inf. processes, detailed data on the previous infectious diseases, undifferentiated hyper thermal states, etc. are necessary. At nevrol, inspection of children specification of the obstetric anamnesis at mother, the pregnancies given about a current, childbirth, a puerperal period, about timeliness of locomotory and intellectual development matters.
For establishment of an etiology of a disease data of the anamnesis on work of the patient, a profession, kind of work, dependence of development of painful symptoms on environmental factors can have special value.
Survey of the patient is begun with assessment of his situation (active, passive, forced), poses, bearings, compliances to passport age. Reveal features of a constitution, a configuration of a skull, skeleton structure, change of a form, expression, and also complexion of the patient (crescent-shaped, bird's, akromegalo-idny, amimichny, cyanochroic, purple-red etc.).
At a research nevrol, the status use various special methods for identification of all-brain and meningeal symptoms, assessment of a condition of cranial nerves, sensitivity, movements, coordination, vegetative and highest cortical functions.
A research of meningeal symptoms (see. Meningitis ) includes assessment of a pose of the patient (a pose of a gun dog of a dog), detection of the general skin hyperesthesia, hypersensitivity to acoustical and visual irritants, muscle tensions of a nape, a lockjaw, tension of a fontanel at children, a ladyeobrazny stomach, Kernig's signs — Brudzinsky, Giyen, Bekhterev, Le Sage, etc.
The research focal nevrol, symptoms is conducted step by step with consecutive studying of a condition of a cranial innervation, the motive sphere, sensitivity, vegetative functions of the highest cortical functions, the emotional and strong-willed sphere, and at each stage the research begins with survey.
Cranial nerves investigate by means of specific loadings.
The I couple (olfactory nerve) is investigated according to sense of smell by means of set various ^пахучих substances (see. Olfaktometriya ), reveal an anosmia or a hyposmia, olfactory hallucinations. Funkts, a condition of the II pair (optic nerve) define, estimating visual acuity and color sensation by means of special tables (see Visual acuity, Color sight), and also measuring a field of vision (see); reveal amblyopias), an amaurosis, disorders of color sensation, disturbance of zero sight (a hemianopsia, concentric narrowing etc.). At a research III, IV and VI of couples (the third cranial nerves which are taking away nerves, block nerves) estimate width and symmetry of palpebral fissures, a form, size of pupils, their photoharmoses (direct, consensual), convergence, accommodation, volume of movements of eyeglobes; reveal doubling in eyes, a ptosis, an exophthalmos, an enophthalmos, anisocorias), absence, slackness or a perversion of reaction of pupils to light, squint, a difference of standing of eyeglobes down, disturbance of the combined movements of eyes (paresis, paralysis of a look), disorders of convergence, an ophthalmoplegia. The V couple (trifacial) is investigated, estimating the movements of a mandible, tension and a trophicity of masseters, sensitivity of skin of muscles, morbidity in points of an exit of branches of a nerve, corneal, conjunctival and mandibular reflexes, a reflex from mucous membranes of a nose; reveal paresis and paralyzes of masseters, disorders of sensitivity on a face (segmented, peripheral, conduction). The VII couple (facial nerve) is investigated on function of mimic muscles and flavoring sensitivity on front 2/3 languages; reveal paresis and paralyzes of mimic muscles, disorders of taste, a ginerakuziya, dacryagogue.
For a research VIII of pair of nerves — its predoor and cochlear parts (see. Eighth cranial nerve ) — define auditory acuity on the right and at the left — perception of the shepotny speech, high-pitch and low tones of tuning forks, existence of a nystagmus, make an audiometriya (see); find out whether there is dizziness, disturbance of balance, nausea, vomiting, investigate vestibular functions by means of a vestibulometriya (see). For assessment IX and X couples (the glossopalatine and wandering nerves) investigate swallowing, phonation, an articulation, sensitivity of a throat and language, taste on a back third of language, palatal and pharyngeal reflexes; reveal droop of a palatine velum, asymmetric position of a uvula, a nasal shade of a voice, a poperkhivaniye at food, disturbance of an articulation, pathology of palatal and pharyngeal reflexes, dysfunction of unstriated muscles of heart, bronchial tubes, intestines. The XI couple (eleventh cranial nerve) is investigated by position of shoulders, shovels, by the heads; reveal asymmetry of shoulders, shovels, change of tension and a trophicity gr fish NOC of l yuchichno-sos tse-shaped and trapezoid muscles.
Function XII of couple (hypoglossal nerve) is investigated but to the provision of language in a mouth and at protrusion; reveal a deviation of language aside, a dysarthtia, disturbance of formation of a food lump, an atrophy of muscles of language, fibrillar twitchings.
At a research of cranial nerves it should be noted existence or lack of reflexes of oral automatism — hobotkovy, sucking, lip, mental, nazolabialny, a distanza-oral-nogo, palmar and mental, etc.
The research of the motive sphere is made by survey of muscles, assessment of a condition of their trophicity and a tone, studying of movements of different body parts and character of reflexes. At survey pay attention to symmetry of development of muscles, disturbance of a bearing and gait, existence patol, movements, synkineses, hyperkinesias, fibrillar and fascicular twitchings. The atrophy and a myopachynsis are revealed by comparison of a relief of muscles on symmetric sites of a trunk and extremities and by their measurements by means of a centimetric tape. Investigate the volume of active movements. At the passive movements, i.e. the movements made by the researcher determine the volume of movements in joints, existence of contractures and a muscle tone — normal, raised, reduced, uneven, changing. Force of muscles is determined by resistance, a cut the patient can render to the passive movement in this or that joint, on the volume of active movements, and also by means of a dynamometer and special tests (see. Muscular work , Ergografiya ).
Investigate tendon, periosteal, cutaneous reflexes. Note a hyporeflexia, a hyperreflexia, an areflexia, reflexogenic zones. Investigate mechanical excitability of muscles and nervous trunks. Reveal hand patol, reflexes (Rossolimo, Jacobson — Lyask, Zhukovsky, a clonus of a brush),-foot patol, reflexes (Babinsky, Oppengeym, Gordon, Schäffer, Redlikh, Bekhterev, Rossolimo, Zhukovsky, Pusepp, clonuses of patellae and feet, protective reflexes), synkineses (see. Protective reflexes in pathologies, the Clonus, Reflexes pathological, Synkineses).
The research of coordination includes studying of gait, features of the speech, performance by the patient static and dynamic the coordinator-nykh of tests (Romberg's pose, Sharbo, paltsenosovy and calcaneal and knee, Shildera, a diadochokinesia, synergies). Reveal a static and locomotory ataxy, adiadokhokinez, an asynergia, a dizmetriya, a scanning speech (see. Ataxy ).
The research of superficial sensitivity is conducted drawing on skin of cold, thermal, pain, tactile stimulations of various intensity (see. Esteziometriya ). Reveal anesthesia, a hyperesthesia, hypesthesias), a dizeste-ziya, a hyperpathia, pain with their detailed characteristic. Analyze conditions, at to-rykh these disturbances appear, amplify or decrease. Reveal conduction, segmented, peripheral types of disturbance of sensitivity. Pay attention to antalgichesky poses. Investigate symptoms of a tension — Lasega, Wasserman, Mickiewicz, Nery, symptoms of landing, painful points of a trifacial, occipital, juxtaspinal, awned, morbidity of nervous trunks, Zakharyin's zones — Geda, pains at percussion of a skull and backbone. Deep sensitivity is investigated by means of passive movements in various joints at the closed eyes. Reveal a sensitive ataxy.
At a research of difficult types of sensitivity — a stereognosis, localizations of parts of a body, two-dimensional and space feeling — reveal an astereognosis, an autotopagnosia, frustration of two-measures-but-space feeling (see. Sensitivity ).
The research of the vegetative and trophic sphere includes assessment of a trophicity of skin, nails, hair, expressiveness and features of distribution of hypodermic cellulose. For a research of vegetative functions study a dermographism, hypersalivation, sebaceous secretion, skin temperature, an urination, defecation, carry out orthostatic tests (see). Analyze the nature of paroxysmal frustration (faints, dizzinesses, urticaria, a Quincke's edema, vasculomotor rhinitis, bronchial asthma, diencephalic attacks, etc.).
The research of the highest cortical functions includes assessment of a praksis, a gnozis, the speech, letter, reading, the account, orientation, memory, attention, the emotional sphere, interests, behavior, intelligence with use of special methods, tests and tasks. Reveal apraxia, agnosia, aphasia, an alexia, an acalculia, amnesia, emotional frustration, decrease in intelligence, a behavior disorder, etc.
Receptions nevrol. Lake. choose taking into account age of the patient and weight of his state. Special approach would be demanded by O. in coma (see). At the same time depth of a loss of consciousness, existence of spasms, meningeal and focal symptoms of defeat of a nervous system comes to light.
Degree of a loss of consciousness is determined by the nature of response to external irritants, a condition of pupillary tests, corneal, conjunctival, palatal and pharyngeal reflexes, by extents of decrease in tendon and cutaneous reflexes, to existence of an involuntary urination and defecation. In coma Meningeal symptoms can not be defined, or patients have a mimicry of suffering during the calling of a symptom of Kerni of hectare or at a prelum the four-head of a muscle of a hip (the shell symptom of Bogolepov). At a research of cranial nerves it should be noted the size of pupils, character of their photoharmose, an anisocoria), the floating movements of eyeglobes, squint and its features, paresis of a look, a nystagmus, hypotonia a century, symptoms Gref, Bernard — Horner, a «parusyashchy» cheek, asymmetry of nasolabial folds, bulbar and pseudobulbar symptoms. For detection of paresis and paralyzes investigate a muscle tone, and also apply the special tests revealing weakness of muscles (symptoms of rotirovanny foot of Bogolepov, Barret's test, etc.). Reveal patol, reflexes, synkineses and other involuntary movements.
At inspection of a nervous system of children of early age assessment of instinctive reflexes, dynamics of formation of motive and mental functions, features of the speech and comparison of data of inspection to the relevant age standards is important.
Additional methods of inspection nevrol, apply the patient to definition or specification of character patol, process.
The research of an eyeground allows to judge a condition of vascular system of a brain and changes of a brain blood-groove, a condition of intracranial pressure indirectly.
The analysis of cerebrospinal liquid (see) helps to diagnose meningitis, encephalitis, an arachnoiditis, tumors, degenerative changes, hydrocephaly. Widely use rentgenol, diagnostic methods — a kraniografiya (see) and a spondilografiya, a cerebral angiography (see), a pneumoencephalography (see), a ventrikulografiya (see), a miyelografiya (see), a computer tomography (see the Tomography computer), and also tracer techniques. The X-ray analysis of a skull is applied to diagnosis intracranial patol, processes, injuries of the head and patol, processes of bones of a skull; a X-ray analysis of a backbone — at patol, changes in vertebrae and the copular device. The pneumoencephalography and a ventrikulografiya are valuable diagnostic methods at diseases of c. and. page. By means of an angiography diagnose various vascular diseases of a brain: anomalies of development of vessels, aneurisms, tumors. The contrast miyelografiya is applied to topical diagnosis of diseases of a spinal cord. Tracer techniques of a research specify localization of the center of defeat at tumors and pseudoneoplasms. The computer tomography is one of the most perfect methods rentgenol, diagnoses focal patol, processes in a brain.
Genetic methods of a research — genealogical, cytogenetic, use a dermatoglyphics for diagnosis of hereditary diseases, chromosomal diseases. Biochemical, methods of a research allow to reveal the diseases of a metabolism proceeding with defeat of a nervous system.
O. with diseases of ENT organs begins with collecting the anamnesis and detection of complaints of the patient. At the same time pay attention to the complicated breath, dysphagias, change of a voice, a hearing impairment, dizziness, loss of balance, change of sense of smell, existence of allocations from ears, a nose. From all main methods O. the greatest value has survey.
Examine in the darkened office with use of a bright hard lighting from the 60 — 100 W electric desk lamp and use of a frontal mirror and other otorhinolaryngological tools (see). At first make outer inspection of ENT organs, paying attention to their anomalies, deformations, cicatricial changes, fistulas, a condition of integuments, mobility of facial muscles. Examine and feel regional limf, nodes.
After outer inspection make endoscopy (internal survey). As all ENT organs anatomically are also functionally tied among themselves, irrespective of complaints of the patient, all ENT organs surely are subject to survey.
Survey of a nose — rinoskopiya (see) carry out for assessment of a condition of a nasal cavity, a mucous membrane of a nose, nasal sinks; define the provision of a nasal partition, contents in the nasal courses. The bellied probe feel found patol. educations, estimate their density, mobility. Localization patol, allocations in the nasal courses has great diagnostic value. The condition of okolonosovy bosoms is defined with the help diafanoskopiya (see) and more precisely — gaymorografiya (see). Survey of a nose and okolonosovy bosoms comes to the end with a research olfactory (see Olfaktometriya) and respiratory functions.
Survey of a throat — faringoskopiya (see) gives an idea of a condition of a mucous membrane of an oral cavity and throat (for what estimate its color, gloss, define existence of plaques, hemorrhages, ulcerations, rashes, new growths, infiltrates), and also about a condition of a lymphadenoid ring, side rollers, granules on a back wall of a throat, palatal handles, a soft palate. An upper part of a throat — a nasal part of a throat is examined by means of a nasopharyngeal mirror, and if necessary carry in addition out manual palpation. A guttural part of a throat is examined by means of a guttural mirror, at the same time pay attention to a condition of a lingual almond, poles of an epiglottis, pear-shaped pockets, an epiglottis.
Survey of a throat — a laringoskopiya (see) make, using guttural mirrors or the laryngoscope in three provisions: at usual breath, at phonation and at a deep breath. Estimate a condition of a mucous membrane of a throat, its color, gloss, a configuration of arytenoid cartilages, interarytenoid space, a condition of vestibular folds, mobility and a condition of a medial surface of true voice folds, and also reveal existence of hemorrhages, infiltrates, plaques, crusts, tumors, hypostasis, an immovability of one or both half of a throat. Pay attention to respiratory and golosoobrazovatelny functions. If necessary the laringoskopiya is supplemented with a stroboskopiya (see).
Survey of an ear — otoskopiya (see) allows to estimate a condition of an auricle, outside acoustical pass, a tympanic membrane, and at its absence or extensive perforation — a drum cavity. R1meyut a form and an arrangement of perforation, the nature of allocations and them began to smell value. Otoskopiya if necessary is supplemented with a X-ray analysis of a temporal bone.
Acoustical function is investigated first of all by definition of sharpness of speech hearing (on distance of audibility of the shepotny speech, a cut 6 — 7 m normal are equal) and is supplemented with a research tuning forks and an audiometriya (see) with use of a number of special tests (see. Bing test , Weber experience , Zhelle experience , Rinne experience , Federichi experience , Shvabakh experience ).
Ventilating and drainage functions of an acoustical pipe are determined by manometers (see. Manometriya ear ) and in a pressure chamber.
About a condition of a vestibular analyzer judge both by complaints of the patient, and by vegetative and motor reactions, to-rye arise at irritation of a vestibular analyzer adequate and inadequate irritants (see. Vestibulometriya ). Identification of a nystagmus is of great importance for diagnosis of defeat of a labyrinth, to-ry it can be written down by an oscillograph (see. Elektronistagmografiya ).
Ophthalmologic inspection represents set of researches of function of the visual analyzer and a condition of an eyeglobe and its appendages special techniques. It is almost always combined about an all-wedge, methods O., since changes of an organ of sight are often connected with diseases of other systems. So, a research of an eyeground (see. Oftalmoskopiya ) it would be applied at O. with diseases of c. N of page, kidneys, cardiovascular, respiratory, endocrine and other systems (an angiopatiya and a retinopathy — at arterial hypertension and at a diabetes mellitus, a congestive disk and an atrophy of an optic nerve — at intracranial patologich. processes). Damages of eyes can be complications of the general infectious and parasitic diseases (conjunctivitis, a keratitis, a sclerite, a uveitis, a retinitis), and also a consequence of reception of high doses of corticosteroids, antimalarial, neuroplegic and somnolent drugs, antidepressants, tranquilizers and other medicamentous means (a ptosis, a nystagmus, a miosis or a mydriasis, a spasm or paralysis of accommodation, a diplopia, a cataract, an atrophy of an optic nerve).
Special methods Ophthalmolum. Lake. are intended for definition of functions of the visual analyzer (cm. Kampimetriya, Visual acuity, Perimetry, Skotometriya, Color sight), and also for assessment of a condition of an eyeglobe and the fabrics surrounding it for what use focal illumination, a transmitted light, biomicroscopy of an eye (see), a gonioskopiya (see), a diafanoskopiya (see), an oftalmoskopiya (see), a fluorescent angiography (see).
Acquaintance of the doctor to the patient begins with clarification of the complaints defining focus of poll. So, if the patient is disturbed by dacryagogue, it is necessary to find out whether there is it under certain conditions (action of cold, winds etc.) or is observed constantly and does not depend on any conditions. At complaints to decrease in sight specify distance, on Krom visibility of objects (worsens at a look afar or during the performance of work at a short distance). Detailed inquiry of the patient helps to gain the correct impression about the nature of a disease and to assume the diagnosis.
From the methods intended for studying of a condition of covers of an eyeglobe the most widespread are a method side, or focal, lighting and a research a transmitted light.
The method of side lighting allows to examine in details skin and edges a century, a conjunctiva, a sclera, a cornea, an anterior chamber, an iris, a front surface of a crystalline lens in the field of a pupil. The research is conducted in the darkened room. At the left and several kpereda from the patient (approximately at an angle 45 ° to the plane of the person), at distance of 50 — 60 cm place a desk lamp of 60 — 100 W. The doctor sits down opposite to the patient, index and big fingers of the right hand takes a biconvex lens +13 dptr and, holding it is perpendicular on the line a bulb — the studied eye, concentrates rays of light on the studied part of an eyeglobe. Thanks to the created contrast between brightly lit small site and dark next parts even insignificant patol, changes of fabrics rather easily come to light. If for survey to use a binocular magnifying glass, these changes are visible even more accurately.
The research in a transmitted light is intended generally for assessment of a condition of a crystalline lens and a vitreous. It is also carried out in the darkened room, but the light source is several kzada from the patient. The doctor, holding the right hand an oftalmoskopichesky mirror at the right eye, directs the bunch of beams reflected by the ophtalmoscope to area of a pupil of the studied eye. If the crystalline lens and a vitreous are transparent, then the doctor, observing through an opening of the ophtalmoscope, will see a uniform red luminescence in the field of a pupil. Opacifications in optical environments will be allocated on a red background of a pupil in the form of separate hulls.
If the most part of a cornea is transparent, then the technique of side lighting or a research in a transmitted light can use for assessment of a condition of average and deep layers of a cornea and structures of an eyeglobe located behind it. In case of disturbance of transparency of a cornea visible beams cannot provide sufficient information. In this case use the infrared diagnostic unit, to-ry it is suitable not only for a research by method of side lighting or in a transmitted light, but also for an oftalmoskopiya, a gonioskopiya, a diafanoskopiya, transillumination and a biomikroskoniya. The last with big effect can be executed by means of an infrared slit lamp (tsvetn. fig. 4 — 6).
Lake. by method of side lighting with use of infrared beams gives the chance to specify weight of defeat of a cornea and to see contusional or inflammatory changes in an anterior chamber and an iris. In a transmitted light of these beams estimate transparency of a crystalline lens and vitreous. The biomicroscopy by means of an infrared slit lamp allows to detail depth of defeat of a cornea. The Gonioskopichesky research in infrared beams reveals the smallest foreign bodys which are in a corner of an anterior chamber. At suspicion on a hemophthalmia, a subconjunctival rupture of a sclera, on existence pristenochno of the located intraocular foreign body transillumination by infrared beams is useful.
Survey of the nek-ry structures of an eye which are not looked through at usual lighting can be carried out by means of ultraviolet rays. So, the luminescence caused by sources of ultraviolet radiation allows to differentiate more precisely tumors of front department of an eye and its appendages, it is better to see cortical layers of a crystalline lens during ekstrakapsulyarny extraction of a cataract.
Dental inspection includes inspection of bodies and tissues of an oral cavity, front area and an upper part of a neck. It begins with clarification of complaints and the anamnesis of a disease. After that examine outside covers of the person and upper part of a neck for establishment of possible changes of their configuration and coloring. Pay attention to outlines of the person, symmetry of the right and left its half, coloring of skin, a form and size of lips, the sizes of an oral crack, existence of inborn uglinesses and the acquired defects (hems and their character), extent of opening of a mouth, and also to symmetry of movement (movement) of the fabrics surrounding an oral crack at a conversation, to purity of the speech.
By palpation define a condition of soft tissues and a facial skeleton (morbidity, deformations, new growths, patol, mobility of certain sites), a state limf, nodes (increase, mobility, cohesion with the subject fabrics, morbidity).
During opening and closing of a mouth consider the volume and correctness of the movement of a mandible (shift aside), check the volume of lateral motions of a mandible.
Having entered the ends of little fingers of the right and left brush into outside acoustical passes and pressing a front wall of the last, define during vertical and horizontal movements of a jaw situation and mobility of a temporal and mandibular joint, emergence of a crunch or clicking in a joint, existence or lack of morbidity during the movement of a mandible and palpation of this joint.
At inspection of sialadens and their output channels consider changes of size of glands, absence or existence of morbidity, limited or diffusion consolidations and morbidity but to the course of salivary channels of submandibular and parotid glands, character of the emitted saliva. In some cases resort to sounding of salivary channels (existence of a concrement, cicatricial narrowing).
Inspection of an oral cavity is made by means of the pallet, and also special dental tools (see). Begin with survey of a mucous membrane of lips, cheeks, alveolar shoots, a hard and soft palate, language, hypoglossal area. Pay attention to a degree of wetness and coloring of a mucous membrane of these departments, existence of puffiness, bleeding of a mucous membrane (sites of the exfoliated epithelial cover, an erosion, a hyperkeratosis, etc.), existence of inflammatory swelling and new growths, inborn crevices of the sky. Examine as well a back wall of a throat.
At a palpation reveal availability of infiltrates and new growths in the thickness of soft tissues, deformations and new growths in the field of an alveolar shoot and partially a body of a top and bottom jaw, and also a bony frame of a hard palate. At inflammatory processes define morbidity and quite often fluctuation. At palpation of a tumor specify its borders, a consistence, depth of an arrangement, mobility of the new growth and the soft tissues covering it. At ulcers it is important to establish existence or lack of morbidity, density of edges, infiltration of surrounding fabrics, a state regional limf, nodes.
At survey of teeth define their amount, size, an arrangement, a form, color and a condition of enamel, existence and localization of carious damages, adjournment of plaques and a dental calculus, degree of mobility of teeth and the size of intervals between them, existence patol, dentogingival pockets, quantity and character separated from them, reaction of teeth to temperature and electric irritations (see. Teeth, methods of a research ).
The probe explore the sites unavailable to survey define degree of a softening of solid tissues of tooth and size of carious defeat, morbidity, the message of a carious cavity with a pulp, and at perforation — with surrounding fabrics.
During the sounding of a dentogingival pocket determine its depth; it is better to conduct this research the graduated probe with millimetric otmetk am and.
Percussions on tooth make in two directions (vertical and horizontal) for identification of degree of morbidity of a parodont and localization in it patol, process (at a top of a root, at a neck of tooth).
It is important to establish a ratio of dentitions — bite (see).
The most important of additional methods of a research in stomatology is the X-ray analysis, with the help a cut specify a condition of bone tissues of a facial skeleton: existence of a tumor, change, change of bone tissues as a result of inflammatory process, a condition of okolonosovy bosoms; reveal also existence of difficult diagnosed carious cavities in the field of contact surfaces of teeth, dental health (changes, curvatures), existence of the impacted teeth, foreign bodys.
A X-ray analysis by means of contrast agents — a sialografiya (see) apply at diseases of sialadens, at cysts and tumors, to definition of the direction of the fistular course, specification of provision of the inflammatory center in a jaw, clarification of a condition of a mucous membrane of a genyantrum.
According to indications carry out additional clinical and laboratory methods of a research: a puncture, tsitol, a research of punctate and prints from the site patholologically the changed fabrics, a biopsy, an intracutaneous allergy test, chewing test, a mastikatsiogra-fiya (with - m. Chewing), wedge., biochemical, and serol, blood tests, analyses of urine, bakterioskopichesky and bacterial. research.
Among new funkts, methods stomatol. Lake. pletizmografichesky techniques in options of a reopletizmografiya and photo-pletizmografii gained development.
Reodontografiya (reopletizmografiya of a pulp of tooth) is carried out in the bipolar or focusing way with a frequency of current of 600 — 800 kHz (depending on the size of tooth) by means of electrodes of a special form and the sizes on standard reopletizmograf (see. Reografiya ). Reoparadontografiya — a reopletizmografiya of a parodont, a mucous membrane of an oral cavity, face skin, sialadens and jaws will be seen off bipolar, tetrapolar and focusing in the ways.
Reopletizmogramma calibrate inclusion of standard resistance, usually equal 0,1 ohms.
Fotodontografiya (a fotopletizmografiya of a pulp of tooth) and a fotoparo-dontografiya (a fotopletizmografiya of a regional parodont) will be seen off by means of special photoplethysmographs and sensors. Fotodontografiya is carried out in the transmitted light (brought to the studied fabrics on fiber glass light guides) with use as a light source of the semiconductor laser generating a light flux in an invisible part of a range that allows to conduct beskontaktno researches patholologically changed (ulcerations, strupa, pigmentation) or painted (methylene blue, tetraethyl-diamino-triphenyl-carbohydride sulfate, spirit solution of iodine) fabrics. Fotoparodontografiya is carried out in a reflected light, using two light guides for illumination of fabric and the photo diode as the receiver. Apply the crystal possessing a high electrooptical constant to calibration of photoplethysmograms, on to-ry give the calibrated tension proportional to the optical density of fabric.
Pletizmografiya in stomatology is applied with use special funkts, and pharmakol, tests: influences of vasoactive means (e.g., nicotinic to - you), temperature irritants (thermal, cold) and dosed (by means of gnatodinamometr) a masticatory stress at a research of a parodont and jaws. These methods help to define indications to pathogenetic therapy and to estimate efficiency of treatment.
Urological inspection includes use of both all-clinical, and special methods of a research.
At history taking and assessment of complaints of the patient consider that the most frequent symptoms the Urals, diseases are frustration of an urination, the pain in lumbar and inguinal areas irradiating to the area of a bladder and generative organs, a quantitative and qualitative change of urine, allocation from an urethra, and men have an impotence and infertility. Pain shall be analyzed carefully. At an allotopia of kidneys localization and irradiation of pain can be atypical that leads quite often to diagnostic mistakes. The intensive acute pain (renal colic) is connected with disturbance of outflow of urine or disorder of intra renal blood circulation; similar pain is observed also at an uric reflux. The attack of pain can be provoked by an error in a diet, the physical tension, concussion, cooling. Pains can accompany fever, a hamaturia, an otkhozhdeniye of a concrement, shock, an anury. Constant pain is observed to a thicket at an inflammation, a tumor of a kidney, a nephroptosis, a hydronephrosis. Diseases of the lower uric ways are followed by pain in the bottom of a stomach and a crotch. Frustration of an urination (dysuria) can have character of the urination complicated (strangury), speeded up (pollakiuria), acute or hron, delays of an urination (ischuria), incontiences of urine, including during sleep (night enuresis), overdue removal of liquid from an organism with urine (opsiuriya), shift of the main diuresis for night time (nocturia). The amount of the separated urine can be increased (polyuria), reduced (oliguria), in nek-ry cases education and department of urine stops (anury). Discoloration of urine is observed at considerable impurity of blood in it (hamaturia), pus (pyuria), a lymph (chyluria), phosphates (fos-faturiya), free hemoglobin, a myoglobin, melanin, porphyrine, bilious pigments, medicines. In nek-ry cases it is possible to observe allocation with urine of air traps (pneumaturia), maggots, parasites, scraps of nekrotizirovanny fabric of a tumor. Very essential moment in assessment of urodynamic is the big duration of the act of an urination, reduction of force of an uric stream, incomplete bladder emptying. Out of the act of an urination or an ejaculation from an urethra blood (urethremorrhagia), pus, sperm (spermatorrhea), a prostatic secret (prostatorrhea) can be emitted.
At survey pay attention to a habit view and a pose of the patient, a xanthopathy from frequent use of a hot-water bottle, to postoperative hems, fistulas or hernias in lumbar and inguinal areas, a condition of urinogenital bodies. It is possible to see the increased kidney eminating through an abdominal wall and vystoyashchiya over a pubis the crowded bladder; maceration of skin of inguinal area, a crotch and hips at an incontience of urine; expansion of saphenas on an abdominal wall at tumors; change of a form and the sizes of a scrotum at a cryptorchism, an edema or elephantiasis. The flexion contracture and assignment of a hip allow to suspect the started paranephritis. At survey of a penis it is possible to observe a short bridle, synechias between a head and a prepuce, a phymosis with formation of smegmolit. On a head and a prepuce the syphilitic chancre, a cancer tumor can be located.
The palpation of kidneys is carried out in position of the patient on spin, on one side and standing. In the beginning make a superficial palpation, then if there is no expressed morbidity, deep. Only the lower pole of a right kidney is usually probed; at people with a flabby abdominal wall it is possible to probe both kidneys. Completely kidneys are available to a palpation at a nephroptosis and an allotopia. By a palpation determine the sizes, a form, a surface condition, a consistence, mobility and morbidity of kidneys. Moderate increase in kidneys is observed at many inflammatory and dystrophic diseases, their significant increase and tuberosity are characteristic for polikisto for, small kidneys happen at a hypoplasia and a nephrosclerosis. Morbidity of kidneys is determined by also easy effleurage by a waist at the level of XII edge (see. Pasternatsky symptom ). Normal ureters do not manage to be palpated usually. At persons with a flabby abdominal wall sometimes it is possible to define patholologically the changed reinforced ureters. At women through a wall of a vagina it is possible to probe a stone in the lower third of an ureter. The bladder is available to a palpation through an abdominal wall when it is filled and will stand over a pubis, at women is area of a neck of a bubble and an urethra it is possible to palpate through a vagina. At men the prostate and seed bubbles are available to a manual research through a rectum. Determine the sizes of gland, its form, a consistence, an otgranicheniye from surrounding fabrics, existence of a median furrow, a smeshchayemost of a mucous membrane of a gut over it. Make massage of gland for receiving a prostatic secret. Bulbouretralny (kuperova) of gland can be probed on both sides from a bulb of a penis if to take a crotch between the thumb imposed on it and the index finger entered into a rectum. The urethra at men is available to a palpation to its prostatic part, at women — throughout. Pressing down an urethra a finger from top to down, define existence of allocations. On the course of an urethra hems, inflammatory infiltrates, diverticulums, stones, tumors, foreign bodys can be revealed. Inspect also cavernous bodies, a head and a prepuce of a penis; in the thickness of cavernous bodies sometimes accurately delimited, painless hardenings — a fibroplastic induration of a penis, hems, inflammatory infiltrates, a tumor and metastasises meet. The scrotum is palpated in position of the patient standing and lying, at the same time note a condition of an integument, its form, the sizes, existence between leaves of liquid, if necessary make a diafanoskopiya. Feel serially testicles, defining their form, the sizes, a consistence, existence patol, unions with covers. Consistently palpate an epididymis, defining a condition of a head, a body and tail. The palpation is completed a research of seed cords, abdominal rings and regional limf, nodes.
Use percussion for delimitation of a bladder and for differential diagnosis of gtakhovo-scrotal hernia and to the gidrotsela. Auscultation is necessary at inspection of vessels of kidneys: aneurism and a renal artery stenosis, an arteriovenous fistula of a kidney can be followed by rather intensive systolic noise over the place of defeat of a vessel.
Additional methods O. at the Urals, diseases are important very. The laboratory research includes bulk analysis of urine (see), quantitative definition of the main components of an uric deposit (see Kakovsky — Addis a method), active leukocytes, bacterial. a research of urine with definition of degree of a bacteriuria, sensitivity of bacteria to antibacterial drugs. Subject to a microscopic and bacteriological examination also a discharge from an urethra, a secret of a prostate. Tsitol, research of an uric deposit widely use at diagnosis of tumors of an ureter and a bladder. Function of kidneys is estimated on a daily urine, Zimnitsky's test (see Zimnitsky test), to tests on cultivation and concoction, clearance tests (see. Kidneys, methods of a research ). At a renal failure determine the content in blood of residual nitrogen, urea, creatinine, uric to - you, electrolytes, crude protein, the effective osmotic pressure of plasma, acid-base equilibrium. According to special indications establish amino-acid composition of blood and urine, investigate exchange of calcium and phosphorus, uric to - you, function of epithelial bodies, a condition of hemocoagulation and a fibrinolysis, a miyelogramma, immunoglobulins of blood, make a treianobiopsiya of a bone.
To the major tool methods the Urals. Lake 6. belong catheterization of an urethra p a bladder, an ureter, a pelvis (see Catheterization of uric ways), uretroskopiya (see), tsistoskopiya (see), hromotsistoskopiya (see). Visual examination of an ureter and a cavity of a pelvis (ureteroniyeloskopiya) can be conducted antegradno through nefrogshelosty or retrogradno by means of a special catheter with the fiber glass light guide.
Rentgenol, a research of bodies of uric system includes survey and excretory urography (see). At a big cyst of a kidney it is possible to execute a contrast kistografiya. Tumors of an adrenal gland, a kidney and a prostate sometimes are better diagnosed if a X-ray analysis supplement that mo-, a zonografiya and a pneumoretroperitoneum (see); the computer tomography is very perspective for these purposes. The research of a bladder and urethra includes survey, the contrast ascending and descending uretrotsistografiya (see. Uretrografiya ), a sedimentary and lacunary tsistografiya (see), a peritsistografiya.
At pnfravezikalny obstruction uretrotsistografiya, the combined Uretrografiya, and also an urokinomatografiya are shown. Helps with diagnosis of uric fistulas Fistulografiya (see). At tumoral and vascular damages of kidneys apply also the angiography including a survey abdominal and pelvic aortoarteriografiya (see. Pelvic angiography), the selection renal angiography (see), a kavogra-fiya. To specify a stage of tumoral process and it is correct to plan ways of treatment the pelvic limfova-zoadenografiya helps.
Essential value in inspection the Urals, the patient have tracer techniques: a direct and computer renografiya (see. Renografiya radio isotope ), renotsistografiya, scanning, dynamic stsintigrafiya (see) and indirect angiography of nights. Ultrasonic methods of a research, a laparoscopy, an elektroureterografiya, an urokimografiya, a puncture and electroresection biopsy of a prostate, a tsistometriya, a sfiikterometriya find application (see. Bladder, methods of a research ).
Diagnosis of disturbances of sexual function and infertility at men, a hypogonadism and intersexuality demand definition of a sex chromatin, concentration in blood of a gonadotrophin, horiogonin, prolactin, uric excretion of testosterone, estrogen, total 17 oxycorticosteroids, 17 ketosteroids and their fractions. One of indispensable conditions of inspection is scoping of an ejaculate, contents in it mobile forms of spermatozoa, a type of an arborization of a prostatic secret. In some cases the puncture biopsy of a small egg and its appendage, a X-ray contrast genitografiya is shown. At a belly anorchism and after transplantation of a small egg apply scanning of testicles, an angiography.
Features of inspection of children
the Anamnesis, especially at inspection of children of early age, collect, as a rule, asking parents. It is better to carry out inquiry in the presence of the child that he could get used to the doctor, a surrounding situation, and the doctor could carry out partial survey at this time, watching it. At inspection of the senior children it is better to collect the anamnesis in the absence of the child. Usually give to parents the chance to express completely a disease of the child, and then direct the story of mother or child by additional questions so that to receive the data lacking, interesting the doctor. They shall contain the general data on the child (a passport part), the characteristic of complaints with their posistemny specification, the anamnesis of this disease and the anamnesis of development of the child.
At detection of the general data special attention is paid on contact of the child with patients inf. diseases and visit of child care facility. During the collecting the anamnesis of development of the child find out the following: 1) from what pregnancy and childbirth this child, the state of health of mother during pregnancy, the course of childbirth; 2) current of the period of a neonatality; 3) main stages of physical and psychological development of the child; 4) food, especially on the first year of life; 5) terms of carrying out preventive inoculations and reaction to them; 6) the postponed diseases, their weight, complications; 7) whether hemotransfusions, plasmas and reaction to them took place; 8) aller-goal. anamnesis (reaction to separate foodstuff, drugs, etc.); 9) the family anamnesis — the age of parents, their profession, the most important diseases transferred them; number of pregnancy and childbirth, number of natural and artificial abortions, and also reasons of premature interruption of pregnancies, number of living children, their age and health; 10) characteristic of material living conditions.
Objective inspection of the child is begun with carrying out the general survey differentiated depending on age and features of its state. Children up to 3 — 4 years need to be undressed completely — to bare seniors gradually, as required. First of all an assessment of the general state is given, the constitution, proportionality of separate parts of a body, growth, deformation of a skeleton, paralyzes of extremities is defined. Pay attention to coloring of skin and visible mucous membranes, existence or absence of rash, hypostases. Especially attentively it is necessary to examine skin folds on a neck, behind auricles, axillary hollows, inguinal folds, a circle of an anus where most often there is intertrigo and other skin defeats. At survey of a pilar part of the head pay attention to baldness, especially on a nape at babies. Survey of an oral cavity and pharynx should be referred for the end of objective inspection. The received results need to be added with a superficial palpation, with the help a cut define humidity or a xeroderma, its temperature, sensitivity, thickness, elasticity. At children of early age definition of elasticity of skin is of especially great importance. For this purpose it is necessary to take skin in a small fold big and index fingers of the right hand in places, where few fatty deposits (on a dorsum of a brush, on an elbow bend), then to release. Elasticity of skin is defined also on a stomach or a breast. For assessment of a hypodermic take big and index fingers of the right hand not only skin, but also hypodermic cellulose. Determine thickness of a hypodermic in various places (on a breast — between a nipple and a breast, on a stomach — at the level of a navel, on spin — under shovels, on the medial surfaces of a hip and shoulder, on a face — in cheeks). Turgor of soft tissues is determined by a prelum big and index by fingers of the right hand of skin and all soft tissues on the medial surface of a hip or shoulder.
The research limf, nodes is conducted by method of a palpation (see): index and average fingers of both hands symmetrically probe nodes; at assessment of their state it should be noted quantity the found limf, nodes, their sizes, a consistence, mobility, the relation to adjacent cross-links, surrounding fabrics, skin and hypodermic cellulose, sensitivity, a condition of skin over them.
At a research of muscular system of the child it is necessary to estimate extent of development of separate muscular groups, a tone and force of muscles, volume and the nature of the movements which are carried out by them. The tone of muscles is estimated on degree of resistance to bending and extension of hands and legs.
The bone system is investigated by means of survey and palpation consistently in the following order: head, trunk, top and bottom extremities. At survey of the head determine the size and its shape, a ratio of a front and brain part of the head. Fontanels, seams, density of bones of a skull investigate palpation them both hands (thumbs on a forehead, a palm — on temporal areas, other fingers consistently feel all surface of a skull). Pay attention to existence of a softening of bones, especially in a nape (craniotabes) or consolidation of bones of a skull. At a palpation of a big fontanel determine its size (distance between two opposite sides), a condition of edges, protrusion or retraction. At survey of a thorax it should be noted its form, existence of deformations; at a palpation on average edges (V—VIII) define rachitic «beads» — thickenings on border of a costal cartilage and a bone part of an edge. Running a finger from top to down over acanthas of vertebrae, it is possible to gain clearer idea of the sizes of scoliosis. At survey of upper extremities pay attention to a thickening of an epiphysis of a beam bone («brasletka») and a diaphysis of phalanxes («thread of pearls»). It is necessary to inspect carefully all joints of extremities taking into account their form, mobility and morbidity.
The research of a respiratory organs is begun with the survey allowing to estimate passability of upper respiratory tracts, depth, frequency and a respiratory rhythm, inflating of wings of a nose, participation of auxiliary respiratory muscles etc. Calculation of a respiration rate is made also the hand put on a breast or a stomach, and at newborns and babies — by means of the stethoscope brought to a nose of the child (it is better during sleep). For assessment of a condition of a respiratory organs features of shout, crying, a voice and cough matter. Determine by a palpation voice trembling at children of early age during shout, at the senior children — the same as at adults. At percussion of lungs it is important to pay attention to the correct position of the child providing symmetric position of a thorax. Percussion of a front surface of a thorax at children of chest age it is better to carry out them in situation lying on spin, a back surface — in a sitting position, and small children need to be supported. Percussion at the children who are not able to hold the head can be carried out, having put them on a stomach or having taken the child on a hand. It is the best of all to percuss children of early age, having put them on a table — in a sitting position or costing the senior children. At percussion of a back surface of a thorax suggest the child to cross hands on a breast and at the same time slightly to bend down kpered. At percussion of its front surface the child shall lower hands along a body. At the senior children mediocre percussion, at younger — direct is applied (see Percussion). Percussion borders of bottom edges of lungs at children determine by mamillar, average axillary and scapular lines. At children of advanced age measure mobility of pulmonary edges. It is the best of all to make auscultation of lungs in a sitting position of the child, at children of early age — with the hands taken to the parties or bent in elbows and pressed to a stomach.
Inspection of cardiovascular system is begun with survey of visible vessels (a pulsation, swelling etc.) and areas of heart. The apical beat at babies is defined in the fourth mezhreberye as by survey, and palpation; since the end of the first year of life the push is probed in the fifth mezhreberye of a knaruzha from a nipple; at preschool age it is probed already knutr from the median and clavicular line. Heart rate is counted within 1 min. It is better to carry out percussion of heart in position of the patient lying, but it is possible also in a standing position. At delimitation of relative cordial dullness use mediocre or a plessesthesia on the same lines that at adults. Listening of heart of the child is made in vertical, horizontal and in situation on the left side in the same points, as at adults. Besides, at children surely listen to all area of heart, and also vessels of a neck on both sides. At measurement of the ABP the size of cuffs shall correspond to age of the child (width of a cuff shall make a half of a circle of a shoulder of the studied child).
At a research went. - kish. a path survey, a superficial and deep palpation, percussion, auscultation of a large intestine, stomach, liver, spleen, a pancreas, mesenteric limf, nodes are carried out as well as at adults. Borders of a liver determine by silent percussion from above by average axillary and median and clavicular lines, from below — on median and clavicular and median. Percussion of borders of a spleen is carried out on the average axillary line (define top and bottom borders), but the X edge behind and on its imagined continuation in front. Survey of an anus is obligatory.
At assessment of a condition of an urinary system by survey note aberrations from outside urinogenital bodies. The palpation which is carried out in position of the child on spin with slightly bent legs is of great importance. It is the best of all to run a research both hands at once. The healthy kidney, as a rule, is not probed. Morbidity of a kidney is revealed effleurage by an edge of one hand on a brush another, put palm on lumbar area of the patient. The bladder filled with urine easily is probed at children over a pubis in the form of the smooth formation of an oval form giving a stupid sound at percussion. Always it is necessary to pay attention to features of an urination and urine.
Inspection of a nervous system of the child and assessment of the obtained data change depending on his age a little. Given poll, for children of all age reaction of the child on surrounding, on stay in a day nursery, kindergarten,-tse, its attitude towards relatives and persons, foreign to it, etc. is noted; the emotional mood of the child, a condition of consciousness, existence of alalias, disorders of motive character is always considered.
At inspection of children of the first year of life pay special attention to a state fiziol, the reflexes inherent to this or that period: sucking, deglutitory, hobotkovy, etc., asymmetric, symmetric cervical reflexes etc. Estimate a condition of motive abilities of the child, features of development of the speech and other manifestations of century of N of; existence or absence at it these or those skills is noted. It is necessary to pay attention to a further differentiation of all these indicators and at inspection of children of more advanced age. The research and assessment of all types of sensitivity, reflexes from mucous membranes of an eye and a throat, belly, knee, bottom, from an Achilles tendon, reaction of pupils to light, patol.refleks are conducted as well as at adults.
Nevrol, inspection of newborns is carried out according to the special scheme daily, for 5 — 7 days, and if necessary and longer time. Pay attention to position of the head, trunk, extremities, to expressiveness of spontaneous movements of hands, legs, a pose of the child. Define a shape of a skull, its sizes, a condition of seams of a skull, the sizes and a condition of fontanels, existence of a cephalhematoma, a condition of bone plates, asymmetries of a skull, and also hemorrhages in head skin, faces, in scleras. Then investigate cranial nerves, paying special attention to the oculomotor, facial, glossopalatine and wandering nerves. At a research of the reflektornodvigatelny sphere determine the volume of spontaneous movements, a muscle tone (the flexor-naya a hypertension normal prevails), tendon jerks, their expressiveness, irradiation, symmetry, inborn fiziol, reflexes.
Additional methods of inspection are applied at children according to the same indications, as at adults. In practice of inspection of children the anthropometrical methods applied to assessment of physical development are of great importance. Most often measure growth, body weight, a circle of a breast and head, and also consider proportions of a body of the child. Measurement of growth of children up to 3 years is performed special, and children of advanced age — usual height meters. Weighing of children from the moment of the birth up to 2 — 3 years is made on cup scales with the most safe bearing load to 20 kg. The child is weighed undressed. Babies are weighed at the same time day, it is better in the morning, after a night break in feeding. At measurement of a circle of the head the centimetric tape is carried out through an occipital hillock and in front on a forehead over eyebrows. At measurement of a circle of a thorax the centimetric tape is imposed behind under corners of shovels, conducted forward and in front capture by her bottom edge of peripapillary circles. At girls with the developed chest glands the tape is carried out under glands on the IV edge. Measurement is performed at the lowered hands, at height of a breath, exhalation and at quet breathing. The circle of a stomach is measured at the level of an iugsh or in the field of the greatest protrusion of a stomach.
Inspection of the newborn begins with his assessment on a scale Apgar. The technique Apgar is applied the first minute after the birth. It is based on assessment of a condition of the newborn on 5 most important wedge, to signs (see Apgar a method).
Make careful survey of the newborn regarding an exception of congenital anomalies and uglinesses, and then a research on separate bodies and systems. The special attention at newborns is required by overseeing by the funic rest and in the subsequent — an umbilical wound.
Special types of inspection at diseases of a nasal part of a throat, acoustic organs and sight carry out at the senior children the same as at adults. At inspection of children of early age the head of the child needs to be fixed. For this purpose mother (or the nurse) sits down before the doctor, presses one hand of a leg of the child to herself, and another holds his hands. The child is stacked on a back so that his head lay between knees of the doctor; in such position of the child examine. If at a disease of eyes at the child it is expressed the century or a nictitating spasm swelled, their violent disclosure is inadmissible. In such cases use an eyelid lifter, and in a fornix conjunctiva previously dig in 0,1% solution of Dicainum.
Are applied to diagnosis of hereditary diseases of exchange screening tests (see. Screening ). At mass screening obligatory examination of all children on a fenilketonuriya, a histidinemia), a mucoviscidosis, a galactosemia is conducted).
At the selection screening among the children who are lagging behind in psychomotor development with visual impairments, hearing, the speech, etc. identification of hereditary diseases of exchange of amino acids, carbohydrates, fats, diseases of connecting fabric, kidneys and urinary tract, diseases of endocrine system, immunodeficiency is provided. For this purpose at the first stage biochemical, high-quality screening tests, determination of content in biol are used, liquids of oxyproline and glikozaminoglikan, general lipids, cholesterol, triglycerides, etc.
Kliniko-genealogichesky inspection is conducted for the purpose of establishment of the hereditary nature of a disease. It includes inspection of a proband (see), collecting information about his relatives, inspection of family members, suspicious on hereditary pathology, drawing up and the analysis of a family tree.
Examination of a proband would be conducted by the practical standards of O. and in the same order, but there are features during the collecting the anamnesis, survey and laboratory diagnosis.
The hereditary nature of a disease is assumed in cases long hron, diseases, not giving in usual therapy (hron, a diarrhea and vomiting, long bronchopulmonary processes); at gradual lag in intellectual and physical development for no apparent reason; when there are primary infertility of spouses, primary amenorrhea with an underdevelopment of secondary sexual characteristics, repeated spontaneous abortions and still births; at intolerance of nek-ry drugs and foodstuff; in the presence of family cases.
Feature of collecting the family anamnesis for drawing up a family tree is in what since a proband of the data needs to be received separately about each living or died member of a family tree (see. Genealogical method). At the same time it is difficult to estimate the obtained data since nek-ry patients are inclined «to find» symptoms of the disease at the relatives who do not have such disease, and sometimes, on the contrary, nek-ry hereditary illnesses relatives carefully disappear. It can lead to mistakes and the wrong conclusions. The information about relatives received from the patient shall be always confirmed with cross poll of other family members.
The family tree is usually made on one main sign, however consider also the accompanying signs relating to the studied disease. Obtaining data on both parent lines since it can sometimes explain features of phenotypical display of the hereditary pathology which is not keeping within a typiform of a disease is necessary. Whenever possible all family members, at least relatives of the first degree of relationship, shall be interviewed and examined by the doctor personally. Special attention needs to be paid on microsymptoms of the studied disease at relatives of a proband, existence to-rykh often is a key to understanding of features of phenotypical manifestation (atipichnost) of a disease.
It must be kept in mind that the exact characteristic not only sick persons, but also record about healthy family members is required. Sometimes without personal survey of the relatives seeming healthy in general pe it is possible to make the diagnosis of hereditary defect. On relatives, to-rye are unavailable to survey, it is necessary to request medical documents from to lay down. institutions, but data of archive hospital materials shall be estimated as rather reliable.
Survey of a proband can reveal the changes of outward characteristic of nek-ry hereditary diseases: a peculiar person (it is described apprx. 200 syndromes with characteristic anomalies of the person), including «doll», «bird's», «senile», «the person of a gargoilik», etc. that is a sign of such hereditary syndromes as a glycogenosis, a progeria, maxillofacial dysostoses, mukopolisakharidoz; extremely high growth (at Marfan's syndromes, Klaynfeltera, etc.) or the dwarfism (observed more than at 30 only one monogenic syndromes); existence of various pigmented spots on skin (e.g., at a neurofibromatosis), teleangiectasias (Louis Bar syndrome), a photo of a dermatosis (Kokkeyn's syndromes, Blum).
Existence of rough inborn multiple malformations with high probability specifies on chromosomal, or mono gene, syndromes. The isolated malformations, as a rule, have various nature. The anomalies of extremities having unilateral localization most often demonstrate influence of environmental factors.
In addition to large anomalies, at O. it is necessary to reveal so-called signs of dysplastic development (the «Gothic» sky, a hypertelorism, an epikant, clinodactylies, a sandalevidny crack, deformation of auricles, a cross furrow on palms, inborn lack of nek-ry teeth, etc.), to-rye often characterize hereditary pathology.
At hereditary diseases detection of malformations of internals is of great diagnostic value (hearts, kidneys, went. - kish. a path, etc.) for what are required careful rentgenol. and elektrofiziol, researches.
It is important that inspection of a proband was multilateral with involvement of different specialists. So, without survey of the oculist it is impossible to make precisely the diagnosis to a disease Teja — the Saxophone, Marfan's syndrome, etc., without the conclusion of the otorhinolaryngologist — Alport's syndrome, etc. For the final diagnosis often it is necessary to use cytogenetic, biochemical, immunogenetic methods of inspection.
Family members, suspicious on hereditary pathology, inspect, as well as a proband, paraclinic and special methods. E.g., for diagnosis of hereditary forms of an oligophrenia investigate amino acids in urine and blood, immunodeficiency — study the level of immunoglobulins of different classes, the characteristic T-and V-lymphocytes. Thus it is possible to track transfer biochemical, immunol., elektrofiziol, and other signs. These signs initially reflect changes at hereditary diseases and consequently, speak about an essence of defect more precisely. Detection similar with received at a proband of symptoms and results of laboratory researches give the chance at erased a wedge, to make to a picture the diagnosis of a hereditary disease.
After drawing up a full family tree with the indication of results of inspection of relatives start its analysis, to-ry gives the chance to establish hereditary character of a sign, a mode of inheritance and to reveal the features connected with various degrees of penetrance of a gene and its expressivity.
Methods of a research of separate bodies — see articles devoted to bodies, e.g. Lungs , Bladder , Liver , Heart etc.; see also diagnostic methods in articles devoted to individual diseases, e.g. Glomerulonephritis , diabetes mellitus , Pneumonia , Sapropyra epidemic etc.
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C. M. Kamenker; L. O. Badalyan (not BP.), V. Bisyarina (ped.), N. I. Vinnikova, Yu. D. Baryshev, 3. F. Lebedenko, A. A. Prokhonchukov (ostomies.), O. A. Dzhaliashvili (oft.), B. A. Zenin (dermas.), S. I. Kozlova (gen.), N. I. Kostrov, V. P. Fomina-Kosolapov (ENT specialist.), I. V. Rubtsov (inf.), V. I. Struchkov (hir.), V. S. Timokhov (Ur.), E. Ya. Shternberg (psikhiat.).