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Danylo Halytskyi Lviv State Medical University

Recommendations for Obstetrics and Gynecology, Surgery

(Part II)

for the 6 Year Studentsof the General Medicine Faculty

Lviv – 2003

“Recommendations for Obstetrics and Gynecology, Surgery” for clinical practice for students of general medicine faculty.

Edited by Prof. Sklyarov E.J., Bilohan N.P., Lemishko B.B., Bohonko O.

Editor-in-chief: Vice-Rector of Education, Professor M.Gzhegotskyi.

Discussed and approved during the Department of Outpatient and Family Medicine methodological meeting, protocol № 8 dated 6.02.2003.

Table of contents

1

Prophylaxis, diagnosis and treatment of the specific inflammatory diseases of the female sexual organs in outpatient clinic................................................................................................................4

Prophylaxis, diagnosis and treatment of the non-specific inflammatory diseases of the female sexual organs in outpatient clinic.....................................................................................................6

Marriage and family. Family planning. Contraception of pregnancy..............................................8

Preeclampsia and eclampsia...........................................................................................................10

Prevention of infertility. Diagnosis and treatment at the outpatients department..........................12

Prevention of miscarriage. Diagnosis and treatment at the outpatients department.......................14

Bibliography (obstetrics and gynecology)......................................................................................16

Acute suppurative diseases of the sleek tissues..............................................................................17

Whitlow and phlegmon of hand.....................................................................................................19

Mastitis...........................................................................................................................................21

Indications for surgical management in ulcer disease....................................................................23

Differential diagnosis of abdominal pain.......................................................................................25

Inflammatory rectal diseases. Hemorrhoids...................................................................................27

Bibliography (surgery)...................................................................................................................29

2

Prophylaxis, diagnosis and treatment of the specific inflammatory diseases of the female sexual organs in outpatient clinic.

IntroductionLast years the increase in quantity of specific etiology inflammatory diseases of female

genitals is marked. Specific inflammatory diseases of female genitals frequently result in temporary disability, operative interventions, female infertility, spontaneous abortions, complications of pregnancy and deliveries, intrauterine fetal infection and child infection during delivery.

Prophylaxis and purposeful treatment with the account of pathogenesis under out-patient conditions results in prevention and reduction of complications.

Learning objectives Good theoretical knowledge in etiology, pathogenesis, classification, symptoms and signs,

complications, methods of diagnosis and differential diagnosis of specific inflammatory diseases of the female sexual organs. Properties of medicament treatment according to pathogenetic variants of diseases. Modern approaches in conservative and surgical treatment, and prevention of specific inflammatory diseases.

To have good practical knowledge of:- vaginal examination- laboratory investigation- deciding the diagnosisDefine the indications for hospitalization if needed.

Tasks for students selfpreparation

Structure and consistence of training Instruction for the class Student’s answer

1. Etiologic factors of specific inflammatory diseases Count

2. Types of vaginitis Define and show criteria

3. Bacterial vaginosis

Describe: - symptoms and signs- 4 diagnostic criteria- treatment

4. Trichomonas vaginitis Describe clinical symptoms, treatment6. Candidal vaginitis. Enumerate typical symptoms, treatment

7. Diseases caused by N. gonorrhoeaeSet treatment protocol:- complications- uncomplicated infections

8. Diseases caused by C. trachomatis

Tell about the:- clinical picture- methods of diagnosis - complications- treatment

9. Prevention of specific inflammatory diseases Enumerate the risk factors

3

Self-control testsCase 1Patient is a 25-year-old woman who came to outpatient’s clinic with complaints about

malodorous yellow frothy discharge, dysuria, dyspareunia, vaginal erythema during two days. During vaginal examination is established: cervix and vagina have a strawberry appearance; pH = 5-6; Whiff (Amine) test – positive.

Evaluation tests? Diagnosis? Plan of treatment?

Case 2Patient is a 27-year-old woman who came to outpatient’s clinic with complaints about

thick, white discharge; pruritus with vulvar itching, burning, irritation during four weeks. Symptoms increase the week before menses. pH is < 4.5; Whiff (Amine) test – negative.

Diagnosis? Evaluation tests? Plan of treatment?

Tasks for students during the class1. Observing patients with specific inflammatory diseases in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. Formulate diagnosis. 4. Study the scheme of conservative treatment.

Self preparation plan 1. Medications for treatment of candidal vaginitis (essay). 2. Treatment for uncomplicated infections caused by C. trachomatis (essay).

4

Prophylaxis, diagnosis and treatment of the non-specific inflammatory diseases of the female sexual organs in outpatient clinic.

IntroductionInflammatory diseases of female genitals occupy one of the first places among

gynecological diseases which result in temporary disability, surgical interventions, female infertility. Prophylaxis and purposeful treatment with the account of pathogenesis under the out-patient conditions with application of physiotherapeutic methods reduces risk of complications occurrence.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, classification, risk factors, clinical

picture, methods of diagnosis and differential diagnosis, complications of nonspecific inflammatory diseases of the female sexual organs. Properties of medicament treatment according to pathogenetic variants of diseases. Modern approaches in conservative and surgical treatment, indications to the surgical treatment. Prevention of specific inflammatory diseases.

To have good practical knowledge of:- vaginal examination- laboratory investigation- deciding the diagnosis- providing emergency helpDefine the indications for conservative treatment, and for hospitalization if needed.



1. Etiologic factors of nonspecific inflammatory diseases

Enumerate factors

2. Acute vulvitis Describe clinical symptoms, methods of treatment

3. Atrophic vaginitis Describe:- clinical picture- treatment

4. Chronic vulvar inflammation Set treatment protocol6. Salpingitis Enumerate typical symptoms, criteria for

diagnosis, treatment of:- acute salpingitis

- chronic salpingitis7. Differential diagnostic of acute salpingitis with other gynecological diseases

Differential diagnostic with:-tubal pregnancy-fibroid-tuboovarial tumors- criminal abortions

8. Tuboovarian abscess Tell about the:- differential diagnosis - complications- conservative treatment

5

- indications to the surgical treatment9. Prevention of nonspecific inflammatory diseases

Enumerate the risk factors


intensive pain in the lower abdomen and in waist, mild fever, yellow discharge during two days. Patient was treated 2 times in out-patient conditions concerning pelvic inflammatory disease ( acute salpingitis ), at vaginal examination found: size of uterus is normal, ovaries and tubes enlarged as tuboovarial tumors, the size is 10х8 cm, painful at physical examination. Discharge from vagina is yellow.

Evaluation tests? Diagnosis? Plan of treatment?

Tasks for students during the class1. Observing patients with nonspecific inflammatory diseases in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. To formulate diagnosis and differential diagnosis. 4. Study the scheme of conservative treatment.5. Define indications for surgical treatment.

Selfpreparation plan 1. Antibiotic therapy in treatment of tuboovarian abscess (essay).2. Differential diagnostic of acute salpingitis with other gynecological diseases (essay).3. Differential diagnostic of acute salpingitis with other non-gynecological diseases

(essay).

6

Marriage and family. Family planning. Contraception of pregnancy.

IntroductionA half of maternal mortality among the women in age from 15 to 35 is connected with the

reproductive system pathology, unwanted pregnancies, abortions, deliveries in the adverse conditions. Using the family planning methods improves women’s situation. Number of abortion and postabortional complications (bleeding, sepsis, inflammatory diseases, traumas) decreases by using contraceptives. Family planning and activity of reproductive health protection services may decrease the number of unwanted pregnancies and high risk pregnancies.

Learning objectivesGood theoretical knowledge about classification of contraception methods, mechanism of

action, effectiveness of different methods, examining before prescribing of contraceptives, adverse effects and complications, benefits, drug interactions, using of contraceptives after pregnancy, emergency contraception.

To have good practical knowledge of:- vaginal examination - deciding the diagnosis- providing emergency helpDefine the indications for conservative treatment, and for hospitalization if needed.



1. Classification of contraception methods Tell about classification 2. Methods for examination Enumerate

3 Barrier contraceptives Describe the methods

4. Methods of natural family planning Describe the methods:- calendar rhythm method- basal body temperature- cervical mucus- symptothermal method

5. Oral contraceptives Define:- action- adverse effects- complications

6. Subdermal implants and progestin injections

Describe their major adverse effects

7. Intrauterine devices Describe:- action- adverse effects - complications

7

Self-control testsCase 1Patient is a 28-year-old woman who came to outpatient’s clinic for intrauterine devices

insertion. Patient was treated 3 times in out-patient conditions concerning pelvic inflammatory disease, at vaginal examination found: size of uterus is normal, ovaries and tubes enlarged as tuboovarial tumors, the size is 3.5х4.5х4.5 cm, painful at physical examination. Discharge from vagina is transparent, liquid, in small amounts.

Diagnosis? Evaluation tests? Define contra-indications for intrauterine devices insertion.


bleeding during three days in the middle of the menstruation cycle. Patient take oral contraceptives during two months. Until that time for contraception she was using methods of natural family planning.


Tasks for students during the class1. Observing patients in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. Formulate diagnosis. 4. Study the scheme of treatment.5. Contraception methods selection.

Self preparation plan 1. Drug interactions while using oral contraceptives (essay). 2. Adverse effects and complications of oral contraceptives (essay). 3. Methods of emergency contraception (essay).

8

Preeclampsia and eclampsia.

IntroductionPreeclampsia develops in 5% of pregnant women, usually in primigravidas and in women

with preexisting hypertension or vascular disease. If untreated, preeclampsia characteristically smolders for a variable time, then suddenly progresses to eclampsia. Eclampsia develops in 1 of 200 patients with preeclampsia and is usually fatal if untreated. A major complication of preeclampsia is abruptio placentae, apparently caused by vascular disease.

Learning objectives Good theoretical knowledge in etiology, pathogenesis, classification, risk factors,

symptoms and signs, complications (abruptio placentae, HELLP syndrome), methods of diagnosis and differential diagnosis of preeclampsia and eclampsia. Different methods of medicament treatment accordingly to variants of diseases (mild preeclampsia, severe preeclampsia, eclampsia). Indications to the vaginal delivery, cesarean section. Prophylaxis.

To have good practical knowledge of:- vaginal examination - blood pressure measuring- deciding the diagnosis- providing emergency helpDefine the indications for conservative and surgical treatment, and for hospitalization if

needed.



1. Etiologic factors of preeclampsia and eclampsia

Enumerate risk factors

2. Classification of preeclampsia Define and show criteria3. Special methods for examination Describe 4. Clinical symptoms of preeclampsia Set treatment protocol:

- mild preeclampsia - severe preeclampsia

6. Symptoms and signs of eclampsia Describe symptoms and signs, methods for examination

7. Complications Define and show criteria of HELLP syndrome

8. Indications to the vaginal delivery, cesarean section

Enumerate indications

9. Prevention of preeclampsia and eclampsia

Describe


edema of the face and hands during two days. During physical examination, pregnancy for 32 weeks is established. BP – 140/90 mm Hg, albuminuria = 1. Two previous pregnancies had

9

resulted in induced abortions in early terms (6-8 wk gestation). Diagnosis? Evaluation tests? Plan of treatment?


edema of the face and hands during two weeks, visual disturbances, abdominal pain. During physical examination, pregnancy for 37 weeks is established. BP – 160/110 mm Hg, albuminuria = 3 is present. The previous pregnancy was ended by induced abortion.


Tasks for students during the class1. Observe patients with preeclampsia in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. Formulate diagnosis. 4. Study the scheme of conservative treatment.5. Define indications for the vaginal delivery.

Self preparation plan 1. Role of BUN and creatinine levels tests for kidney disease diagnostics

(essay). 2. Prophylaxis of HELLP syndrome (essay).

10

Prevention of infertility. Diagnosis and treatment at the outpatients department.

IntroductionInfertility affects about 1 in 5 couples; its increasing incidence partly reflects deferment of

marriage and of birth of the first child. The reason of infertility in 40-50 % of cases is due to the pathology of reproductive system of one partner, or in 5-10 % - of both. Diagnosis and treatment require thorough assessment of both partners; the extend and course of treatment should be individualized. Counselling and psychologic support are important adjuncts to the treatment. Prevention and early diagnosis of infertility plays on important role in the success of solving this problem.

Learning objectivesGood theoretical knowledge in etiologic factors, classification, clinical signs, methods of

diagnosis and differential diagnosis of infertility. Modern approaches in conservative and surgical treatment, assisted reproductive techniques, prevention of infertility.

To have good practical knowledge of:- vaginal examination- decide the diagnosis- provide emergency helpDefine the indications for conservative and surgical treatment, and for hospitalization if

needed.



1. Classification of infertility. Define and show criteria2. Etiologic factors Enumerate causes of:

- primary infertility- secondary infertility

3. Special methods for examination Describe the methods of:- monitoring ovulation- semen analysis- hysterosalpingogram- postcoital test

4. Tubal dysfunction Count causes, indications for surgical treatment

5. Ovulatory dysfunction Set treatment protocol:- polycystic ovary syndrome- chronic anovulation- hypothalamic amenorrehea- luteal phase deficiency

6. Sperm disorders Define causes, treatment of:- azoospermia- varicocele- retrograde ejaculation- endocrine disorders- genetic disorders

11

7. Assisted reproductive techniques Describe the methods:- in vitro fertilization- GIFT- intracytoplasmic sperm injection


infertility during 3 years. A history is obtained and physical examination is performed in searching for the causes of infertility: the patient was treated 2 times in out-patient conditions concerning pelvic inflammatory disease, at vaginal examination found: the size of uterus is normal, ovaries and tubes enlarged as tuboovarial tumors, the size is 6х8х5.5 cm, painful at physical examination. Discharge from vagina is transparent, liquid, in small amounts.

Diagnosis? Evaluation tests? The plan of treatment?

Tasks for students during the class1. Observing patients with infertility in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. To formulate diagnosis and differential diagnosis. 4. Study the scheme of conservative treatment.5. Define indications for surgical treatment.

Self preparation plan 1. Causes of secondary infertility in women with pelvic inflammatory disease (essay). 2. Using of assisted reproductive techniques for patients with tubal disease and unexplained

infertility (essay).

12

Prevention of miscarriage. Diagnosis and treatment at the outpatients department.

IntroductionAbout 20 to 30% of women bleed or have cramping at some time during the first 20 wk of

pregnancy; half of these women spontaneously abort. In up to 60% of spontaneous abortions, the fetus is either absent or grossly malformed, and in 25 to 60%, it has chromosomal abnormalities that is incompatible with life; thus spontaneous abortion in > 90% of cases may be a natural rejection of a maldeveloping fetus.

About 85% of spontaneous abortions occur in the 1st trimester and tend to have fetal causes; those occurring in the 2nd trimester are more likely to have maternal causes. Early diagnosis of complications of pregnancy has great value in the successful treatment and prevention of miscarriages.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, classification, symptoms and signs,

complications, methods of diagnosis and differential diagnosis of miscarriage. Modern approaches in conservative and surgical treatment, and prevention of miscarriage.

To have good practical knowledge of:- vaginal examination - decide the diagnosis- provide emergency helpDefine the indications for conservative and surgical treatment, and for hospitalization if

needed.



1. Etiologic factors of abortion Count:- maternal causes- fetal causes

2. Classification of abortion Define and show criteria3. Diagnostic investigation of habitual abortion

Decide.

4. Clinical symptoms of missed abortion Set treatment protocol:- up to 18 wk gestation- up to 28 wk gestation- after 28 wk gestation

6. Septic abortion Describe symptoms and signs, special methods for examination

7. Threatened abortion Define the indications for conservative and surgical treatment

8. Inevitable and incomplete abortions Define the indications for:- suction curettage- cervical cerclage

9. Prevention of miscarriage Count the risk factors of high-risk pregnancy

13


bloody discharges, pain in the lower abdomen and in waist during two days. During physical examination, pregnancy for 10 weeks is established. The diagnosis is confirmed by ultrasonography: cardiac activity has disappeared. Two previous pregnancies had resulted in spontaneous abortions in early terms (8-12 wk gestation). No diagnostic investigation after previous abortions have been carried out.


Case 2Patient is a 25-year-old woman who came to outpatient’s clinic with complaints of fever,

pains in the lower abdomen, plentiful discharge of yellowish-green color with unpleasant smell. Leukocytosis (WBC count, 19,000/µL) is present. During physical examination, pregnancy for 12 weeks is established. The previous pregnancy was ended by induced abortion.


Tasks for students during the class1. Observing patients with miscarriage in outpatient’s clinic. 2. Evaluate the laboratory and instrumental tests results. 3. To formulate diagnosis. 4. Study the scheme of conservative treatment.5. Define indications and methods of surgical treatment for miscarriage.

Selfpreparation plan 1.Role of urogenital infection in the etiology of miscarriages (essay). 2.Prophylaxis of spontaneous abortions (essay).

14

Bibliography (obstetrics and gynecology)

1. Pastorek J. Obstetric and gynecologic infections disease. – New York, 1994.2. Clinical reproductive medicine / Ed. by Cowan B. - New York, 1997. – 292p.3. Medicine of the fetus, mother / Ed. by Reece E. - New York, 1993. – 1605p.4. Handbook of in vitro fertilization / Ed. Trounson A. Gardner D. – New York, 1999.

– 560 p.5. Pregnancy loss: medical therapeutics and practical considerations / Ed. by I.R.

Woods, I.Z. Esposito. – Baltimore ets.: Williams and Wilkins, 1987. – 355 p.6. Ultrasound in obstetrics and gynecology. Vol. 1,2. Ed. by Cherrenak F. – Boston,

1993. – 882 p.7. Human reproduction: growth and development / Ed. by goustan D. - New York,

1995. – 498 p.8. Benson R., Pernoll M. Handbook of obstetrics and gynecology. - New York, 1994.

– 317 p.9. Benson M. Gynecologic pearls. – Philadelphia. – 2000. – 245 p.10. Danforth’s obstetrics and gynecology / Scott J. Disaia Ph. Hammond Ch. et. - New

York, 1997. – 1121 p.11. Behrman S. Patton G. Holtz. Progress in infertility - New York, 1994. – 413 p.

15

Acute suppurative diseases of the sleek tissues

IntroductionNear one third of the patients who need surgical help are the ones with acute suppurative

diseases of sleek tissues. In connection with wide and sometimes inefficient antibiotics usage clinical features of disease changed considerably. The cases of acute forms transition into chronic and relapses in festering infection became more frequent. Quick recognition, proper treatment and prevention of such diseases matter very much in work of outpatient clinic.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis and classification is needed.

Clinical features, diagnosis and differential diagnosis of acute suppurative infection (furuncle, carbuncle, abscess, etc.), methods of conservative and surgical treatment are also have to be known.

To have good practical knowledge in setting diagnosis, define indications and methods of surgery treatment. Make decision on hospitalization need.

Tasks for student’s self preparation


1. Classification of the acute suppurative infections

Specify the criteria of surgical infection

2. Clinical features (local and general); Describe

3. Main principles of antibacterial therapy;

Describe

4. Enzyme and immunologic therapy in treatment scheme Define the indications

5. Indications and methods of surgical interference Define them

6. Prevention of complications during antibiotics use Work out a plan

7. Peculiarities of surgical infections Explain

Tasks for students during the class1. Observation of the patients with the acute suppurative diseases of sleek tissues in the

outpatient clinic.2. Interpret the laboratory and additional test results.3. Prescribe conservative treatment.4. Determine surgery treatment indications and methods.

16

Self control testsCase1The patient is 18 years old man, who appealed to physician on a 6th day from the

beginning of disease. On itch on the front surface of middle third of right high extremity were the first displayed. Later the skin on this area turned red, the painful compression with measure 2 on 2 cm with a blackish dot in center determined.

Define diagnosis.Prescribe treatment.

Case 2The patient is 33 years old man. For past 2 days a general weakness, headache were

marked. On the third day suddenly the body temperature rose to 40C, there vomit was. It is marked during physical examination that on the skin of the overhead third of left shin is a red spot with the unequal japged edges. The skin was swollen, hot and sharply painful on touch.

Define diagnosis.Prescribe treatment.Define the type of medical establishment.

Case 3The patient is 17 years old man, who appealed into clinic with complaints about sharply

painful compression in a left in a left inguinal area, evening rise of body temperature to 37.6C. He is sick for 5 days, during which he oiled painful area by 3% solution of iodine.

Define diagnosis.Prescribe treatment.

Self preparation plan1. Features of medical tactics at a festering infection in diabetes mellitus patients.2. Analyze the origin causes and prevention methods for acute suppurative infection of

the sleek tissues.

17

Whitlow and phlegmon of hand.

IntroductionA whitlow and phlegmon of hand in majority are the complications of microtrauma.

Looking at the quantity of days of the disability this group of patients occupies one of the first places among outpatient clinic patients with the festering diseases. They also make up large number among hospitalized patients. Organization of festering diseases prevention of brush and fingers is the important task in work of general physician.

Quantity reduction of such patients relies on the correctly organized sanitary and educational work and fulfillment of simple preventive actions.

Learning objectivesGood theoretical knowledge in anatomic features of hand and fingers after distribution of

festering-inflammatory process, pathogenesis, classification, diagnosis of festering diseases of brush and fingers. It’s prevention, methods of conservative and treatment.

To have good practical knowledge in stating diagnosis and providing emergency surgical help. Define the indications and methods of surgical treatment. Make decision on hospitalization.

Tasks for students self-preparation


1. Anatomical and topographical features of hand and fingers after distribution of festering process

Work on table

2. Whitlow classification Count them

3. Principles for treatment of different whitlow forms Define

4. Phlegmon of palm’s surface hand classification, clinical features, diagnosis, treatment

Define and work out table

5. Phlegmon of back surface of hand classification, clinical features, diagnosis, treatment

Indicate

6. V-similar and Parona-Pirogova spacious clinical features, diagnosis, treatment

Describe

7. Antibiotics therapy Work out a plan

8. Enzyme and immunotherapy in treatment plan Define the indications

9. Prevention Work out a plan

18

Self-control testsCase 1.The patient is 40 years old man, inflicted a superficial sword-cut on palm’s surface of

the V finger basis. The day before appeal, suddenly he noticed a strong pain in the area of the V finger and the body temperature rose to 38º C. Objectively: there is oedema of the V finger, painful motion of the V finger flexor tendon that disseminates on a forearm. The swelling and pain in the area of lower third of palm’s surface of forearm are marked.Define diagnosis. Prescribe treatment.

Case 2.The patient is 60 years old man. One week ago he run a splinter into II finger of hand,

after that deleted splinter himself. Two days later the man felt pain in the II finger. The body temperature rose to 39º C. The patient complains of sharp pain in left hand. There is oedema on the back surface of left hand. Second finger is evenly stilled, there is hyperaemia at the finger and hand back surface skin. Active movements of the finger are limited. Examination by sound testifies sharp pain of the finger palm surface. Define diagnosis. Prescribe the treatment.

Task for students during the class1. Observing outpatient clinic patients with the acute purulent diseases of hand and

fingers in the conditions.2. Working out the plan of different forms of whitlow treatment.3. Working out the plan of phlegmon of hand palm’s surface treatment and surgery

interference.4. Methods of hand back surface phlegmon treatment.

Self-preparation plan 1. Peculiarities of the Parona-Pirogova cavity and V-similar phlegmons of hand and

forearm, treatment and tactics.2. Analyse causes and method of prevention for purulent infection of hand and fingers.

19

Mastitis

IntroductionMastitis is mainly diagnosed at women. More frequently it develops at mothers who

breast-fed their children (87%), especially at birth of the first child (65%). Mastitis can arise up also at pregnant women in the last weeks before births and very rarely at girls and women in a climacteric period. Frequency of acute mastitis (5-15%) grows and the level of lethality does not diminish (1,7%).

Therefore prevention and management of mastitis are the issues of the day.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, classification, clinical features,

differential diagnosis of mastitis.To have good practical knowledge in setting diagnosis and conducting differential

diagnosis. Provide emergency help, work out a plan of clinical tests and treatment principles. Define the necessity of hospitalization.

Tasks for students self preparation

Structure and consistence of training Instruction for the class Student’s answers

1.Risk factors of mastitis development To count down.2. Classification of mastitis Point out the classification criteria.3. Clinical features To name signs.

4. Differential diagnosis To count down the diseases which have similar symptoms.

5. Methods of laboratory and special tests To define the indication for their conducting.

6. Treatment principles

To work out a plan of treatment:А) at stagnation of milkB) at the cracks of nippleC) at the initial stage of mastitis (infiltration)D) on the stage of abscess formation.

Task for self-controlCase 1.Patient, 25 year-old-woman, appealed with complaints on ache and increase of left

mammary gland, headache, evening rise of body temperature to 38oC. Months ago normally delivered a child. Two weeks ago a crack on left nipple appeared. The patient was treated in ambulance, oiled nipples by methilen dark blue, used the ultraviolet rays.

As the result of physical examination it is set that a left mammary gland is bigger than right, condensed and painful. Milk secretes from nipple.

Define diagnosis.Work out plan of examination and treatment.

Task for students during the class1. Observing patients with mastitis in the outpatient clinic.

20

2. Define of diagnosis.3. Interpretation of the results of laboratory and additional tests.4. Work out the plan of conservative treatment.5. Decide for indications and methods of surgery treatment.

Self-preparation plan1. The major mastitis causes.2. Modern methods for mastitis prevention and treatment.

21

Indications for surgical management in ulcer disease

I ntroduction The outpatient clinic physician is the first person to meet patient with gastrointestinal

complaints. It is very important for physician to make preliminary diagnosis, and to choose appropriate treatment. Especially in terms of possible complications from gastric and duodenal ulcer disease: -choosing appropriate time for surgical consultation and treatment is important for the patient.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, clinical features and diagnosis of

gastric and duodenal ulcer disease is required. Modern approaches to conservative and surgical treatments.

To have good practical knowledge in anamnesis collection, performing clinical tests, physical examination and give correct interpretation of collected test results. Perform differential diagnosis for gastric and duodenal ulcer; identify the possible complications. Decide on the diagnosis and further indications for conservative or surgical treatments.



1. Describe the structure and function of stomach and duodenum

Draw stomach and duodenum. Describe it’s parts and it’s relation to other organs.

2. Describe blood and lymph supply to these organs Draw the scheme

1. What are the patient’s major complaints? Define them

2. Clinical features of gastric and duodenal ulcer disease Describe

3. Complaints in gastric and duodenal ulcer disease

Count all of them and describe clinical features.

4. What are the major complaints if ulcer disease complications occur Describe them

5. Indications for surgical treatment Describe

6. Types of operations Draw the scheme

7. Gastric and duodenal ulcer disease hemorrhage treatment Prescribe haemostatic therapy.

22

Self-control testsCase 1Patient is a 40-year-old man. 4 hours ago he had nausea, general weakness, dizziness,

hematemesis. During physical examination, the state of the patient is tough. Skin is pale, cold sweat on his face, pulse 120 per minute, blood pressure 90/60 mmHg. Blood hemoglobin 42g/l. One month ago he experience heartburn, sour belch and pain in epigastrium was decreasing after taking baking soda per os.

Diagnosis? Treatment?

Case 2 Patient is a 60-year-old woman. She has proven gastric ulcer for 2 years. She received

advanced conservative treatment as an inpatient in hospital for several times. Worsening of disease happens in the spring and fall. During last 3 months – decrease in appetite, weight loss – 5 kg. Quick fatigability, drowsiness, general weakness, apathy, dull pain in the lower back, foul-smelling eructation.

What complication should you think of?What further diagnostic tests must be performed?What are the treatment tactics?

Tasks for students during the class1. Physical examination of patients with gastric and duodenal ulcer disease in outpatient clinic.2. Defining preliminary diagnosis.3. Take part in X-ray scanning and endoscopic examination of digestive system.4. Define the indications and possible surgical methods.5. Observation of the patient as an outpatient.

Selfpreparation plan1. Functional substantiation of surgical methods in patients with gastric and duodenal ulcer

disease.2. The causes of complication in such patients.

23

Differential diagnosis of abdominal pain

IntroductionLate hospitalization due to outpatient clinic physician is one of the major causes for bad

surgical outcomes in patients with acute abdomen. The patient with an acute abdomen poses a diagnostic challenge to the physician. In

approaching such patient, it is necessary to form a broad set of differential diagnosis. Monitoring the patient, complete examination, well-collected anamnesis, correct tests interpretation – are basic for an acute abdomen determination. As soon as such diagnosis is determined surgeon should further consult the patient. Or referred to inpatient clinic.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, clinical features and differential

diagnosis for diseases that can cause abdominal pain.To have good practical knowledge in recognizing pain syndrome in cases of acute abdomen. Perform differential diagnosis make decision on hospitalization and immediate surgical or other specific treatment. Provide emergency help.

Tasks for student’s selfpreparation


1. Diseases which have abdominal pain as a symptom

Define and describe them using reference literature

2. Types of colic Define and describe clinical features3. Types of abdominal syndrome Describe4. Indications for immediate hospitalization Define them5. Emergency help Describe6. Differential diagnosis for abdominal pain Compile a table, using reference literature

Self-control testsCase 1Patient is a 40-year-old man, who had appendectomy 1 year ago and abdominal drainage

because of destructive appendicitis.Now the complains of abdominal pain, mostly in the right lower iliac region, which

occurred after hard physical effort. Patient’s skin is pale, he’s anxious; abdomen is asymmetric due to the expansion of the right part over abdomen surface, tachycardia.

What kind of disease will you suspect in such patient?

Case 2Patient is a 25-year-old man. He felt acute pain in epigastric region during tough physical

effort. During 2 hours the intensity of pain decreases, but localized in right lower iliac region. Body temperature is 37.5C. Patient doesn’t want to move, lays down on the right side with his feet flexed towards abdomen. The abdominal wall is tense, mostly in right lower iliac region. The pain is concentrated in the same region, involuntary guarding, rebound and peritoneal irritation.

What disease should you think of?What other symptoms you have to check?

24

Should you perform stomach lavage for the patient?

Tasks for students during the class1. Observing patients with acute abdominal pain2. Define diagnosis3. Perform differential diagnosis4. Decide the treatment principles

Selfpreparation plan1. Compile a table of differential diagnosis for abdominal colic based on etiologies.2. Analize the causes of late hospitalization in patient with acute abdominal pain due to the

mistakes in pain syndrome evaluation.

25

Inflammatory rectal diseases. Hemorrhoids.

IntroductionInflammatory rectal diseases appear most often in elderly patients. 10 percent of

population suffers hemorrhoids and it makes up to 40 percent of rectal and anal canal pathology. More than half of all colon cancers is found in the rectum, and about 80 percent of intestinal cancers are located in the rectum and the sigmoid colon. Physician should be strongly aware that success in the treatment is closely related to its early diagnosis.

Learning objectivesGood theoretical knowledge in etiology, pathogenesis, classification, clinical, diagnosis

and differential diagnosis of rectal disease is required, especially hemorrhoids, anal fissure and cancer. Modern approaches to conservative and surgical treatments.

To have good practical knowledge of:-rectal examination (by finger, anoscopy, rectoromanoscopy).

- decide on the diagnosis - provide emergency help

Define the indications for conservative and surgical treatment, and for hospitalization if needed.



1.Classification of rectal disease Define and show criteria

2.Health hazards of hemorrhoids, anal fissure and cancer Count them

3.Clinical symptoms and factors, which determine hemorrhoids, anal fissure and cancer clinical features

Describe

4.Special methods for rectal examination Define indications

5.Hemorrhoids, anal fissure treatment

Set treatment protocol:a) uncomplicated hemorrhoidsb)complicated hemorrhoidsc)anal fissures

6. Indications and operative surgical methods for intestinal cancer Decide. Draw the scheme

7.Indications for surgery treatment Define

8.Methods of operation Draw the scheme of basic operations.

26

Self-control testsCase 1Patient is a 40-year-old woman. She came to family-medicine practitioner with the

complaints of pain in the rectal area and drops of red blood on feces at the end of defecation. Similar complaints were present 1 year ago.

The state of patient is fair good. Abdomen examination showed no pathology. During rectal examination were found hemorrhoid nods, blood filled with hyperemic mucous on 3 and 11 hours positions. Blood hemoglobin 100g/l.

Diagnosis? Evaluation tests?Treatment?

Case 2 Patient is a 43-year old man who came to outpatient clinic with sharp pain in the rectum

after defecation took place, blood stir in feces. Have proven hemorrhoids for 5 years. For week pain did not decrease. During rectal examination, anal fissure is found, size - 2 on 1 cm.

Diagnosis?Treatment?

Case 3Patient is a 60-year-old man who came to proctologist complaining on dull pain in rectal

area, serous-pus egestion from rectum with some blood, feelling of incomplete defecation and general weakness. He has these complaints for the last 3 months.

Diagnosis? Evaluation tests?Treatment?

Tasks for students during the class1. Observing patients with rectal pathology in outpatient clinic.2. Evaluate the laboratory and instrumental tests results.3. Study the scheme for conservative and surgical hemorrhoids treatment.4. Define indications and surgical methods for rectal cancers.

Selfpreparation plan1. Causes of anal fissures (essay).2. Modern methods for hemorrhoids prophylaxis and hemorrhoids treatment (essay).

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Bibliography (surgery)

1. Guide to clinical preventive services. / An Assesment of the Effectiveness of 169 Interventions. / Report of the U.S. Preventive Services Task Force. // Editor: Michael Fisher – Baltimore, Maryland – 1989 – 420 pg.

2. Barlett J. G. Pocketbook of Infections Disease Therapy. Baltimore. Williams & Wiilkins. 1991.

3. Burton J. L. Essentials of Dermatology. Churcill Livingstone. Edinburgh. 1985.4. Hunter J. A., Savin D. S., Dahi M. V. Clinical Dermatology. Blackwell Scientific

Publications., Oxford. 1989.5. Davis J. H. Clinical Surgery. St. Louis. Washington-Toronto: the C.V.Mosby comp. 1987. 6. Digout G., West A. Anaerobic Infections. Toronto. 1974.7. David N. Gilbert et all. The 2002 Edition of the Sanford Guide to Antimicrobial Therapy.

2002.8. Abrams R. A., Botte M. J. Hand Infections: Treatment Recomendation for Specific

Types. J. Of Am. Acad. Of Orthop. Surg. 1996. Vol. 4 №4.9. Davis J. H. Clinical Surgery. St. Louis. Washington-Toronto: the C.V.Mosby comp. 1987. 10. Lin Y.C, Su H.Y. A surgical approach to ingrown nail: partial matricectomy using CO2

laser. // Dermatol Surg 2002 Jul;28(7):578-580;11. Rounding C, Hulm S. Surgical treatments for ingrowing toenails. Cochrane Database Syst

Rev 2000;(2):CD001541.12. Takahashi M, Narisawa Y. Radical surgery for ingrown nails by partial resection of the

nail plate and matrix using a carbon dioxide laser. // J Cutan Laser Ther 2000 Mar;2(1):21-25.

13. Yang K.C, Li Y.T. Treatment of recurrent ingrown great toenail associated with granulation tissue by partial nail avulsion followed by matricectomy with sharpulse carbon dioxide laser. // Dermatol Surg 2002 May;28(5):419-421;

14. Blumgart L. Surgery of the liver and biliary tract. Churcill Livingstone. Edinburgh. 1988.15. Shearman D. C., Finlayson N. D. Diseases of the gastrointestinal tract and liver. Churcill

Livingstone. Edinburgh. 1989.16. Gliedman M. L. Atlas of surgical techniques. McGraw – Hill Co. New York. 1997. 17. Hall R., Besser M. Fundamentals of clinical endocrinology. Pitman Medical. London.

1989. 18. Keen H., Jarrett R. J. Complications of diabetes. Arnold. Sevenoaks. 1982. 19. De Bono D. P. Examination of the cardiovascular system. Churcill Livingstone.

Edinburgh. 1989.20. Geoffrey H. White, Rodney A. White. Angioscopy: vascular and coronary applications.

YBMP. Chicago. 1994.

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