OSCE
* Therapy (Internal Medicine)
* Neurology
* Surgery
* Pediatrics
* Psychiatrics
* Urology
OSCE EXAMINATION :
(Objective Structured Clinical Examination) is a multi-station, clinical skills assessment method that is based on objective testing and direct observation of student performance.
Neurology for the 4th year medical students
"Diagnose Bulbar syndrome"
1. Greet and name yourself (name, level of competence, explanation or clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest, respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey:
- evaluate the patient's language (ask the patient to say colloquialisms "thirty
three, three hundred and thirty-third artillery brigade", etc.). At pathology - language
is dysarthric;
- assess the patient's voice (in pathology - hoarse, with a nasal tinge, hoarse);
- to assess the function of swallowing solid (in pathology - difficulty swallowing,
the need to drink food with water) and liquid food (in pathology - soaking water,
pouring water through the nose);
To conclude the diagnosed deviations (dysarthria, dysphonia, dysphagia).
- Assess the soft palate at rest (sagging, tongue deviation) and phonation (ask the
patient to say "yes"). In pathology - immobile (immobile) palate unilaterally or
bilaterally;
- assess the function of the muscles of the tongue (the volume of movements of
the tongue forward, sideways, upward, the presence of malnutrition, atrophy, fibrillar
twitching, tremor);
- to investigate the palatine and pharyngeal reflexes (in pathology - reduced or
absent);
Conclude the presence/absence of bulbar syndrome.
7. Explain the results of the examination to the patient.
"Diagnose epileptic syndrome"
Complaints and anamnesis of patient
Complaints of patient with epileptic syndrome.
1. You should communicate with the patient with a friendly facial expression, a smile.
2. Greet, introduce yourself (Name, position), explain the purpose of communication, get consent.
3. Ask how you can address the patient.
4. Check the patient's passport data.
5. Collect the main complaints, ask about the details of each of them:
If the patient has a seizure, the examination process is determined by the patient's
condition. In most cases, the patient's seizures end before the doctor arrives. If
possible, the examination should include a history taking and a physical examination
(including a neurological examination).
If the patient is in the postictal phase of seizures, information may be collected
from family members or passers-by who witnessed the event. Important components of
the patient's history are:
1. History of seizures:
a. frequency;
b. compliance with the prescribed drugs;
c. use of home remedies to control seizures (herbal medicines, vitamins).
2. Description of convulsive activity:
a. duration of the attack;
b. typical or atypical for the patient scenarios of seizures;
c. the presence of an aura;d. generalized or focal;
e. urinary or fecal incontinence;
f. tongue biting.
3. Recent or past history of head injury
4. Recent history of fever, headache, occipital muscle rigidity (indicates
meningeal syndrome)
5. Concomitant pathology
a. diabetes
b. heart disease
c. stroke
General overview.
- Maintaining the patient's airway potency is always important.
- You should pay attention to the signs of injury (head and neck injuries, tongue
damage, lip dissection). These injuries could have occurred before or during the attack.
- The patient's mouth should be examined for signs of gum hypertrophy (swollen
gums). This is a sign of chronic phenytoin therapy.
- Other components of the physical examination include the following:
- level of consciousness, including the presence or absence of amnesia
- assessment of the function of the cranial nerves, in particular the reaction of the
pupils
- assessment of motor and sensory functions, including coordination
(abnormalities may be caused by metabolic disorders, meningitis, intracranial
hemorrhage and drug use)
- control of blood pressure, saturation and glucose
- the presence of urine or feces (indicates incontinence of the bladder or
intestines)
- automatisms
- cardiac arrhythmia
Carry out a differential diagnosis of seizures and syncope
6. Find out if the patient has anything to add. Answer the patient's questions.7. End the conversation: summarize the identified data and clarify with the patient
whether you have received the information correctly, thank the patient, wish him a
speedy recovery, say goodbye.
"Diagnose ischemic strokes"
I. Сomplaints of patient with ischemic stroke.
1. You should communicate with the patient with a friendly facial expression, a
smile.
2. Greet, introduce yourself (PIP, position), explain the purpose of
communication, get consent.
3. Ask how you can address the patient.
4. Check the patient's passport data.
5. Collect the main complaints and ask about the details of each:
- weakness in the extremities (severity, dynamics since the onset of the disease)
- numbness (severity, dynamics since the onset of the disease)
- general cerebral symptoms (headache, nausea, vomiting, dizziness, loss of
consciousness)
- other focal symptoms (speech disorders, diplopia, swallowing disorders,
shakiness while walking).
6. Ask about possible accompanying complaints.
7. Check if the patient has anything to add
8. Answer the patient's questions.
9. End the conversation: summarize the identified data and clarify with the patient
whether you have received the information correctly, thank the patient, wish him a
speedy recovery, say goodbye.
ІІ. Past medical history of patient with ischemic stroke.
1. You should communicate with the patient with a friendly facial expression, a
smile.2. Greet, introduce yourself (PIP, position), explain the purpose of
communication, get consent.
3. Ask how you can address the patient.
4. Check the patient's passport data.
5. Ask the history of his illness:
- onset: acute or gradual (does the patient remember when the disease started)
- when and from what symptoms the disease began
- what is its cause, according to the patient
- development of symptoms in dynamics (strengthening, disappearance,
emergence of new symptoms)
- blood pressure in the onset of the disease
- whether you have sought medical help before
- what preliminary examinations have already been made and their results
- what previous treatment he received and its effectiveness;
6. Find out if the patient has anything to add
7. Answer the patient's questions.
8. End the conversation: summarize the identified data and ask the patient whether
you received the information correctly, thank the patient, wish him recovery.
III. Motor system exam.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey. Explore:
a) the volume of active movements (ask the patient to bend and unbend the neck,
raise and lower the shoulders, arms, bend and unbend the upper extremities in the elbow, carpo-radial, interphalangeal joints, sit down, bend and unbend the legs in the
hip, knee and shin foot joints).
If the patient has no active movements in the limb, it may be paralysis, but if they
are limited - paresis.
b) the volume of passive movements - helps to differentiate paresis and paralysis
of the extremities from the restriction or absence of movements in them due to different
diseases of the musculoskeletal system. To do this in the upper and lower
limbs resistance is assessed when performing passive movements by type of
flexion-extension in the joints of the upper and lower extremities, starting from the
proximal parts, ending with the distal;
c) muscle strength (strength in antagonist muscles from the proximal to distal parts
of the upper and lower extremities is studied by counteraction). Muscle strength is
assessed on a 5-point scale, where
5 points - the norm,
4 points - mild paresis,
3 points - moderate paresis,
1-2 points - deep paresis,
0 points - paralysis.
To detect mild paresis, Barre tests are performed: the upper (the patient is asked
to extend both arms forward and hold for 1-2 minutes. The paretic arm is lowered
faster) and the lower (the patient who is in a supine position is asked to raise the legs.
The paretic leg is lowered faster. ), as well as the test of the Buddha
d) muscle trophism (assess the condition of muscle groups by examining and
measuring the volume of symmetrical areas of the limbs with a centimeter tape);
e) muscle tone (check by passive flexion - extension in the joints of the upper and
lower extremities. Assess whether the muscles resist such
movement (hypertonia) or vice versa, the muscles are too relaxed (hypotonia).
When the corticospinal tract is affected, spastic muscle hypertension occurs, which has
the following features:
- on the hands the tone is increased in the flexors, on the legs - in the extensors;
- as you check the tone decreases, weakens;- symptom of "folded knife" - resistance at the beginning of passive movement is
expressed,
then decreases.
e) physiological superficial (skin and mucous) and deep (tendon and periosteal)
reflexes. It is necessary to estimate expressiveness of reflexes (absent, reduced
(torpid), lively, tall, clonus) and symmetry (D = S - normal). In pathology, reflexes
may increase (hyperreflexia, clonus), decrease (hyporeflexia), disappear (areflexia),
lose symmetry
(anisoreflection - D> S or D <S);
g) the presence of pathological reflexes on the upper and lower extremities of the
flexor and extensor group;
g) the presence of pathological synkinesis (involuntary movements that appear
reflexively in the paralyzed limb under stress), protective reflexes (involuntary
complex, often flexion, movements of the paralyzed limb in response to its irritation
(eg, passive flexion of the fingers));
h) the presence of fibrillar and fascicular twitching.
7. Explain the results of the examination to the patient.
IV. Coordination and synergy
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conducting the survey:
a) to investigate the presence of nystagmus, while assessing its nature (horizontal,
vertical, rotational), amplitude (small-amplitude, large-amplitude);
b) to assess the language, which in pathology of the cerebellum loses fluency and
becomes intermittent - chanted;c) evaluate handwriting - "macrography";
d) to conduct coordination tests: finger-nose, finger-finger, finger-hammer, index,
heel-knee tests. With cerebellar ataxia, the patient cannot get a finger in the nose or a
hammer or a heel in the knee (misses), there is an intentional tremor (tremor of
movement, which intensifies when trying to make a purposeful, finely coordinated
movement);
e) to investigate samples for hyperopia of movements:
- pronator - supinator (the patient is asked to perform rapid pronator - supinator
movements with the hands, following the appearance of hyperpronation or
hypersupination);
- Schilder's test (the patient on command sharply raises hands accurately to
horizontal level. At hypemetry from the affected hemisphere of a cerebellum the
patient raises his hand higher, and then under visual control straightens it);
- Tom's hammer test (the patient is asked to touch the thumb and forefinger of the
wider and narrower part of the neurological hammer, following the accuracy and
proportionality of movements);
- test for diadochokinesis when trying to perform rapid synchronous pronation and
supination of the hands and forearms (as when screwing a light bulb) in patients with
cerebellar pathology, the movements of both hands are asynchronous: on the side
lesions they are slow, awkwardly sweeping (adiadochokinesis);
e) synergy of movements with the help of:
- Babinsky's test (the patient with the arms crossed on a breast in a position lying
on a back tries to sit down. At cerebellar asynergy at it legs will rise, and the leg on the
party of the struck hemisphere of a cerebellum will rise above);
- Stuart-Holmes test (back push);
- Ozhekhovsky's test (if a patient standing in the position of "legs together" is
asked to bend back, then he falls, because the center of gravity, due to the lack of
flexion in the knees, moves back too much. In healthy patient there is a tilting of the
head and bending of the knees.
7. Explain the results of the examination to the patientV. Examination of balance.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey.
a) assess the patient's progress in a straight line;
b) the course of additional steps;
c) hold a simple and complicated (feet one in front of the other on each other
lines) Romberg test. At pathology of a cerebellum the patient sways towards the
center of defeat (in both - at bilateral defeat) or the tendency to falling forward or back
is shown;
7. Explain the results of the examination to the patient
VI. Superficial sensation
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conducting a survey. A number of conditions must be met in the sensitivity
study. The study should be conducted in a calm atmosphere, if possible in a warm
room. Ask the patient to close his eyes. He needs to be explained what to look for when
studying each type of sensitivity. Irritation should be applied to symmetrical areas of
the body from top to bottom, keeping in mind the segmental structure of the body.a) tactile sensitivity is checked with a brush by applying irritation in the form of
touch on the symmetrical areas of the skin of the right and left halves of the body on
the front and back surface from top to bottom;
b) similarly investigated pain sensitivity with a neurological needle. At the same
time the patient is asked whether he feels equally acute irritation in symmetrical parts
of the body;
c) temperature sensitivity is checked by means of two test tubes with warm and
cold water, which are alternately applied to the patient's skin. Healthy people
distinguish a temperature difference of 1-2 degrees.
7. Explain the results of the examination to the patient.
VII. Deep sensation exam
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey. Explore:
a) musculoskeletal sensation is studied by performing passive movements up and
down starting from the interphalangeal joints of the hands and feet, then in the radial
wrist and ankle-foot joints, etc. The patient with closed eyes should indicate the
direction of movement. Loss of musculoskeletal sensation - batianesthesia, decreased
musculoskeletal sensation - bathyhypesthesia.
b) vibration sensitivity is measured using a Weber tuning fork.
The leg of the vibrating tuning fork is placed on the areas on the body where the
bone is covered only a thin layer of skin (the back of the feet, hands, along the tibia,
etc.). Normally, the vibration sensitivity on the hands reaches 15-20 seconds, on feet -
10-15. At decrease in vibration sensitivity seismic hypoesthesia is diagnosed, in the
absence of vibration sensitivity - seismonesthesia.c) kinesthetic sensation is checked by moving the skin fold up or down, left or
right, and the patient must recognize the direction of movement
7. Explain the results of the examination to the patient.
VIII. Complex sensation
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conducting a survey. Explore:
a) feeling of localization - by applying painful irritation to the skin. The patient
with closed eyes should point the finger at the site of irritation. Permissible error - 1
cm;
b) a sense of discrimination with a compass with two needles. Two simultaneous
painful stimuli are applied, the branches of the compass are gradually narrowed until
the patient feels two stimuli as one;
c) two-dimensional-spatial sense (graphoaesthesia) by writing numbers or letters
on the skin of the shoulder, thigh or other area. The patient with closed eyes should
name the written symbols;
d) studies of three-dimensional-spatial sensation (stereognosis) to a patient with
closed eyes is given an object in his hand and offered to identify it.
Loss of three-dimensional-spatial sensation - astereognosia.
7. Explain the results of the examination to the patient.
IX. Speech disorders
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the survey.
6. Conduct a survey. Assess the patient's language.
- spontaneous language (vocabulary, the ability to build sentences, express
opinions);
- repetitive language (in the absence or restriction of spontaneous speech);
- automated language (in case of absence or restriction of spontaneous
language);
- ability to operate with nouns;
- understand the spoken language and follow the instructions.
- understanding of complex grammatical constructions.
7. To draw a conclusion. Depending on the nature of the disorders, there are
motor, sensory, amnestic, semantic and total aphasia.
X. Examination of cranial nerves.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey.
Irst pair - the olfactory nerve. The function of the sense of smell is studied using
substances with a mild odor (lavender, rose oil, etc.), as pungent odors are also
perceived by the receptors of the Vth pair of CN. Each nasal passage is examined
separately. Detect a decrease or absence of smell (hyposmia, anosmia), its distortion
(disosmia),
The second pair is the optic nerve. At research of functions of an optic nerve it is
required:
a) assess visual acuity according to Sivtsev's tablesb) check the fields of vision, confrontation test, towel test, perimeter to
investigate the direct and indirect reaction of the pupil to the light of each eye;
ІІІ (oculomotor), IV (trochlear), VI (abducens) pair of CN. While research of
function of oculomotor nerves pay attention to
a) symmetry of the orbits (presence of ptosis, exo-, enophthalmos);
b) the position of the eyeballs in the orbits;
c) symmetry of the pupils (the presence of anisokoria in the form of myosis or
mydriasis;
d) check the volume of active movements of the eyeballs to the side, up and
down, while monitoring the appearance of nystagmus or diplopia (diplopia);
e) evaluate the response to convergence and accommodation, as well as the
direct and allied reaction of the pupils to light.
V pair (trigeminal). To study the function of the trigeminal nerve it is required
to verify:
a) superficial (tactile, pain and temperature) sensation on the face in the areas of
innervation of the branches of the trigeminal nerve and Zelder areas;
b) palpate the exit points of the branches of the trigeminal nerve from the cranial
cavity (supra-, infraorbital, mental points;
c) to investigate superciliary, corneal, conjunctival and mandibular reflexes;
d) to study the active movements of the lower jaw (ask the patient to open his
mouth, move the lower jaw to the side - with paresis of the masticatory muscles, the
jaw is displaced towards the lesion);
e) ask the patient to clench his teeth and make a few chewing movements,
palpating the degree of tension and tone of the masticatory muscles.
VII th pair. When studying the function of the facial nerve, attention is paid to
the symmetry of the face at rest, the presence of facial wrinkles on the forehead, the
symmetry of the nasolabial folds, the lowering of the corner of the mouth. Also, you
need to explore:
a) active movements of facial muscles (we ask the patient to frown, frown, close
his eyes tightly, brush his teeth, puff out his cheeks, swell);
b) superciliary, corneal and conjunctival reflexes;c) taste on the front 2/3 of the tongue (use substances with sweet, salty, sour
taste. A few drops of liquid are alternately applied to the right and left halves of the
tongue, the patient must identify the taste);
VIII pair. To study the function of the vestibulo-cochlear nerve should be
checked
a) hearing acuity of each ear separately by whispering from a distance of 6 m;
b) perform tests with a tuning fork for differential diagnosis of pathology of the
sound-conducting and sound-receiving apparatus (Rinne's test: the leg of the
vibrating tuning fork is attached to the mastoid process. vibrating tuning fork is
attached to the parietal bone. If the patient feels better vibration in the diseased ear
(lateralization of sound in the direction of the lesion) - this is a pathology of the
auditory apparatus. Lateralization of sound to the healthy side indicates pathology of
the auditory apparatus);
c) identify signs of vestibular ataxia (assess gait and stability in the Romberg
position, the presence of nystagmus, hearing loss or tinnitus).
IX, X pairs. Motor function: assess voice (hypophony, dysphonia), swallowing
(dysphagia, aphagia), language (dysarthria, anarthria). Reflex sphere: to study the
palatine and pharyngeal reflexes. Vegetative function: to examine the taste (ageusia,
hypogeusia, parageisia on the back 1/3 of the tongue), dry mouth, salivation. Detect
the presence of pain in the tonsils, the posterior wall of the pharynx, in the back of the
tongue, in the depths of the ear.
XIth pair. Investigate the function of the sternocleidomastoideus and trapezius
muscles (strength and volume of movements, the presence of malnutrition, atrophy,
hypertrophy, fibrillary and fascicular twitching).
XII th pair. Investigate the function of the muscles of the tongue (the volume of
movements of the tongue forward, sideways, upward, the presence of malnutrition,
atrophy, fibrillary twitching, tremor).
7. Explain the results of the examination to the patient.
XI. Evaluate changes in CT of the brain at ischemic stroke
1. Examine the computed tomography of the brain
2. Evaluate:- symmetry of the hemispheres
- the position of the middle structures of the brain
- the presence of changes in the density of the brain substance
- size and shape of the ventricles
- integrity of skull bones
- the severity of interhemispheric fissures and fissures of the subarachnoid space
- the presence of plus tissue in the hemispheres or membranes
- the presence of signs of edema
- the presence of signs of dislocation
3. Indicate the topical location of the pathology on CT (pool, artery).
"Diagnose meningeal syndrome"
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey:
- palpate trigeminal points;
- check the soreness of the eyeballs by pressing on them;
- to evaluate the cheekbone phenomenon of Bekhterev;
- palpate occipital points;
- check the rigidity of the occipital muscles;
- check the upper symptom of Brudzinski;
- check the average symptom of Brudzinski;
- check Kernig's symptom on the right;
- check Kernig's symptom on the left;
- check the lower symptom of Brudzinski;
- check for Guillain's symptom.
7. Explain the results of the examination to the patient.
"Diagnose radiculopathy"
I. Complaints and anamnesis taking from the patient
Complaints taking from a patient with radiculopathy.
1. You should communicate with the patient with a friendly facial expression, a
smile.
2. Greet, introduce yourself (name, position), explain the purpose of
communication, get consent.
3. Ask how you can address the patient.
4. Check the patient's passport data.
5. Collect the main complaints, ask about the details of each of them:
- pain syndrome (intensity, nature, location, factors that increase pain);
- limited movement (due to pain or weakness of certain muscle groups);
- the presence of muscle weakness (their location, severity);
- sensitivity disorders (their localization, intensity).
6. Find out if the patient has anything to add. Answer the patient's questions.
7. End the conversation: summarize the identified data and clarify with the
patient whether you have received the information correctly, thank the patient, wish
him a speedy recovery, say goodbye.
II. Past medical history of a patient with radiculopathy.
1. You should communicate with the patient with a friendly facial expression
and a smile.
2. Greet, introduce yourself (NS, position), explain the purpose of
communication, get consent.
3. Ask how you can address the patient.
4. Check the patient's passport data.5. Ask the history of his illness:
- Onset: acute or gradual (does the patient remember when the disease started?)
- When and with what symptoms did the disease begin?
- What is its reason, according to the patient?
- Development of symptoms in dynamics (strengthening, disappearance,
appearence of new symptoms)?
- Have the patient sought medical help before?
- What preliminary examinations have already been performed (radiography,
CT, MRI) and their results?
- What previous treatment did the patient receive (did not receive, was treated on
an outpatient basis, inpatient, sanatorium) and its effectiveness.
6. Find out if the patient has anything to add. Answer the patient's questions.
7. End the conversation: summarize the identified data and clarify with the
patient whether you have received the information correctly, thank the patient, wish
him a speedy recovery, say goodbye.
III. Physical examination of a standardized patient
Diagnose vertebrogenous syndrome in patient with radiculopathy.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent).
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style).
3. Explain the need for the survey, its purpose.
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conducting a survey:
a) examine the lumbosacral region. Assess - the configuration of the spine:
lordosis (normal, smoothed, absent, the presence of scoliosis, kyphosis); the presence
of asymmetry of the waist triangles; visible tension of paravertebral muscles;b) assess the position of the patient in bed (the presence of unloading postures:
knee-elbow position, a symptom of a tripod, can lie only on the side or only on the
back with a bent leg;
c) assess the amount of active movements in the lumbosacral spine: anterior,
posterior, lateral (restriction of movements or their impossibility), the appearance of
scoliosis when leaning forward, the appearance or intensification of pain during
movements;
d) to determine by palpation the degree of tension of the paravertebral muscles
(I, II, III centuries);
e) palpate pain points: paravertebral, intercostal spaces, spinous processes, points
along the sciatic, femoral nerves;
e) to determine the patient's symptoms of Laseg, Neri, Wasserman, Matskevich,
Spurling, Fenz.
7. Explain the results of the examination to the patient.
Investigate the system of voluntary movements in a patient with radiculopathy.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent).
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style).
3. Explain the need for the survey, its purpose.
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey. Explore:
a) the volume of active movements (ask the patient to bend and unbend the neck,
raise and lower the shoulders, arms, bend and unbend the upper extremities in the
elbow, carpo-radial, interphalangeal joints, sit down, bend and unbend the legs in the
hip, knee and shin foot joints).
If the patient has no active movements in the limb, it may be paralysis, but if
they are limited – paresis;b) the volume of passive movements - helps to differentiate paresis and paralysis
of the extremities from the restriction or absence of movements in them due to
various diseases of the musculoskeletal system. For this purpose in the upper and
lower extremities resistance at performances is estimated and passive movements by
type of flexion in the joints of the upper and lower extremities, starting from the
proximal parts, ending with the distal;
c) muscle strength (strength in antagonist muscles from the proximal to distal
parts of the upper and lower extremities is studied by counteraction). Muscle strength
is assessed on a 5-point scale,
where 5 points is the norm,
4 points - mild paresis,
3 points - moderate paresis,
1-2 points - deep paresis,
0 points - paralysis.
To detect mild paresis, Barre tests are performed: the upper (the patient is asked
to extend both arms forward and hold for 1-2 minutes. The paretic arm is lowered
faster) and the lower arm (the patient who is in a supine position is asked to raise the
legs. The paretic leg is lowered faster), as well as the Buddha test;
d) muscle trophics (assess the condition of muscle groups by examining and
measuring the volume of symmetrical areas of the limbs with a centimeter tape);
e) muscle tone (check by passive flexion - extension in the joints of the upper
and lower extremities. Assess whether the muscles resist such movements
(hypertonia) or vice versa, the muscles are too relaxed (hypotonia);
e) physiological superficial (from the skin and mucous membranes) and deep
(tendon and periosteal) reflexes. It is necessary to evaluate the expressiveness of
reflexes (absent, reduced (torpid), lively) and symmetry (D = S - normal). At
pathology reflexes can increase (hyperreflexia), decrease (hyporeflexia), disappear
(areflexia), lose symmetry (anisoreflexia D<S);
h) investigate the course: paretic, "rooster";
g) determine the presence of paresis and its degree (mild paresis, moderate
paresis, deep paresis, plegia).7. Explain the results of the examination to the patient.
Examination of superficial sensation in patient with radiculopathy.
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conducting a survey.
Research should be performed in a calm atmosphere, if possible in a warm room.
Ask the patient to close his eyes. He needs to be explained what to look for when
studying each type of sensation. Irritation should be applied to symmetrical areas of
the body from top to bottom, keeping in mind the segmental structure of the body;
a) tactile sensation is checked with a brush by applying irritation in the form of
touch on the symmetrical areas of the skin of the right and left parts of the body on
the front and back surface from top to bottom;
b) similarly check pain sensation with a neurological needle. At the same time
the patient is asked whether he feels equally acute irritation in symmetrical parts of
the body;
c) temperature sensation is checked by means of two test tubes with warm and
cold water, which are alternately applied to the patient's skin.
Healthy people distinguish a temperature difference of 1-2 degrees.
Investigate the deep sensitivity of a standardized patient with radiculopathy.
1. Greet and name yourself (name, level of competence, explanation or
finding out the reason for consultation, obtaining patient consent).
2. Establish a trusting relationship (friendly facial expression, showinterest, respect and care, appropriate communication style).
3. Explain the need for the survey, its purpose.
4. Explain the details of the survey, their safety, possible sensations when
this.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey. Explore:
a) muscle-joint sense is studied by performing passive movements up and down
starting from the interphalangeal joints of the hands and feet, then in the carpo-radial
and ankle-foot joints, etc. The patient with closed eyes should indicate the direction
of movement. Loss of musculoskeletal sensation - batianesthesia, decreased
musculoskeletal sensation - bathyhypesthesia.
b) vibration sensation is measured using a Weber tuning fork.
The leg of the vibrating tuning fork is placed on the areas on the body where the
bone is covered only a thin layer of skin (the back of the feet, hands, along the tibia,
etc.). Normally, the vibration sensation on the hands reaches 15-20 seconds, on the
feet -10-15. The absence of vibration sensation is seismonesthesia.
c) kinesthetic sensation is checked by moving the skin fold up or down, left or
right, and the patient must recognize the direction of movement.
7. Explain the results of the examination to the patient.
Examination of autonomic disorders in a patient with radiculopathy
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent).
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style).
3. Explain the need for the survey, its purpose.
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey.a) examine the skin (dryness, peeling, color, the presence of trophic spots,
ulcers, hair loss).
b) examine the nails (hyperkeratosis, streaks).
c) to detect in the patient disorders of pelvic functions: urination, defecation.
Determine the type of pelvic disorders: central or peripheral.
7. Explain the results of the examination to the patient.
"Diagnose aphasia"
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for the consultation, obtaining the patient's consent).
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style).
3. Explain the need for the survey, its purpose.
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the survey.
6. Conduct a survey. Assess the patient's language:
- spontaneous language (vocabulary, the ability to build sentences, express
opinions);
- repetitive language (in the absence or restriction of spontaneous speech);
- automated language (in case of absence or restriction of spontaneous language);
- the ability to operate with nouns;
- understand the spoken language and follow the instructions.
- understanding of complex grammatical constructions.
7. To conclude. Depending on the nature of the disorders, there are motor, sensory,
amnestic, semantic, and total aphasia.
"Diagnose paresis and paralysis"
1. Greet and name yourself (name, level of competence, explanation or
clarification of the reason for consultation, obtaining the patient's consent);
2. Establish a trusting relationship (friendly facial expression, show interest,
respect and care, appropriate communication style);
3. Explain the need for the survey, its purpose
4. Explain the details of the survey, their safety, possible sensations.
5. Prepare for the examination (clean warm hands).
6. Conduct a survey. Explore:
a) volume of active movements (ask the patient to bend and unbend the neck, raise
and lower the shoulders, arms, bend and unbend the upper extremities in the elbow,
carpal-radial, interphalangeal joints, sit down, bend and unbend the legs in the hip,
knee and shin foot joints). If the patient has no active movements in the limb, it may
be paralysis, but if they are limited - paresis.
b) the volume of passive movements - helps to differentiate paresis and paralysis
of the extremities from the restriction or absence of movements in them due to different
diseases of the musculoskeletal system. To do this in the upper and lower
limbs resistance is assessed when performing passive movements on the type of
flexion-extension in the joints of the upper and lower extremities, starting from the
proximal parts, ending with the distal;
c) muscle strength (strength in antagonist muscles from the proximal to distal parts
of the upper and lower extremities is studied by counteraction). Muscle strength is
assessed on a 5-point scale, where:
5 points - the norm,
4 points - mild paresis,
3 points - moderate paresis,1-2 points - deep paresis,
0 points - paralysis.
Barre tests are performed to detect mild paresis: the upper one (the patient is
asked to extend both arms forward and hold for 1-2 minutes. The paretic arm is lowered
faster) and the lower one (the patient who is in a supine position is asked to raise the
legs. The paretic leg is lowered faster), as well as the test of the Buddha
d) muscle trophism (assess the condition of muscle groups by examining and
measuring the volume of symmetrical areas of the limbs with a centimeter tape);
e) muscle tone (check by passive flexion-extension in the joints of the upper and
lower extremities. Assess whether the muscles resist such movements (hypertonia) or
vice versa, the muscles are too relaxed (hypotonia). When the corticospinal tract is
affected, spastic muscle hypertension occurs, which has the following features:
- on the hands the tone is increased in the flexors, on the legs - in the extensors;
- in process of checking the tone decreases, weakens;
- symptom of "clasp-knife" - resistance at the beginning of the passive movement
is expressed, then decreases.
e) physiological superficial (from the skin and mucous membranes) and deep
(tendon and periosteal) reflexes. It is necessary to estimate the expressiveness of
reflexes (absent, reduced (torpid), lively, tall, clonus) and symmetry (D = S - normal).
In pathology, reflexes may increase (hyperreflexia, clonus), decrease (hyporeflexia),
disappear (areflexia), lose symmetry (anisoreflection - D> S or D <S);
g) the presence of pathological reflexes on the upper and lower extremities of the
flexor and extensor group;
g) the presence of pathological synkinesis (involuntary movements that appear
reflexively in the paralyzed limb under stress), protective reflexes (involuntary
complex, often flexion, movements of the paralyzed limb in response to its irritation
(eg, passive flexion of the fingers));
h) the presence of fibrillar and fascicular twitching.
7. Explain the results of the examination to the patient.
INTERNAL MEDICINE
Estimate the glucose level in the blood and interpret glucose tolerance test
1. Interpretation of laboratorial and instrumental results
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
- evaluate the glycemia level in the capillary blood (normal level 3,3 – 5,5). To
estimate HbA1c level: good compensation <7 %, satisfactory 7-8 %, unsatisfactory >8
%.
- evaluate the results of the glucose tolerance test
Glucose tolerance test
Fasting glucose level in
the capillary
blood, mmol/l
The glucose level in the
capillary blood in 2 hours
after glucose load, mmol/l
Normal
3,3-5,5
<7,8
Impaired glucose
tolerance
5,6-6,1
7,8-11,1
Diabetes mellitus
≥6,1
≥11,1
Impaired fast glucemia
5,6-6,1
<7,8
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
Carry out of pH-metry, evaluate its results
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
1. Interpretation of pH-metry results:
· 0 functional interval (FI) (pH 7.0-7.5 )
· I FI (3,6-6,9)
· II FI (рН 2,3-3,5)
· III FI (рН 1,6-2,2)
· IV FI (рН 1,3-1,5)
· V FI (рН 0,9-1,2)
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.Determination of ascites
Collection of complaints and anamnesis in patients with ascites
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
- Collect complaints in patients with ascites (enlargement of
abdomen, dyspnoea during physical overstrain, hardness in
right hypochondrium)
- Collect anamnesis in patients with ascites (when enlargement of
abdomen was observed, efficiency ot treatment)
2. Physical examination of patient
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
- Perform examination this patient and shows the changes common
for ascites (dropping abdomen in vertical position of the patient, frog-like
abdomen in lying position, positive “swimming ice-floe“ syndrome, dullness in
the lateral side in lying position and dullness in the suprapubic region
in in vertical position of the patient during percussion of the abdomen)
3. Interpretation of results of laboratory and instrumental diagnostics
- Interpret ultrasound examination results of abdominal cavity (presence of free fluid,
fibrosis)
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with chronic pancreatitis”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Collect complains of the patient with chronic pancreatitis (pay attention of the
peculiarities of pain and dyspeptic syndrome).
2. Collect anamnesis of the patient with chronic pancreatitis(pay attention on the
nutrition character, smoking, stressful factors, taking the alcohol, heredity, frequency
and seasonal of exacerbation).
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Perform examination of the patient and show the changes characterizing the
chronic pancreatitis (to investigate the skin and mucous (pallor, dryness of skin),
tongue (covered by white incrustation), superficial (local muscular defense) and deep
palpation (pain during palpation in paraumbilical region, Shofar’s zone).
4. Interpret the results of laboratory and instrumental methods of examination:- evaluate the ultrasound examination of the pancreas (enlargement of the
gland, induration, infiltration, presence of the cysts and pseudocysts).
- evaluate the biochemical blood test (amylase, alkaline phosphatase)
- evaluate the results of urine diastaze
- evaluate the coprogram results.
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with chronic hepatitis”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Collect complains of the patient with chronic hepatitis (pay attention on the
peculiarities of pain, dyspeptic and astenovegetative syndrome).
2. Collect anamnesis of patient with chronic hepatitis (pay attention on the nutrition
character, smoking, stressful factors, taking the alcohol, heredity, transfusion of the
blood).
3. 6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
Perform examination of the patient and show the changes characterizing the chronic
hepatitis (to investigate of the skin and mucous (pallor and dryness of skin,
jaundice, teleangioektazy, hemorrhages), tongue (covered by white or yellow
incrustation), superficial(local muscular defense) and deep palpation (pain during
palpation in left and right hypochondrias regions, size of the liver, characteristic of
the liver lower border).
4. Interpret the results of laboratory and instrumental methods of examination:
- evaluate the ultrasound examination of the liver (enlargement, induration, change
of echostructure, presents of node, fibrose);
- evaluate the gastroscopy results;
- evaluate the results of biochemical blood test (ALT, AST,
alkaline phosphatase, bilirubine unconjugated, conjugated, protein, creatinine, urea,
Na, Ca, Cl, K).
- evaluate the coprogram’s results;
- evaluate the serologic’s results (virus antigenic marker).
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with liver cirrhosis”.
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.1. Collect the complains of the patient with liver cirrhosis (pay attention on the
peculiarities of pain, dyspeptic and astenovegetative syndrome).
2. Collect anamnesis of patient with liver cirrhosis (pay attention on the nutrition
character, smoking, stressful factors, taking the alcohol and drugs, heredity,
frequency and seasonal of exacerbation, the onset, duration of the disease, transfusion
of the blood, gastroenteral bleeding).
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Perform examination of the patient and show the changes which characterized liver
cirrhosis (to investigate of the skin and mucous (pallor and dryness of skin,
jaundice, teleangioektazy, hemorrhages), tongue (covered by white or yellow
incrustation), edema on the legs, “caput medusae”, superficial (local muscular
defense, presence of the free fluid in abdominal cavity) and deep palpation (pain
during palpation in left and right hypochondrial region, liver size, spleen size).
4. Interpret the results of laboratory and instrumental methods of examination:
- evaluate the ultrasound examination of the liver(enlargement, induration, change
of echostructure, presents of node, fibrose);
- evaluate the gastroscopy results;
- evaluate the results of biochemical blood test (ALT, AST,
alkaline phosphatase, bilirubine, unconjugated, conjugated, protein, creatinine, urea,
Na, Ca, Cl, K);
- evaluate the coprogram’s results;
- evaluate the serologic’s results (virus antigenic marker);
- evaluate the computer tomography.
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
Curation of the patient with chronic gastritis, duodenitis”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take the complaints of the patients with chronic gastritis, duodenitis (pay
attention on pain and dyspeptic syndromes peculiarities)
5. Take the anamnesis in the patients with chronic gastritis, duodenitis (pay
attention on the nutrition character, smoking, stress, heredity, frequency of
exacerbation)
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
9. Perform the exanimation of the patients and show the changes, which
characterize chronic gastritis, duodenitis (to investigate skin and mucosa membrane (pale, dryness) tongue (presents of white covering; atrophy of the papilla),
superficial (mucous defense) and deep palpation (painless during palpation in
epigastria region and pyloroduodenal area).
10. The interpritation of laboratory and instrumental methods results:
-evaluate gastroscopy results (hyperemia, oedema of mucosa, erosions)
- evaluate results of X-ray examination of stomach, duodenum (thikining of the
wall, changes of motor function)
- presence of Hp (determination of Hp antibody)
- evaluate results of the Gregersen test
- evaluate pH-metry results (functional interval)
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
Curation of the patient with peptic ulcer disease”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Take the complaints of the patients with peptic ulcer disease (pay attention on
pain and dyspeptic syndromes peculiarities)
2. Take the anamnesis of the patients with peptic ulcer disease (pay attention on
the nutrition character, smoking, presents of stress, taking of NSAD, heredity,
frequency and seasonality of exacerbation)
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Perform the exanimation of the patients and show the changes, which
characterize the peptic ulcer (to investigate of skin and mucosa membrane
(pale, dryness) tongue (presents of white covering; atrophy of the papilla),
superficial (mucous defense) and deep palpation (painless during palpation in
epigastria region and pyloroduodenal area), to determinate
of Mendelya’ssyndrome)
4. The interpritation of laboratory and instrumental methods results:
– evaluate of gastroscopy result (presents of ulceration of mucosa)
– evaluate of digestive tract X-ray examination result (direct an indirect
sings)
– evaluate of IEA (determination of Hp antibody) (antibody’s titer to
Hp antigen)
– evaluate the Gregersen test results
– evaluate of pH-metry results (functional interval)
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with hemorrhagic diathesis”1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Collect the complains of the patient with hemorrhagic diathesis (pay attention
on the peculiarities of anemic and hemorrhagic syndrome, type of hemorrhagic).
2. Collect anamnesis of patient with hemorrhagic diathesis (pay attention on the
nutrition character, smoking, presence of hemorrhages in patients or there
relatives).
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Perform examination of the patient and show the changes which characterized
the hemorrhagic diathesis (investigation of the skin and mucous, garrote test,
bandage test).
4. Interpret the results of laboratory and instrumental methods of examination:
- evaluate the general blood test (thromboctes less than 150 х 109 /l.;
- evaluate the coagulogram’s result and blood clotting time.
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with anemia”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Collect complains of the patient with anemia (pay attention of the peculiarities of
anemic and sideropenic syndrome).
2. Collect anamnesis of patient with anemia (pay attention on the nutrition character,
smoking, presence of the bleeding in the past).
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Perform examination of the patient and show the changes which characterized the
anemia (investigation of the skin and mucous (pallor and dryness of skin), tongue
(covered by white incrustation, smoothing of the papilla), tachycardia, systolic
murmur, dilatation of the heart border).
4. Interpret the results of laboratory and instrumental methods of examination:
- evaluate the gastroscopy results (presents of gastritis, erosion, ulceration of the
mucous);
- evaluate the biochemical blood test results (iron and iron-connecting serum
possibility);
- evaluate the Gregersen test;
- evaluate the pH-metry results (functional interval).11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
“Curation of the patient with the leukemia”
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Collect the complain patient with leukemia (pay attention on peculiarities of
anemic and prolipherative polyadenopathy, immunodeficiency syndrome
and nevroleukemia).
2. Take the anamnesis in patients with leukemia (pay attention on the heredity
presents contacts with toxic, chemical and others poisons substances).
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Exanimate the patient and show the changes charactering for leukemia (pallor
and skin eruption, palpation of lymphatic nodes, liver and spleen present
of sternalgia).
4. Interpret the laboratory and instrumental methods results:
– to evaluate the general blood tests changes (Anemia,
thrombocytopenia, blastemia, leukopenia common for acute
leukemia. Leukocytosis, absolute lymphocytosis, Botkin- Gumpreht’s shade
common for chronic leukemia. Leukocytosis, presence
of myelocytes, myeloblasts, basophilic and eosynophlic dissociation common
for myeloid leukemia.)
– to scow changes in myelogram (presents of blastemia, hypo
and hyperprolipheration of bone marrow, more than 30 % blasts as criterium of
acute lekemia, leukocytosis amd more than 40 % lymphocytes as criteria of
chronic lympholekemia, lekocytosis and proliferation of cells of
myeloid rowto myeloblasts)
– to evaluate of results of ultrasound examination of the liver and
the spleen
11. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
12. Conversation accomplishment.
1. Curation of the patient with hypothyroidism.
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
1. Take the complaints of the patients with hypothyroidism (pay attention on
general weakness, fatigue, somnolence, worsening of memory, ear, difficulty of
speech, constipations, sensitiveness to the cold, edema). Take the anamnesis in the patients with hypothyroidism: presence of infectious, infiltrative,
autoimmune diseases, operative interferences or irradiation of thyroid gland).
2. Explanation of investigation results.
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
3. Explain the actions (hospitalization, making of certain tests which are planned
to perform in the future).
4. Conversation accomplishment.
2. Physical examination of patient.
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the patient examination that will be done and take his consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the
examination.
7. Prepare for
the examination (clean warm hands, cut nails,
warm phonendoscope, etc.).
8. Perform the exanimation of the patients and show the changes, which
characterize hypothyroidism (big face, peryorbytal swollen, large language
with the imprints of teeth, skin is pale, icteric, dry (hyperkeratosis),
cold, edema of skin, loss of hair, bradycardya, increased of heart borders in
percussion, enlargement of liver)
9. Explanation of investigation results.
10. Conversation accomplishment.
3. The interpretation of laboratory and instrumental methods results:
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explanation of investigation results.
5. Interpretation of received results of inspection, taking into account norms:
a. TSH: 0,23-4,0
b. Т4 free: 10-35
c. Аb to PО: less 30
6. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
7. Conversation accomplishment.
1. Curation of the patient with diabetes mellitus.
1. Friendly facial expression and smile.2. Gentle tone of speech.
3. Greeting and introducing.
4. Take the complaints of the patients with diabetes mellitus (pay attention on the
presence of hyperglycemyc syndrome, complaints which characterize micro-
(angyopathy of lower extremities, nephropathy) and makroangyopathy (ischemic
heart disease) and neuropathy (central, peripheral, visceral). From anamnesis:
began, flowing of disease, presence of risk factors in general and depending on
the type of diabetes.
6. Find a contact with the patient and make an attempt to gain his/her trust.
7. Inform about the possibility of appearing of unpleasant feelings during the
examination.
8. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope,
etc.).
5. Explanation of investigation results.
6. Explain the actions (hospitalization, conducting of certain inspections) which
are planned to perform in the future.
7. Conversation accomplishment.
2. Physical examination of patient.
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the patient examination that will be done and take his consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the
examination.
7. Prepare for the examination (clean warm hands, cut nails,
warm phonendoscope, etc.).
8. Perform the exanimation of the patients and show the changes, which
characterize diabetes mellitus (pay attention to the skin, pulse, blood pressure,
enlargement of liver, presence of peripheral edema, pulsation on peripheral
arteries).
9. Explanation of investigation results.
10. Conversation accomplishment.
3. The interpretation of laboratory and instrumental methods results:
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explanation of investigation results.
5. Interpretation of received results of inspection, taking into account norms.
6. Involve the patient into the conversation (compare present examination results
with previous ones, clarify whether your explanations are clearly understood).
7. Conversation accomplishment.
«Curation of patients with hypothyroidism»
І. Complaints and anamnesis data taking in patient:
1. Look neat, presentable and smile.
2. Gentle speech, show interest, respect and be compassionate.
3. Greet and introduce yourself: state your role/position in the patient’s evaluation,
explain to the patient whether you will be taking an interview, ask the patient how he
or she wants to be addressed.
4. Collect complaints and anamnesis in patient with hypothyroidism (look out for the
following symptoms: general weakness, fatigue, lethargy, loss of memory, deafness,
difficulty speaking, constipation, cold intolerance, peripheral edema. In anamnesis:
previous infections, infiltrative diseases, autoimmune diseases, surgical intervenion
and radiotherapy of thyroid gland).
5. Explanation of examination results.
6. Give answers and reply to patient.
7. After review make a short conclusion and ask patient if he/she understands all
information, ask if he/she has additional information, explain to patient all plans of
investigation, indication and aim of future treatment, hospitilization according to
clinical situations.
8. Finish communication, thank the patient, wish patient healthy recovery and say
goodbye.
II. Physical examination of patient
It is necessary before physical exmainaion of patient for student to greet, explain the
aim of examination, make contact, get permission for examination, make sure your
hands are dry and warm then start objective examniation.
1. Algorithm of examination
To perform examination of patient and reveal changes which are characteristic of
hypothyroidism (puffy face, periorbital edema, enlargement of tongue with teeth
imprints, pale skin, slight yellowish discoloration, dryness (hyperkeratosis), cold
extremities, slight swelling of skin, hair loss; bradycardia; shift heart borders during
percussion, weak heart tone, hepatomegaly), demonstrate methods of thyroid gland
palpation and define changes.
Method of paplation of thyroid gland
Inspection: • Neck:
– Observe the whole neck, but pay particular attention to the area of the thyroid
gland. Inspect the neck from the front and side, and look for any obvious
abnormalities, scars, or swellings.
– Hand the patient a glass of water, and observe them as they take a drink. Watch the
movement of any swellings as they drink as this can help to differentiate betweendifferent causes.
– Comment on size, symmetry, and visible nodule in the neck.
Palpation: • Next feel the gland:
– The approach is from behind so always tell the patient what you will be doing and
that you will be behind her. Warn her again the moment before you actually touch
her neck.
– Palpate the entire length of both lobes of the gland as well as the isthmus. Note any
swellings or abnormal lumps. Comment on the shape and consistency of any
lumps as well as whether they are tender or mobile. Also examine while the patient
drinks to assess whether the lump moves with swallowing.
– While still behind the patient, take the opportunity to examine the cervical lymph
nodes.
– Examine the eyes from behind and above to look for any exophthalmos
Ask pateint to tilt head slightly forward.
Student should stand in front of the patient. Flex the 2nd -5 th fingers of both hands
and put on the posterior margin of the sternocleido-mastoid muscle and put thumb on
the thyroid cartilage. Ask patient to swallow, at this moment one can feel the
movement of the thyroid gland.
According to another method, the student should stand at the right side of the
patient. The left hand should be fixed to the back of neck, and by fingers of the right
hand carries out the palpation of thyroid gland. Palpation of the right lobe by thumb,
and the left lobe by 2 nd -5 th fingers.
For palpation of thyroid gland isthmus, put left hand on the neck of patient. 2nd
and 3rd fingers of right hand put on the anterior surface of the neck at the level of
thyroid cartilage. Ask patient to raise head. During palpation, press deeply and slide
fingers up and down to the jugular groove ( across of isthmus). Then stop movement
of fingers. Ask patient to swallow, during swallowing the isthmus moves up then
down; determine the width, consistency, movement during swallowing.
According to another method of palpation of the thyroid gland, the student
stands behind the patient. The four fingers together should be put on the thyroid
cartilage from both sides and the thumb on the posterior surface of the neck. The
middle finger palpates the isthmus of the thyroid gland while the remaining fingers
feel the lobes of the thyroid gland.
2. Determination of the main syndrome and diagnosis.
3. Plan of laboratory and instrumental investigations.
4. Plan of treatment.
III. Interpretation of the laboratory-instrumental methods results
Interpretation of results including normal values
TSH: 0,23 – 4,0 µU/мл
Т4 free: 10 – 35 pmol/l Thyroperoxidase (TPO) Antibodies: < 30 µU/мл
Thyroid ultrasound examination data: Thyroid gland is located in a typical anatomic
site and not enlarged, the boders are clear. The thyroid gland tissue mild
echogenisity, echostructure is homogeneous.
Isthmus 10,7 mm
Right lobe length (Craniocaudal dimension) 40 mm
thickness (anteroposterior dimension) 19 mm
width (mediolateral dimension) 18 mm
The volume of Right lobe by Brunn - 5,1 cm3
Left lobe length (Craniocaudal dimension) 40 mm
thickness (anteroposterior dimension) 24 mm
width (mediolateral dimension) 27 mm
The volume of Left lobe by Brunn – 5,9 cm3
The thyroid gland total volume - 11,0 cm3
(upper limit of the normal thyroid gland volume according to age - 12,0 см3)
Color Doppler imaging demonstrated normal parenchymal vascularity of thyroid
gland.
Regional lymph nodes are not visible.
The margings are regular, the focal lesions are absent.
1. Determination of the main syndrome and diagnosis.
2. Determination of treatment plan.
«Curation of patients with diabetes melitus»
І. Complaints and anamnesis data taking in patient:
1. Look neat, presentable and smile.
2. Gentle speech, show interest, respect and be compassionate.
3. Greet and introduce yourself: state your role/position in the patient’s evaluation,
explain to the patient whether you will be taking an interview, ask the patient how he
or she wants to be addressed.
4. Collect complaints and anamnesis in patient with hypothyroidism (look out for the
following symptoms: general weakness, fatigue, lethargy, loss of memory, deafness,
difficulty speaking, constipation, cold intolerance, peripheral edema. In anamnesis:
previous infections, infiltrative diseases, autoimmune diseases, surgical intervenion
and radiotherapy of thyroid gland. (pay attention to the presence of hyperglycemic
syndrome, complaints characteristic for micro (angiopathies of lower extremities,
nephropathies); -macroangiopathies (IHD) and neuropathies (central, peripheral, visceral). In anamnesis: onset of diesease, course of disease, presence of risk factors
which is general and specific for the type of diabetes).
5. Explanation of examination results.
6. Give answers and reply to patient.
7. After review make a short conclusion and ask patient if he/she understands all
information, ask if he/she has additional information, explain to patient all plans of
investigation, indication and aim of future treatment, hospitilization according to
clinical situations.
8. Finish communication, thank the patient, wish patient healthy recovery and say
goodbye.
II. Physical examination of patient
It is necessary before physical exmainaion of patient for student to greet, explain the
aim of examination, make contact, get permission for examination, make sure your
hands are dry and warm then start objective examniation.
1. Algorithm of examination
To perform examination of patient and reveal changes which are characteristic of
diabetes mellitus (pay attention to skin abmormalities; pulse characteristics; blood
pressure level; hepatomegaly; presence of peripheral edema; peripheral artery
pulsation changes)
2. Determination of the main syndrome and diagnosis.
3. Plan of laboratory and instrumental investigations.
4. Plan of treatment.
III. Interpretation of the laboratory-instrumental methods results.
Interpretation of results including normal values:
Glycated hemoglobin - <6.5%
Glycemic profile - 3.5-5.5 mmol|l
C-peptide 0.53-2.9 ng/ml
1. Determination of the main syndrome and diagnosis.
2. Determination of treatment plan.
«Curation of patient with diffuse toxic goiter»
І. Complaints and anamnesis data taking in patient:
Algorithm of student action in a clinical situation:
1. Look neat, presentable and smile.
2. Gentle speech, show interest, respect and be compassionate.
3. Greet and introduce yourself: state your role/position in the patient’s evaluation,
explain to the patient whether you will be taking an interview, ask the patient how he
or she wants to be addressed.
- Ask for age and occupation.4. Collect main complaints (detailise each of them). Pay attention on the metabolic
syndrome (weakness or hyperactivity, easy fatiguability or irritability, loss of
weight or overweight), syndrome of cardioovascular system dysfunction
(brady- or tachycardia, arrhymthia or blood pressure changes).
- Ask about possible concommitant complaints
- Discover about opthamological symptoms and when it appears.
- Ask about history of disease:
- Onset ( acute or gradual), duraton of disease
- Provoking and risk factors
- Initial symptoms.
- Dynamic of symptoms.
- Previous medical aid or treatment.
- Social and occupational conditions, family anamnesis.
In case of fever - to find out the epidemiological history, infectious diseases.
5. Determination of possible cause of disease (allergic reactions, hormonal
disturbances, insolation, stress).
6. Explanation of examination results.
6. Give answers and reply to patient.
7. After review make a short conclusion and ask patient if he/she understands all
information, ask if he/she has additional information, explain to patient all plans of
investigation, indication and aim of future treatment, hospitilization according to
clinical situations.
8. Finish communication, thank the patient, wish patient healthy recovery and say
goodbye.
II. Physical examination of patient
It is necessary before physical exmainaion of patient for student to greet, explain the
aim of examination, make contact, get permission for examination, make sure your
hands are dry and warm then start objective examniation.
1. Algorithm of examination
To perform examination of patient and reveal changes which are characteristic of
hypothyroidism (puffy face, periorbital edema, enlargement of tongue with teeth
imprints, pale skin, slight yellowish discoloration, dryness (hyperkeratosis), cold
extremities, slight swelling of skin, hair loss; bradycardia; shift heart borders during
percussion, weak heart tone, hepatomegaly), demonstrate methods of thyroid gland
palpation and define changes.
Method of paplation of thyroid gland
Inspection: • Neck:
– Observe the whole neck, but pay particular attention to the area of the thyroid
gland. Inspect the neck from the front and side, and look for any obvious
abnormalities, scars, or swellings.– Hand the patient a glass of water, and observe them as they take a drink. Watch the
movement of any swellings as they drink as this can help to differentiate between
different causes.
– Comment on size, symmetry, and visible nodule in the neck.
Palpation: • Next feel the gland:
– The approach is from behind so always tell the patient what you will be doing and
that you will be behind her. Warn her again the moment before you actually touch
her neck.
– Palpate the entire length of both lobes of the gland as well as the isthmus. Note any
swellings or abnormal lumps. Comment on the shape and consistency of any
lumps as well as whether they are tender or mobile. Also examine while the patient
drinks to assess whether the lump moves with swallowing.
– While still behind the patient, take the opportunity to examine the cervical lymph
nodes.
– Examine the eyes from behind and above to look for any exophthalmos
Ask pateint to tilt head slightly forward.
Student should stand in front of the patient. Flex the 2nd -5th fingers of both hands
and put on the posterior margin of the sternocleido-mastoid muscle and put thumb on
the thyroid cartilage. Ask patient to swallow, at this moment one can feel the
movement of the thyroid gland.
According to another method, the student should stand at the right side of the patient.
The left hand should be fixed to the back of neck, and by fingers of the right hand
carries out the palpation of thyroid gland. Palpation of the right lobe by thumb, and
the left lobe by 2nd-5th fingers.
For palpation of thyroid gland isthmus, put left hand on the neck of patient. 2nd and
3rd fingers of right hand put on the anterior surface of the neck at the level of thyroid
cartilage. Ask patient to raise head. During palpation, press deeply and slide fingers
up and down to the jugular groove ( across of isthmus). Then stop movement of
fingers. Ask patient to swallow, during swallowing the isthmus moves up then down;
determine the width, consistency, movement during swallowing.
According to another method of palpation of the thyroid gland, the student stands
behind the patient. The four fingers together should be put on the thyroid cartilage
from both sides and the thumb on the posterior surface of the neck. The middle finger
palpates the isthmus of the thyroid gland while the remaining fingers feel the lobes of
the thyroid gland.
Evaluation of endocrine ophtalmopathy signs:
о Darlimple's sign: widening of the palpebral fissure with inferior and superior scleral
show;
о Stellwag's sign: infrequent blinking (eyelid retraction) ;
о Moebius's sign: Squint and lack of convergence of eyeball become obvious when
patient stares at a close object;о Kocher's sign: dissinergism between eyeballs and frontal muscles movements when
patient is looking upward; on upward gaze the globe lags behind the movement of the
upper eyelid.
о von Graefe's sign: lig lag sign (dissinergism between eye ball's and superior eyelid's
movement especially when patient is looking downward);
о Rosenbach's sign: eyelids are animated by thin tremors when closed;
Jellinek's sign: Superior eyelid folds is hyperpigmented;
2. Determination of the main syndrome and diagnosis.
3. Plan of laboratory and instrumental investigations.
4. Plan of treatment.
III. Interpretation of the laboratory-instrumental methods results
Interpretation of results including normal values
TSH: 0,23 – 4,0 µU/мл
Т4 free: 10 – 35 pmol/l
Thyroperoxidase (TPO) Antibodies: < 30 µU/мл
Thyroid ultrasound examination data: Thyroid gland is located in a typical anatomic
site and not enlarged, the boders are clear. The thyroid gland tissue mild
echogenisity, echostructure is homogeneous.
Isthmus 10,7 mm
Right lobe length (Craniocaudal dimension) 40 mm
thickness (anteroposterior dimension) 19 mm
width (mediolateral dimension) 18 mm
The volume of Right lobe by Brunn - 5,1 cm3
Left lobe length (Craniocaudal dimension) 40 mm
thickness (anteroposterior dimension) 24 mm
width (mediolateral dimension) 27 mm
The volume of Left lobe by Brunn – 5,9 cm3
The thyroid gland total volume - 11,0 cm3
(upper limit of the normal thyroid gland volume according to age - 12,0 см3)
Color Doppler imaging demonstrated normal parenchymal vascularity of thyroid
gland.
Regional lymph nodes are not visible.
The margings are regular, the focal lesions are absent.
1. Determination of the main syndrome and diagnosis.
2. Determination of treatment plan.
«Management of patients with pneumonia»
І. Interviewing of a patient
1. Friendly facial expression, smile.
2. Gentle tone of speech, expression of interest, respect and care.
3. Greetings and introducing: name, level of competence (what year student),
explaination of the communication’s purpose, getting consent; to ask how to
approach the patient.
4. To collect main complains (detailing each of them).
To pay attention to
intoxication syndrome (weakness, fever, loss of appetite),
infiltrative syndrome
(cough and his character, shortness of breath), pulmonary insufficiency syndrome
(severity of dyspnea).
- To ask about possible concomitant complains.
5. To collect the history of the disease:
- Onset (acute or gradual),
The student asks about possible reason of patient’s condition.
- Primary symptoms
- Dinamics of symptoms (severity of respiratory manifestations of the disease: caugh,
dyspnea etc, dynamics of the fever, chest pain, its character and localisation),
- Working and living conditions
- Previous treatment.
6. To answer the patient’s questions.
7. After the interview: to make short resume and clarifies whether the information
had been perceived correctly, whether the patient can add something; to explains
further examinations, the necessity and essence of management.
8. To finish conversation: to say thank and goodbye to the patient, to wish him (her)
quick recovery.
II. Physical examination
It should be assumed that the student greeted, explained the purpose of the
examination, set the contact, received consent before the start of the examination; and
has begun an objective examination with a clean, warm hands.
To conduct a survey of the patient with pneumonia and indicate the
characteristic changes (pay attention to the scin – colour, moisture, temperature);
pulse; BP; symmetry of chest movements, to conduct chest palpation (excursion,
vocal fremitus), percussion (comparative and topographical) and lung auscultation.
Auscultation rules and techniques
1. It must be quiet and warm in the room where the auscultation is conducted.
2. It is better to auscultate the patient in a sitting position, while relaxing the
respiratory muscles as much as possible. It is possible to auscultate in a standing position, but in this case it is nessessary to remember, that deep breathing can lead to
dizziness due to hyperventilation, sometimes even syncope.
3. Stethoscope should be put in strictly symmetrical parts of the chest (in those places
and along the same lines where comparative percussion was conducted);
4. Auscultation is carried out in different phases of breathing - on the breath, on
exhalation, sometimes after coughing.
During auscultation the first attention is paid to the main respiratory sounds -
vesicular, bronchial, rigid breathing. Characteristics of additional breathing sounds
(crackles, rales, wheezing, pleural friction rub).
To conduct an auscultation of the dummy’s lungs. To demonstrate an auscultation of
lungs technique on a torso equipped with a radiofonodex and audio speakers. To
indicate changes that are specific for pneumonia (to pay attention on weakened
vesicular breathing and crepitation, moist rales, wheezing).
5. Determination of the leading syndrome or diagnosis.
6. Prescription of the nessessary laboratory and instrumental investigation.
7. Prescription of the treatment.
III. Interpretation of laboratory and instrumental methods of examination
1. Determine specific for the pneumonia changes in the complete blood count.
2. Evaluate sputum analysis (microscopic and macroscopic).
3. Evaluate results of spirometry: specify stage and type of pulmonary insufficiency
according to spirometry.
4. Evaluate results of chest X-ray.
5. Determination of the leadin syndrome or diagnosis.
6. Determination of futher management of patient.
«Management of patients with bronchial asthma»
І. Interviewing of a patient
1. Friendly facial expression, smile.
2. Gentle tone of speech, expression of interest, respect and care.
3. Greetings and introducing: name, level of competence (what year student),
explaination of the communication’s purpose, getting consent; to ask how to
approach the patient.
4. To collect main complains (detailing each of them). To pay attention to
bronchoobstructive syndrome (attacks of expiratory dyspnea, cough – dry with futher
expectoration of viscous sputum), intoxication syndrome (weakness, fever, loss of
appetite), pulmonary insufficiency syndrome (severity of dyspnea), nasal
conjunctival syndrome.
- To ask about possible concomitant complains.5. To ask about the beginning of the disease (acute or gradual), duration of the
disease.
To find out the provocative factors, presence of precursors.
To clarify the severity of the disease (daily and seasonal variability, the severity of
respiratory manifestations of the disease: dyspnea, caugh etc):
- To find out frequency of attacks of dyspnea in a day/week/month.
- To find out presence or absence attacks of dyspnea at night.
- To find out frequency, duration and severity of exacerbations’ periods, seasonal
variability of exacerbations.
- The student asks about possible reason of patient’s condition, to collect family
history.
- Working and living conditions.
6. To answer the patient’s questions.
7. After the interview: to make short resume and clarifies whether the information
had been perceived correctly, whether the patient can add something; to explains
further examinations, the necessity and essence of management.
8. To finish conversation: to say thank and goodbye to the patient, to wish him (her)
quick recovery.
II. Physical examination
It should be assumed that the student greeted, explained the purpose of the
examination, set the contact, received consent before the start of the examination; and
has begun an objective examination with a clean, warm hands.
To conduct a survey of the patient with bronchial asthma and indicate the
characteristic changes (pay attention to the scin – colour, moisture, temperature);
pulse; BP; form of the chest, the involvement of additional muscles in the breath, to
carry out chest palpation (excursion, vocal fremitus), percussion (comparative and
topographical) and lung auscultation.
To conduct an auscultation of the dummy’s lungs. To demonstrate an
auscultation of lungs technique on a torso equipped with a radiofonodex and audio
speakers. To indicate changes that are specific for bronchial asthma (to pay attention
on hard breathing, dry rales, wheezing).
5. Determination of the leading syndrome or diagnosis.
6. Prescription of the nessessary laboratory and instrumental investigation.
7. Prescription of the treatment.
III. Interpretation of laboratory and instrumental methods of examination
1. Determine specific for the bronchial asthma changes in the complete blood count.
2. Evaluate sputum analysis (microscopic and macroscopic).
3. Interpretation of the results of instrumental methods- specify stage and type of pulmonary insufficiency according to spirometry;
- to evaluate results of chest X-ray.
5. Determination of the leadin syndrome or diagnosis.
6. Determination of futher management of patient.
«Management of patients with COPD»
І. Interviewing of a patient
1. Friendly facial expression, smile.
2. Gentle tone of speech, expression of interest, respect and care.
3. Greetings and introducing: name, level of competence (what year student),
explaination of the communication’s purpose, getting consent; to ask how to
approach the patient.
4. To collect complains in the virual patient correctly. To pay attention to
bronchoobstructive syndrome (dyspnea, cough and its character), intoxication
syndrome (weakness, fever, loss of appetite), pulmonary insufficiency syndrome
(severity of dyspnea).
5. To collect complains in the patient: especially pay attention to the onset of disease
(acute, abrupt, gradual), its duration, genetical predisposition, provoking factors,
presence of prodromal symptoms, dynamics of the symptoms, results of the previous
treatment, working and living conditions.
6. To answer the patient’s questions.
7. After the interview: to make short resume and clarifies whether the information
had been perceived correctly, whether the patient can add something; to explains
further examinations, the necessity and essence of management.
8. To finish conversation: to say thank and goodbye to the patient, to wish him (her)
quick recovery.
II. Physical examination
It should be assumed that the student greeted, explained the purpose of the
examination, set the contact, received consent before the start of the examination; and
has begun an objective examination with a clean, warm hands.
To conduct a survey of the patient with COPD and indicate the typical changes
(pay attention to the skin – colour, moisture, temperature); pulse; BP; shape of the
chest, the involvement of additional muscles into the respiratory act, bulging of the
neck veins; to carry out chest palpation (excursion, vocal fremitus), percussion
(comparative and topographical) and lung auscultation.
To auscultate the dummy’s lungs. To demonstrate an auscultation of lungs
technique on a torso equipped with a radiofonodex and audio speakers. To indicate
changes that are specific for COPD (to pay attention to a hard breathing, dry rales,
wheezing).
2. Determination of the leading syndrome or diagnosis.3. Prescription of the nessessary laboratory and instrumental investigation.
4. Prescription of the treatment.
III. Interpretation of laboratory and instrumental methods of examination
1. Determine specific for the COPD changes in the complete blood count.
2. Evaluate sputum analysis (microscopic and macroscopic).
3. To specify the stage and type of pulmonary insufficiency according to spirometry;
4. To evaluate the results of chest X-ray.
5. Determination of the leading syndrome or diagnosis.
6. Determination of futher management of patient.
Auscultation rules and techniques
1. It must be quiet and warm in the room where the auscultation is conducted.
2. It is better to auscultate the patient in a sitting position, while relaxing the
respiratory muscles as much as possible. It is possible to auscultate in a standing
position, but in this case it is nessessary to remember, that deep breathing can lead to
dizziness due to hyperventilation, sometimes even syncope.
3. Stethoscope should be put in strictly symmetrical parts of the chest (in those places
and along the same lines where comparative percussion was conducted);
4. Auscultation is carried out in different phases of breathing - on the breath, on
exhalation, sometimes after coughing.
During auscultation the first attention is paid to the main respiratory sounds -
vesicular, bronchial, hard breathing. Then characteristics of additional breathing
sounds should be given (crackles, rales, wheezing, crepitation, pleural friction rub).
“Algorithm of patient’s examination – Pneumonia”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with pneumonia (pay attention to the peculiarities of cough
syndrome, intoxication syndrome, character of dyspnea, chest pain and palpitations).
4.
Collect anamnesis of the patient with pneumonia (pay attention on the order of development of
symptoms, previous respiratory infections, harmful environmental factors, respiratory
allergies).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of pneumonia:
a.
inspection of the skin and mucous membranes for pallor, dryness, cyanosis
b.
measuring patients' respiratory rate (tachypnea)
c.
comparative percussion of the lungs (local changes of percutory sound),
d.
auscultation of the lungs (local changes of respiratory sounds),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the plain chest X-ray (infiltrative shadows, infiltration of the roots of the
lung)
b. Interpretation of the complete blood count (leukocytosis, left shift of leukogram, elevated
ESR)
c. Interpretation of the blood gases testing (decreased oxygen saturation)
d. Interpretation of the sputum test (bacterial growment)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Rickets”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with rickets (pay attention to the peculiarities of muscular
syndrome, skeletal changes, dyspeptic syndrome, neurological features).
4.
Collect anamnesis of the patient with rickets (pay attention to the nutrition, child’s lifestyle,
heredity, allergies, teeth eruption, vitamin D supplements introduction).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Inform about the possibility of appearing of unpleasant feelings during the examination.
3.
Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4.
Perform the exanimation of the patient and note the typical changes in case of rickets:
a. inspection of the skin and mucous membranes for pallor, sweating
b. inspection of skeletal deformations (craniotabes, frontal bossing, rachitic rosaries, garrison
groove, knock-knees, bow-legs, scoliosis)
c. assessment of muscular tonus (hypotonus),
d. assessment of physical development (poor growth and development),
5.
Explanation of investigation results.
6.
Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the long bones X-rays (widening of the epiphyseal plate, bone deformities)
b. Interpretation of the biochemical blood test (alkaline phosphatase, Ca, Na, P, 25-
hydroxyvitamin D levels)
c. Interpretation of the complete blood count (anemia)
d. Interpretation of the urinalysis (Ca and P level)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Bronchial asthma”
Interviewing the patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Find a contact with the patient and make an attempt to gain his/her trust.
3. Collect complains of the patient with Bronchial asthma (pay attention to the peculiarities of
cough syndrome, character of dyspnea).
4. Collect anamnesis of the patient with Bronchial asthma (pay attention on the order of
development of symptoms, previous respiratory infections, present of harmful environmental
factors, allergies, nutrition, heredity, frequency and seasonal character of attacks ).
5. Explane the results of interviewing.
6. Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Bronchial
asthma:
a.
inspection of the skin and mucous membranes for pallor, dryness, cyanosis
b.
measuring patients' respiratory rate (tachypnea, dyspnea)
c.
comparative percussion of the lungs (tympanic percutory sound),
d.
auscultation of the lungs (wheezing),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the plain chest X-ray (hyperinflation, increased lung pattern)
b. Interpretation of the complete blood count (leukocytosis, eosinophilia, elevated ESR)
c. Interpretation of the blood gases testing (decreased oxygen saturation)
d. Interpretation of spirometry (decreased forced expiratory volume)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Arthritis”
Interviewing the patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Find a contact with the patient and make an attempt to gain his/her trust.
3. Collect complains of the patient with Arthritis (pay attention to the pain syndrome, joints’
motor function).
4. Collect anamnesis of the patient with Arthritis (pay attention on the order of development of
symptoms, previous respiratory infections or traumas, harmful environmental factors, allergies,
heredity, frequency and seasonal character of exacerbation).
5. Explane the results of interviewing.
6. Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Arthritis:
a.
examination of joint (deformations, enlargement, tenderness, mobility, skin changes
above the joint)
b.
check the posture (poor posture)
c.
physical development assessment (physical development retardation),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the complete blood count (leukocytosis, elevated ESR)
b. Interpretation of the biochemical blood test (CRP, rheumatoid factor, anti-CCP, ANA)
c. Interpretation of the X-ray of affected joint (deformations, joint erosion, osteoporosis)
d. Interpretation of the ultrasonic picture of affected joint (synovitis)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Malnutrition ”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient / patient’s mother and make an attempt to gain her trust.
3.
Collect complains of the patient with Malnutrition (pay attention to the peculiarities of
dyspeptic syndrome, neurological signs, gain of the physical parameters).
4.
Collect anamnesis of the patient’s mother / caregiver (pay attention to the odstetrical and
perinatal conditions, nutrition, congenital malformations, developmental anamnesis).
5.
Explane results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform examination of the patient and note the typical changes in case of Malnutrition:
a. Inspection of the skin, and mucous membranes for pallor, dryness, thickness of
subcutaneous fold, tongue (covered by white coating, atrophy of the papilla),
b. Assessment of physical development (measurement of weight, length/height, calculation of
deficiency)
c. Assessment of psychomotor development (reflexes for infants, activity for toddlers)
d. Superficial palpation of abdomen (tenderness, bloating, edema)
5. Explanation of examination results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a.
Interpretation of the complete blood count (anemia, leukopenia)
b.
Interpretation of the biochemical blood test (ALT, AST, amylase, alkaline phosphatase,
total protein, glucose)
c. Interpretation of the ultrasonic examination of the abdominal organs (enlarged liver,
induration of pancreas).
d. Interpretation of the coprogram results (degree of digestion of food , the presence of
bacteria, parasites, yeasts, blood).
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Congenital heart defect”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with Congenital heart defect (pay attention to the syndrome of
cardiomegaly, cardiac failure, respiratory failure, signs of hypoxia).
4.
Collect anamnesis of the patient with Congenital heart defect (pay attention the odstetrical and
perinatal conditions, mother’s diseases, harmful environmental and occupational factors,
nutrition, other congenital malformations, developmental anamnesis).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Congenital heart
defect:
a.
inspection of the skin and mucous membranes for pallor, cyanosis
b.
measuring patients' heart rate (tachycardia)
c.
percussion of the heart borders (expanded heart borders)
d.
auscultation of the heart (murmurs, loudness of the S1 and S2),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the plain chest X-ray (deformed cardiac silhouette, pulmonary vasculature)
b. Interpretation of ECG (signs of overload and enlargement of chambers, rhythm changes)
c. Interpretation of the blood gases testing (decreased oxygen saturation)
d. Interpretation of the echocardioscopy (structure of the heart, ejection fraction)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Carditis with arrhythmia”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with Carditis (pay attention to the syndrome of cardiomegaly,
cardiac failure, respiratory failure, signs of hypoxia).
4.
Collect anamnesis of the patient with Carditis (pay attention the odstetrical and perinatal
conditions, mother’s diseases, harmful environmental and occupational factors, nutrition, other
congenital malformations, developmental anamnesis).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Carditis:
a.
inspection of the skin and mucous membranes for pallor, cyanosis
b.
measuring patients' heart rate (tachycardia, arrythmia)
c.
percussion of the heart borders (expanded heart borders)
d.
auscultation of the heart (murmurs, loudness of the S1 and S2),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a.
Interpretation of the plain chest X-ray (changes of cardiac silhouette)
b.
Interpretation of ECG (tachycardia, ventricular arrhythmias, AV conduction defects, QRS /
QT prolongation)
e.
Interpretation of the complete blood count (leukocytosis or leukopenia, left shift of
leukogram, elevated ESR)
c.
Interpretation of the echocardioscopy (thickening, echogenicity, and dyskinesis of the
walls)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Pyelonephritis”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with Pyelonephritis (pay attention to the peculiarities of
dysuria, pain syndrome, intoxication syndrome).
4.
Collect anamnesis of the patient with Pyelonephritis (pay attention on the order of development
of symptoms, previous respiratory infections, hygienic habits, harmful enviroment, allergies).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Pyelonephritis:
a.
inspection of the skin and mucous membranes (pallor, “shadows” below the eyes)
b.
superficial palpation of abdomen (tenderness in flank region/s)
c.
costovertebral angle tenderness (Pasternatsky’s sign) (positive in one side or both sides),
d.
determination of pitting edema (not found),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of urinalysis (increased acidity, leukocyturia, bacteriuria, positive leukocyte
esterase, positive nitrite)
b. Interpretation of the complete blood count (leukocytosis, left shift of leukogram, elevated
ESR)
c. Interpretation of the urine sediment test (Nechyporenko test) (leukocyturia, castsuria)
d. Interpretation of Urine culture test (bacterial growment)
e. Interpretation of the ultrasonic examination of the abdominal organs (dilatation of calyceal
systems of kidneys, induration of kidneys).
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Glomerulonephritis”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with Glomerulonephritis (pay attention to the peculiarities of
dysuria, oliguria, arterial hypertension, edema syndrome).
4.
Collect anamnesis of the patient with Glomerulonephritis (pay attention on the previous
respiratory infections, order of development of symptoms, harmful enviroment, heredity,
allergies).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of
Glomerulonephritis:
a.
inspection of the skin and mucous membranes (pallor, periorbital edema)
b.
measurement of arterial blood pressure (increased BP)
c.
costovertebral angle tenderness (Pasternatsky’s sign) (negative in both sides),
d.
determination of pitting edema (found),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of urinalysis (hematuria, proteinuria, RBC-casts, hypostenuria)
b. Interpretation of the complete blood count (anemia, elevated ESR)
c. Interpretation of the urine sediment test (Nechyporenko test) (erythrocyturia, castsuria)
d. Interpretation of biochemical blood test (creatinine, urea, cholesterol)
e. Interpretation of kidney biopsy (immune complexes and/or glomerular deposition of
circulating immune-complexes).
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.“Algorithm of patient’s examination – Hepatitis”
Interviewing the patient
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Find a contact with the patient and make an attempt to gain his/her trust.
3.
Collect complains of the patient with Hepatitis (pay attention to the peculiarities of asthenic
syndrome, jaundice, pain syndrome, portal hypertension, hemorrhagic syndrome, intoxication
syndrome).
4.
Collect anamnesis of the patient with Hepatitis (pay attention on the previous infections, order
of development of symptoms, epidemiological anamnesis, blood transfusions, harmful
environmental factors, heredity, allergies).
5.
Explane the results of interviewing.
6.
Conversation accomplishment.
Physical examination of patient
1. Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2. Inform about the possibility of appearing of unpleasant feelings during the examination.
3. Prepare for the examination (clean and warm hands, warm and disinfect phonendoscope).
4. Perform the exanimation of the patient and note the typical changes in case of Hepatitis:
a.
inspection of the skin and mucous membranes (jaundice, hemorrhagic rash)
b.
palpation of liver edge (dislocation of liver edge below costal margin, firm consistency)
c.
Orthner sign (positive),
d.
Percussion of hepatic span (hepatomegaly),
5. Explanation of investigation results.
6. Conversation accomplishment.
Interpretation of results of laboratory and instrumental testing
1.
Greeting and introducing, friendly facial expression and smile, gentle tone of speech
2.
Interpretation of received results
a. Interpretation of the complete blood count (anemia, elevated ESR)
b. Interpretation of biochemical blood test (ALT, AST, bilirubin level, cholesterol, GGT, total
protein)
c. Interpretation of the ultrasonic examination of the abdominal organs (enlarged liver,
induration of pancreas).
d. Interpretation of liver biopsy (stages of scarring (fibrosis) and the amount of inflammation)
3.
Involve the patient’s parents into the conversation (compare present examination results with
previous ones, clarify whether your explanations are clearly understood).
4.
Conversation accomplishment.