Donetsk national medical university the name of M. Gor\

Donetsk national medical university the name of M. Gor'kogo




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DONETSK NATIONAL MEDICAL UNIVERSITY

The name of M. Gor'kogo

A DEPARTMENT|pulpit| of SURGERY is the Name of V. M. Bogoslavskogo


METHODICAL POINTING|indication|

FOR STUDENTS FROM INDEPENDENT PREPARATION

BEFORE PRACTICAL EMPLOYMENTS|occupation| FROM HOSPITAL SURGERY


проф|. O.I. Miminoshvili, доц|. V.Ya. Merry|lively|, проф|. G.D. Popandopulo, проф|. O.S. Kuznecov, проф|. O.G. Kot, доц|. V.M. Wheat, доц|. A.G. Popandopulo, доц|. A.O. Ivanenko, доц|. O.S. Antonyuk, доц|. I.M. Shapovalov, ace. A.O. Miminoshvili.


(edited professor O.I. Miminoshvili)


Donetsk, 2009


DONETSK NATIONAL MEDICAL UNIVERSITY

The name of M. Gor'kogo

A DEPARTMENT|pulpit| of SURGERY is the Name of V. M. Bogoslavskogo


METHODICAL POINTING|indication|

^ FOR STUDENTS FROM INDEPENDENT PREPARATION

BEFORE PRACTICAL EMPLOYMENTS|occupation| FROM HOSPITAL SURGERY


Prof. O.I. Miminoshvili, associate professor V.Ya. Veseliy,Prof. | G.D. Popandopulo, Prof. .Î.Ñ. Kuznecov, Prof. O.G. Kot, associate professor V.M. Wheat, associate professor A.G. Popandopulo, associate professor A.O. Ivanenko, associate professor O.S. Antonyuk, associate professor | I.M. Shapovalov, ace. A.O. Miminoshvili.


Reviewers:


Basiy r.V. –associate professor|, manager by a cabinet|study|

Nosenko v.M. – associate professor, methodist, from surgical disciplines


It is ratified Scientific Advice of University. Protocol ¹ 2 from March, 24, 2009


TABLE OF CONTENTS


1. UNTUMOUR|swelling| DISEASES of THIN AND THICK BOWELS 1

2. DISEASE OF RECTUM 10

3. SYNDROME OF PORTAL GIPERTENZII 17
^

4. DISEASE OF THYROID 27


5. SHARP INTESTINAL IMPASSABILITY (GKN) 34

6. PERITONITIS 41

7. BURNS 49

8. PLASTIC SURGERY AND TRANSPLANTOLOGIYA 57

9. DEFECTS|vice| OF HEART ARE INNATE|nee| AND PURCHASED 66

^ 10. ISCHEMIC HEART TROUBLE 75

11. SHARP THROMBOSES AND EMBOLISMS OF BIFURKACII OF AORTA AND MAIN|arterial| ARTERIES 82

12. ATHEROSCLEROTIC DEFEAT of AORTA AND ITS BRANCHES|branch| 91

13. VARICOSE ILLNESS 99

^ 14. PISLYATROMBOFLEBITNIY SYNDROME OF LOWER|bottom| EXTREMITIES(PTFS) |ending|

106


The methodical pointing|indication| from surgery for the students of medical faculties is made|component| in accordance with|according to| the program of practical employments|occupation| after the unique|single| methodical system, accepted in the Donetsk national medical university the name of M. Gor'kogo.

Purpose of the methodical pointing|indication| - to provide|secure| independent preparation of student to|by| practical employment|occupation| in hospital surgery. The improvement of process of studies|teaching| is provided|secure| the certain|definite| volume of knowledges, skills, abilities, development of creative capabilities. For realization of these tasks|task| it is necessary to manage an educational process. Taking into account it it was developed and inculcated system of programmatic management by the objectives of preparation of specialists quality. Its basic principle is an orientation of studies|teaching| on ultimate|end| goals, professional medical|medicinal| activity.

In a section|division| "Actuality of theme of object" is laid|expounds| out educational, professional, world view, social value|importance| of theme, it|her| from (with other medical disciplines. In next sections|division| the "Whole studies|teaching|", "Providing of initial|elementary| level of knowledges-abilities", "Maintenance of studies|teaching|", basis|foundation| of action|act|", "System of having a special purpose educational tasks", is "Oriented, "Methodical development|elaboration| of practical employment|occupation|" concrete tasks|task|, literature, tasks, are expounded. In "Addition" it is given|provide| count of theme, on what student must turn the special attention, as he allows to get|receive| the whole picture of diseases which are studied|learn|.

Thus|on this grow|, utillizing|use| the methodical pointing|indication|, a student must possibility prepare to|by| independent work during practical employment|occupation| after the main|head| sections|division| of clinical surgery of, which are planned|glide| on a 5 course.


^ NONNEOPLASTIC DISEASES OF SMALL AND LARGE INTESTINES.

OVERVIEW (topicality)


The considered theme is actual for professional work of therapeutist, infectious diseases specialist, gynecologists, surgeons, urologists, oncologists and other doctors because diseases of colon meet often enough in public medical practice. Among all illnesses of abdominal cavity the diseases of the colon takes the fourth place for frequency among surgical pathologies. Ability to find out illness signs helps to make the correct decision in individual diagnostic search, and then in the necessary qualified or special treatment of the patient. Symptoms of diseases of small and large intestines are multiple, usually monotonous that complicates diagnostics and can lead to tactical errors. And now get acquainted with the employment purposes, consider them and realist necessity of studying of a theme.

MAIN AIM.

To be able to make the diagnosis, to define tactics of conducting patients with nonneoplastic diseases of small and large intestines. For main aim realizations it is necessary to be able:


Concrete aims


The program of initial level of knowledge and skills

1. Define displays which reflect the basic syndromes at diseases of colon


1. To collect and estimate complaints, to carry objective investigation of patients (departments of the general and faculty surgery, therapy).


2. To make the individual plan of diagnostic inspections, to interpret results of the spent researches.

2. To define volume and sequence of laboratory, roentgenological, endoscopic and morphological researches and also to estimate and interpret this findings (departments of the general and faculty surgery, roentgenology)

3. To carry out the differential diagnostics of diseases of small and large intestines.

3. To define the symptoms of intestines diseases (departments of the general and faculty surgery, therapy)

4. To formulate the preliminary diagnosis, to prove medical tactics and the forecast

4. To prove methods of conservative and operative tactics (departments of the general, faculty surgery, therapy, pharmacology)


More low there are tasks for definition of initial level of knowledge.


^ THE TASKS FOR CHECK.


1. What complaint can confirm colon's diseases?

a. bleeding during defecation, red blood;

b. diarrhea;

c. general weakness;

d. peritonitis;

e. fever


2. The best diagnostic method for a 42 year old man with bloody diarrhea is:

a. endoscopy

b. ultrasound

c. physical examination

d. X-ray of the abdomen

e. rectal examination


3. How many parts in the colon?

a. 2;

b. 3;

c. 4;

d. 5;

e. 6.


4. What sequence of inspection at patients with rectum diseases?

a. digital rectal investigation – proctosigmoidoscopy – proctoscopy;

b. irrigography – proctoscopy – proctosigmoidoscopy;

c. digital rectal investigation – proctosigmoidoscopy – irrigography

d. proctosigmoidoscopy –irrigography – digital rectal investigation

e. colonoscopy – proctosigmoidoscopy.


^ ANSWERS: 1-A;1-B; 2-A; 3-E; 4-C.


Solve the following questions and correctness of the answer will be checked up during employment.


1. The passage of stools rendered black and tarry by the presence of altered

blood is called:

a. melena

b. hemoptysis

c. hematemesis

d. hematochezia

e. loose stool


2. What source of a bleeding is possible at the patient with presence of melena?

a. stomach;

b. small intestine;

c. rectum;

d. cecum;

e. lungs.


3. Which of following procedures has the highest sensitivity in the

diagnosis of colon carcinoma?

a. colonoscopy

b. barium enema

c. digital rectal examination

d. proctoscopy and sigmoidoscopy

e. ultrasound


4. What is your tactics of treatment of full intestinal fistulas?

a. conservative;

b. operative;

c. symptomatic;

d. obturation fistulas;

e. chemotherapy.


SOURCES of the INFORMATION

1. Bruce E. Jarrell., R. Anthony Carabasi, III. National medical series for independent study. Surgery. Fifth Edition. Baltimore, Philadelphia 2008

2. Ю.Л.Шевченко. Частная хирургия . – Спб; 2000. – С.98-111.

3. П.Н. Зубарева, М.И. Лыткин, М.В. Епифанов Общая хирургия. – Спб; 2000. - С. 5 - 37

4. В.В. Кованов. Оперативная хирургия и топографическая анатомия.; Медицина, 1978.


^ THE TRAINING MAINTENANCE ACCORDING TO THE PURPOSES:

I. THEORETICAL QUESTIONS.


1. Clinic and diagnostics of nonneoplastic diseases of the colon.

2. Principles of inspection of patients with a pathology of colon.

3. Classification of inflammatory diseases of colon (chronic colitis, ulcerative colitis, Crohn's disease) and benign tumours of the colon (tubular polyposes, family polyposes).

4. Differential diagnostics of nonneoplastic diseases of the colon.

5. Principles of conducting patients with a pathology of the colon. Principles of treatment of external intestinal fistulas.


ІІ. The COUNT of LOGIC STRUCTURE of the THEME (the appendix №1)

ІІІ. SOURCES of the INFORMATION FOR MASTERING of the PURPOSES


Obligatory sources:

1. Bruce E. Jarrell., R. Anthony Carabasi, III. National medical series for independent study. Surgery. Fifth Edition. Baltimore, Philadelphia. P.219-248., 2008.

2. Short practice of Surgery. Bailey and Love’s. 24th edition. International students’ edition. P. 1153-1186., 2004.

3. В.В. Іващенко. Шпитальна хірургія. - Донецьк: Донеччина, 1995. - С.388-402.

4. Л.Я. Ковальчук, Ю.П. Спітенко, В.Ф. Саєнко, Г.В. Книшов, М.Ю. Ничитайло. Шпитальна хірургія. – Тернопіль: Укрмедкнига, 1999. - С.541-576.

5. Lecture “Nonneoplastic diseases of the small and large intestines”.

6. The COUNT of LOGIC STRUCTURE of the THEME (the appendix №1)


Additional source:

1. Principles of Surgery. Schwartz’s, eighth edition. 2004.

2. Кузин М.И., Хiрургические болезни. – М: Медицина, 1986. - С.595-373.


PROVISIONAL BASIS of ACTION.

As means for the decision of educational tasks the scheme of a writing of the history of disease, the table (the scheme of histologic formation of a mucous membrane of a colon, anatomy of a colon, feature of blood supply of a colon), target educational tasks, diagnostic algorithm (the appendix №2) are used.


^ SET OF TASKS FOR CHECK OF ACHIEVEMENT OF CONCRETE AIMS OF TRAINING


1. What basic syndrome allows to suspect colon's disease?

a. irritable bowel syndrome

b. anemic syndrome

c. intoxication

d. painful syndrome

e. alimentary syndrome.


2. Ulcerative colitis is suspected in:

a. 32 year old woman with abdominal pain and vomiting

b. 26 year old man with abdominal cramps and bloody diarrhea

c. 58 year old man with abdominal cramps and anal fistulae

d. 62 year old man with jaundice, diarrhea and palpable abdominal mass

e. 72 year old woman with loss of weight and weakness


3. Which of the following gastrointestinal lesions is the most precancerous lesion?

a. gastric ulcer

b. villous adenoma

c. crohn's disease

d. familial polyposis

e. tubular polyposis


4. The most frequent site of the carcinoma of colon is:

a. appendix

b. sigmoid

c. ascending colon

d. cecum

e. transverse colon


5. The patient, 33 years, has arrived with complaints on frequent loose stool with an impurity of blood and slime to 15 times for days, temperature to 37C, loss of weight to 20 kg for 2 months. Within 5 years in the spring and in the autumn similar conditions were observed. Last point within 2 months. At objective research a condition heavy. An abdomen hollow. At proctosigmoscopy - musous of the rectum is covered by fibrin. What is your diagnosis?

a. cancer of the rectum

b. acute proctosigmoiditis

c. Crohn's disease

d. ulcerative colitis

e. irritable bowel syndrome


^ SHORT METHODICAL INSTRUCTIONS TO WORK ON PRACTICAL EMPLOYMENT.


Employment begins with definition of initial level of knowledge by means of the test control. Then students receive patients for conducting examination. For a diagnosis establishment results of additional laboratory, tool and special methods of research are used. After performance of tasks by all students the teacher analyzes and corrects results of the performed work of each student. Employment comes to an end with carrying out of the total test control and an estimation of its results.


The appendix №1.

The count of logic structure of a theme: «Nonneoplastic diseases of small and large intestines»


Nonneoplastic diseases of small and large intestines






Complaints

The objective findings:

Survey.

Palpation.

Complaints.


Anamnesis.


History






The main syndromes of disease of colon


Infringement of motility:

- constipations; - diarrhea ; - a dyskinesia


Digestion's infringement:

- pathological impurity;

- loss of weight of a body;

- dysproteinemia;

- hypovitaminosis.

Visceropathic changes:

-endocrinopathy;

-сardiomyopathy;

-hepatopathy;

-synovial infringements.





Additional methods of reseaches




X-rays:

-irrigography;

-proctography


Endosсopic:

-proctosigmoidoscopy

- colonoscopy


The morphological: - cytologic; - histologic.




The differential diagnosis




Previous diagnosis



Tactics of conducting the patient




The combined.


The conservative

The surgical



Preventive maintenance and rehabilitation

Addition №2. Tactical diagnostic algorithm of a theme.

“Nonneoplastic diseases of small and large intestines

1. Nonspecific ulcerative colitis;

2. Crohn's disease;

3. polyposis;

4. diverticulosis.

Pathological impurity in stool



Rectal examination






There is a volume formation

There is no volume formation.


anoscopy


proctosigmoidoscopy

Theme

Diseases of rectum,








Ulcer defeat of a mucous membrane.

There is not ulcer defeat of a mucous membrane





1.2.4 2.4.


Colonoscopy



Segmentary type of defeat

Presence of polyposis.

Pseudopolyposis.

Strictures

There is no pathology.



2

3

1.2

1



Volume process

Consultation of the oncologist

A theme Tumoral diseases of a colon

4

^ RECTUM DISEASE.

Overview.

Rectum disease is the pathology which doctors of different trades every day meet: therapists, gastroenterologists, proctologists, surgeons, infectious diseases specialists and so forth.

During population routine inspections on almost healthy 1000 people, according to different authors, it is shown, from 5 to 30 patients with various inflammatory diseases of a rectum, and among people of able-bodied age this indicator fluctuates from 6,1 to 22,4 %.

As it is known, the end of disease, first of all, depends on the timely diagnosis and correct medical tactics. Symptoms of disease of a rectum numerous and various that complicates diagnostics. At research of the patient with such pathology it is important to pay attention to revealing of leading symptoms, to estimate them and according to it to use the most rational in each specific case research means. Diseases of a rectum demand from the researcher of certain delicacy at interrogation and survey. Sparing mentality of the patient, it is necessary to create such conditions which exclude any erroneous shame and to provide close contact between the doctor and the patient.


MAIN AIM.

To be able to make the diagnosis, to define tactics of conducting patients with rectum disease. For main aim realisation it is necessary to be able :


^ Concrete aims


The program of initial level of knowledge and skills

1. To define the basic syndromes of rectum disease.

1. To collect and estimate complaints, the disease anamnesis, to carry objective investigation of patients with thyroid diseases (departments of the general and faculty surgery, therapy, endocrinology).


2. To make the individual scheme of diagnostic examinations and to interpret results of the spent examinations.

2. To define volume and sequence of laboratory, roentgenological, ultrasonic and morphological researches and also to estimate and interpret this findings at patients with rectum diseases (departments of the general and faculty surgery, roentgenology, therapy).


3. To carry out the differential diagnostics of diseases of a rectum.

3. To define symptoms of endocrinological diseases (departments of the general and faculty surgery, therapy).


4. To formulate the diagnosis, to prove medical tactics and the forecast.

4. To prove methods of conservative tactics (departments of the general and faculty surgery)



More low there are tasks for definition of initial level of knowledge.


^ THE TASKS FOR CHECK.

1. What syndrome concern - infiltrate in anal areas, a skin with hyperemia, a body temperature 38,3 C?

a. Local infringement of blood circulation;

b. tumor's process;

c. inflammation;

d. Hernial process;

e. autoimmune infringements


2. What kind of research specifies the diagnosis at acute paraproctitis?

а. proctography

b. X-rays

c. digital rectal investigation of rectum

d. ultrasound

e. colonoscopy


3. What sequence of inspection at patients with rectum diseases?

a. digital rectal investigation – proctosigmoidoscopy – proctoscopy;

b. irrigography – proctoscopy – proctosigmoidoscopy;

c. digital rectal investigation – proctosigmoidoscopy – irrigography

d. proctosigmoidoscopy –irrigography – digital rectal investigation

e. colonoscopy – proctosigmoidoscopy.


4. How many departments there are in a rectum?

a. 2;

b. 3;

c. 4;

d. 5;

e. 1.


^ ANSWERS 1-C; 2-С; 3-С; 4-В.


Solve the following questions and correctness of the answer will be checked up during employment.


1. What kind of research is used as professional regular survey?

a. proctosigmoidoscopy;

b. colonoscopy;

c. proctography;

d. digital rectal investigation;

e. irrigography.


2. How many arteries provides rectum blood circulation?

a. 2

b. 3

c. 4

d. 5

e. 1


3. Occurrences of bright red blood in stool testifies to a bleeding from?

a. stomach

b. duodenum

c. transverse colon

d. cecum

e. rectum


SOURCES of the INFORMATION

1. Bruce E. Jarrell., R. Anthony Carabasi, III. National medical series for independent study. Surgery. Fifth Edition. Baltimore, Philadelphia 2008

2. П. Н. Зубарева, М. И. Лыткин, М. В. Епифанов. Общая хирургия. - Спб. - 2000.

3. Ю. Л. Шевченко. Частная хирургия. - Спб. - 2000.

4. В. В. Кованов. Оперативная хирургия и топографическая анатомия.- М.: Медицина, 1978.


^ THE TRAINING MAINTENANCE ACCORDING TO THE PURPOSES:


I. THEORETICAL QUESTIONS.


1. Classification of diseases of a rectum. An etiology, pathogenesis, clinic and diagnostics of diseases of a rectum.

2. Principles of preoperative preparation of patients.

3. Additional methods of researches at patients with diseases of a rectum.

4. Inflammatory diseases of a rectum: an etiology, pathogenesis, diagnostics and treatment methods.

5. Indicators to operative treatment at different diseases of a rectum.


ІІ. The COUNT of LOGIC STRUCTURE of the THEME (the appendix №1)

ІІІ. SOURCES of the INFORMATION FOR MASTERING of the PURPOSES


Obligatory sources:

1. Bruce E. Jarrell., R. Anthony Carabasi, III. National medical series for independent study. Surgery. Fifth Edition. Baltimore, Philadelphia. P.219-248., 2008.

2. Short practice of Surgery. Bailey and Love’s. 24th edition. International students’ edition. P. 1219-1242., 2004.

3. В. В. Іващенко. Шпитальна хірургія.-Донецьк: Донеччина, 1995.

4. Л. Я. Ковальчук, Ю.П. Спітенко, В.Ф. Саєнко, Г.В. Книшов, М.Ю. Ничитайло. Шпитальна хірургія.- Тернопіль: Укрмедкнига, 1999. - С.541-576.

5. The COUNT of LOGIC STRUCTURE of the THEME (the appendix №1)


^ ADDITIONAL SOURCE:

1. Principles of Surgery. Schwartz’s, eighth edition. 2004.

2. Кузин М. И. Хирургические болезни.- М.: Медицина, 1987.


PROVISIONAL BASIS of ACTION.

As means for the decision of educational tasks the scheme of a writing of the history of disease, diagnostic algorithm, target educational tasks, diagnostic algorithm (the appendix №2) are used.


^ SET OF TASKS FOR CHECK OF ACHIEVEMENT OF CONCRETE AIMS OF TRAINING


1. What method of research will confirm tumors morphology in a rectum?

a. X-ray;

b. lymphography

c. irrigography

d. pneumoperitoneum

e. proctosigmoidoscopy with biopsy


2. What is the most dangerous complication happens at patients with a rectum polyp?

a. Intestinal obstruction

b. bleeding

c. malignancy

d. perforation

e. paraproctitis


3. What tactics of treatment of the patient with chronic fissure of a rectum?

a. urgent operation;

b. planned operation;

c. conservative treatment;

d. chemotherapy

e. X-rays therapy


4. Which of the following is the most common cause of rectal bleeding associated with pain during defecation in young people?

a. colon cancer

b. diverticulosis

c. external hemorrhoid

d. internal hemorrhoid

e. anal fissure


5. What complaints are shown by the patient with perianal fistula?

a. pain;

b. pruritus;

c. blood impurity in stool;

d. frequent stool;

e. purulent discharge from a fistula


6. In what case operative intervention is not applied at a bleeding from hemorrhoidal bolus?

a. cirrhosis;

b. chronic venous insufficiency;

c. small bleeding;

d. old age of the patient;

e. bronchial asthma;


^ SHORT METHODICAL INSTRUCTIONS TO WORK ON PRACTICAL EMPLOYMENT.


Employment begins with definition of initial level of knowledge by means of the test control. Then students receive patients for conducting examination. For a diagnosis establishment results of additional laboratory, tool and special methods of research are used. After performance of tasks by all students the teacher analyzes and corrects results of the performed work of each student. Employment comes to an end with carrying out of the total test control and an estimation of its results.


(the appendix №1)

The COUNT of LOGIC STRUCTURE of the THEME«Rectum disease»


^ Rectum disease







Complaints

Anamnesis


The objective data


Infringement of function of a rectum





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