Methodical directions for the i-st III- rd year students icon

Methodical directions for the i-st III- rd year students




Скачати 103.33 Kb.
НазваMethodical directions for the i-st III- rd year students
Дата03.08.2012
Розмір103.33 Kb.
ТипДокументи
1. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/KTP_CPC_UA.doc
2. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/KTP_UA.doc
3. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/MVOPR_EN.doc
4. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/MVOPR_UA.doc
5. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/PROGRAM.doc
6. /propedvnutrmed 2011 2012/propedvnutrmed_bioetika 3/Time_EN, UA, RU.doc
7. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/KTP_EN .doc
8. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/KTP_UA.doc
9. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/MVOPR_EN.doc
10. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/MVOPR_UA.doc
11. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/PROGRAM.doc
12. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/Time_EN, UA, RU.doc
13. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/VOPR_EN 10.doc
14. /propedvnutrmed 2011 2012/propedvnutrmed_doglyad 2/VOPR_UA 10.doc
15. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/ISTORIA_UA.doc
16. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/KTP_EN.doc
17. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/KTP_UA .doc
18. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/KTP_UA.doc
19. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/MVOPR_EN.doc
20. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/MVOPR_UA.doc
21. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/OTHER_EN.doc
22. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/OTHER_UA.doc
23. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/PROGRAM.doc
24. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/TIME_UA.doc
25. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/VOPR_EN.doc
26. /propedvnutrmed 2011 2012/propedvnutrmed_propedvnutrmed 3/VOPR_UA.doc
27. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/KTPSelf _worc.doc
28. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/KTP_CPC_UA.doc
29. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/KTP_EN.doc
30. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/KTP_UA.doc
31. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/MVOPR_EN.doc
32. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/MVOPR_UA.doc
33. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/PROGRAM.doc
34. /propedvnutrmed 2011 2012/propedvnutrmed_sestr/Time_EN, UA, RU.doc
Декан лікувального факультету 27. 01. 2012 р. Протокол №8
Проф. С. М. Смірнов 2012р
List of questions for the preparation to module determination of notion „safety of vital functions”
Перелік питань для засвоення модулю визначення поняття „безпека життєдіяльності”
“Затверджую”
На кафедрі пропедевтики внутрішньої медицини у весняному семестрі
“confirmed” Confirmed at the Сhair Sitting 2012
Затверджую затверджено на засіданні кафедри
List of practical skills for final module control in “taking care of patients
Перелік практичних навичок для підсумкового модульного контролю з виробничої практики "догляд за хворими терапевтичного профілю"
Міністерство охорони здоров’я україни дз „луганський державний медичний університет”
На кафедрі пропедевтики внутрішньої медицини у весняному семестрі
Questions for studies in taking сare of (looking after)
Перелік запитань
Методичні рекомендації з клінічного обстеження хворого терапевтичного профілю І методики написання історії хвороби на кафедрі пропедевтики внутрішньої медицини
“Confirmed” Confirmed at the Сhair Sitting
Затверджую затверджено на засіданні кафедри
Проф. Смірнов С. М. 2010р
Main purposes and objects of study of propaedeutic medicine
Перелік теоретичних питань
Methodical directions for the i-st III- rd year students
“Затверджую”
На кафедрі пропедевтики внутрішньої медицини у осінньому семестрі
Practical classes
Перелік питань, що підлягають вивченню на практичних заняттях з пропедевтики внутрішньої медицини
“confirmed” confirmed at the Сhair Sitting 2011
Календарно-тематичний план
Confirmed” “confirmed” at the Сhair Sitting
Затверджую затверджено на засіданні кафедри
List of practical skills for final module control „basic duties and professional actions of medical nurse of therapeutic departament”
Перелік практичних навичок для підсумкового модульного контролю з модулю 1 „основні обов'язки та професійні дії медичної сестри терапевтичного відділення”
Міністерство охорони здоров’я україни дз „луганський державний медичний університет”
На кафедрі пропедевтики внутрішньої медицини у весняному семестрі


LUGANSK STATE MEDICAL UNIVERSITY


Departmen of Propaedeutics of Internal Medicine


METHODICAL DIRECTIONS

FOR THE I-st - III- rd YEAR STUDENTS

ON ACQUISITION OF PRACTICAL SKILLS

IN CLINICAL STUDY OF THE PATIENT IN HOSPITAL


2005


Methodical instructions were approved by central methodical committee and Academic Council of LSMU.


Methodical directions were composed by:

chief of the department of propaedeutics of internal

medicine prof. L.M.Ivanova,

assistant prof. H.V.Pilieva, assistant prof.V.Ye.Sabadash, assistant prof. N.B.Rykova, assistant prof. O.I. Nishkumay.


LUGANSK STATE MEDICAL UNIVERSITY


Department of Propaedeutics of Internal Medicine

Chief of the department, professor Doctor of Medicine _________________

Teacher _____________________


CASE HISTORY

Patient’s name, patronymic, surname


BASIC clinical diagnosis … … … … …


CONCOMITANT diagnos… … … … …


COMPLICATIONS … … … … … …


Curator-student of III year of study, number of group … .

Time of observation … … … … … … …

Title-page of training case history

INQUIRY OF THE PATIENT


I. PASSPORT PART (data) OF THE CASE HISTORY


1. Name, patronymic, surname.

2. Age

3. Nationality

4. Occupation

5. Position

6. Place of work

7. Home

7. Date of hospitalisation

I. Complaints of the patient

What the patient complains of, the detailed characteristics of the basic complaints.

Additional inquiry on systems and organs with the purpose of revealing additional complaints, is made in the following order:


COMPLAINTS FROM SYSTEM OF ORGANS

OF BREATH


Respiration (Breathing): through a nose free, complicated

Dyspnea: character of dispnea: constant, periodic, paroxysmal. What conditions amplify dyspnea: physical activity (walking).If there are attacks of pulmonary asthma, character of duration, what they are accompanied with.

Cough: frequency, intensity, character (dry, damp), conditions of occurrence. Character of sputum (mucous, mucopurulent, purulent, foamy, bloody sputum, rusty).

Hemoptysis: frequency, time of occurrence.

Pains in the thorax: localization, character: sharp, dull. Intensity and duration.

Fever, night sweats. Character of a fever (constant, paroxysmal, evening increase and so forth).

COMPLAINTS FROM CARDIOVASCULAR SYSTEM


Palpitation (tachycardia):

Intermissions of the heart: constant or periodic, frequency, conditions of their occurrence.

Pains in the area of the heart: constant, periodic or paroxysmal (attack-like). Character of the pain: smarting, shooting, aching. Localization of the pain: in the area of the heart, behind a retrosternal region. Irradiation (in the left hand, shoulder, scapula, neck, jaw, etc.), intensity, duration.

Dyspnea: character, connection with physical activity (walking) or rest at night.

Cardiac asthma - character, intensity of an attack, time of occurrence, duration.

Sensation of the pulsation: in what parts of a body.

Hypostases (oedema): localization, constant and passing. Time of occurrence (in the morning, in the evening); connection with physical activity (walking), reception of a liquid, reduction of diuresis.

COMPLAINTS FROM ORGANS of DIGESTION


Appetite: good, mild, increased, lowered.

Saturability: normal, quick, constant feeling of hunger.

Thirst:dryness in the mouth. Salivation. Quantity of the taken liquid.

Taste in the mouth: ordinary, sour, bitter, metal.

Chewing of the food: is well or bed (absence of teeth). Pains in the throat at swallowing, difficulty at passage of the food along oesophageus. The patient feels a stop of food lump behind the sternum.

Dyspeptic disorder (syndrom):

Heartburn - constant, periodic, its connection with character of food, its intensity.

Eructation: empty, air, sour, bitter, with a smell of rotten eggs, yeast, the rancid oil.

Regurgitation: the eaten food.

Nausea: its dependence on the taken food, intensity, duration.

Vomiting: time of occurrence, connection with reception of food, color, taste, smell. Character of emesis (vomiting) (the eaten food, with an impurity of bile, with blood: scarlet, dark, color of coffee grounds. Vomiting by the food eaten on the day before.

Hiccups: what the patient connects its occurrence with: intensity, frequency.

Pains in the abdomen: Their localization in areas (epigastric, subcostal, iliac areas, etc.). Character –periodical, constant, attack-like (paroxysmal), colic-like. Intensity of pain: sharp, dull pain, aching pain, pricking, knife-like pain». Pain during the time of reception of food (on an empty stomach, soon after meal-early pain or in some hours- late pains, night pains). Their connection with quantity of food and quality (cold, hot, rough, sweet, salty, sharp, fat and so forth). Character of pain - Irradiation of pains: in the back, subcostal, shoulder, iliac area, sacrum, legs.

Dejection: free, painful. Flatus (passage of gases). Constipation or diarrhea. Blooding.

COMPLAINTS FROM EXCRETORY SYSTEMS


Pains: localization (in the waist, sacrum above pubis), character (sharp, dull pain, aching pain} constant or paroxysmal, colic- type). Intensity of pain, duration, under what conditions it appears. Irradiation of pains: downwards, in the leg, in genitals.

Dysuric disorder : morbidity, sharp pain in urination – strangury, pollakiuria (frequent urination) quantity of urine a day: nycturia, polyuria).

Color of urine: usual, dark color of beer (dark beer- like colour), sanguinolent (with blood), meat slops, presence of a deposit, character of a deposit.

COMPLAINTS ON THE PART


OF PSYCHOLOGICAL SPHERE

State of memory, self -service, mood, sleep (normal, insomnia, drowsiness, nightmares and so forth).

Headaches: localization, time of occurrence, intensity, duration, what they are accompanied with.

Dizzinesses: frequency, intensity, duration, character. If they are accompanied by noise in the ears, nausea, vomitting, frustration of balance. Under what conditions it appears, amplifies, stops.

Faints: frequency, duration. Sensations of creeping body, pricking, burnings, coolness, dumbness (in what places).

Rushes of blood to the head.


CONDITION OF SENSE ORGANS

Sight, hearing, sense of smell, taste, touch.


III. THE HISTORY OF DEVELOPMENT AND THE COURSE OF THE PRESENT


DISEASE. THE ANAMNESIS OF DISEASE.

(Anamnesis morbi)

In this section of case history time of the prospective beginning of disease, its first attributes and their further development are described from the words of the patient. The reason of disease assumed by the patient is underlined. It is necessary, that in the anamnesis all complaints of sick man will be reflected from the time of their occurrence in the development of a disease. It is necessary to specify the stages of treatment of the patient. The periods of an exacerbation, change of character of the course of disease, results at the beginning of the treatment, ways of treatment which were used, including sanatorium, their efficiency. What helped more effectively. What medicines the patient didn’t bear. The anamnesis of a disease ends in the description of the last exacerbation and the moment of hospitalization.


HISTORY OF THE LIFE OF THE PATIENT

(Anamnesis vitae)

This section first of all provides the study of the various reasons which took place in the life of the patient which could lead to the development of a disease or its deterioration.

Where and when he was born, his development from birthday, in the early childhood, young age: whether he lagged behind in the physical and intellectual sphere from the children of his age: the period of study, ability and capabilities to various occupations, the beginning of labour activity.

Conditions of a life, nourishment (regularity and frequency of reception of food a day), work. The labour anamnesis. If he had any operations, traumas, diseases in the childhood and mature age. Moral conditions in the family.

Presence of venereal illnesses (syphilis, gonorrhoea). Tuberculosis, Botkin's illness.

Presence of bad habits (smoking, the use of alcohol, drugs).

Sexual life: for women time of occurrence of turns, their character, regularity, time of disappearance. Quantity of pregnancies, what they have ended with. Whether there were spontaneous abortions, miscarriages. Quantity of children. If there are no children, its reason.

For men - the beginning of a sexual life, whether there are any infringements, their character.

The family anamnesis – what diseases his parents and close relatives had and currently and if some of them died, then the reason of their death. Whether there was a contact with a sick of tuberculosis.


CONDITION OF THE PATIENT NOW

(Status presens)

1. THE GENERAL INSPECTION

Consiousness: clear or deranged, stuporous, soporose, lost, a faint, coma, excitation, delirium.

General condition of the patient: good, satisfactory, of moderate severity, severe, very severe, agonal.

Position of the patient: active, passive, forced (sedentary, standing, lying on one side, orthopnoea, etc.).

Appearance of the patient: according to the age.

Behaviour of the patient: adequate, inadequate behavior

Expression of the face: quiet, scared, excited, indifferent, masklike face, feverish, suffering, etc.

Bearing: a straight line, languid, proud.

Gait: usual, shuffling, limping, etc.

Height - normal (high, average, low, gigantism, nanism). Height in - cm ….

Weight … kg. A circle of a thorax … cm.

Indexes (a statural-weight index, an index of proportionality, index Pinier).

Constitution: correct, wrong.

Constitutional type: normosthenic, hypersthenic, asthenic.

Body temperature: the data of a body temperature are brought also in to a temperature chart.

Cutaneous covering: color of a skin - pale, waxlike, red, cyanotic, earthy-grey, usual. Pigmentation, depigmentation, rash, cicatrix (scar): (localization, the form, the sizes, cohesion with surrounding fabrics). Trophic ulcers, decubitus. Humidity or dryness of the skin. Elasticity, turgor.

Visible mucous membranes: color - pink, pale, cyanotic, hyperemic, jaundice. Ulcers. Rash. Stains.

Scalp: dryness of hair, loss. Alopecia (pelade), fragility. Hypertrichosis, hirsutism.

Nails: the form (usual, rounded, «watch glass»-like, spoon-shaped with longitudinal fragility.

Fatty tissue: development even, uneven, excessive, insufficient, absent).Thickness of fold, plica in the field of edges and corners of scapulas equals … cm.

Hypostases: localization (general, local) soft, dense, pasty, small oedema.

Lymph nodes: visible approximately. The data of palpation - presence, absence, localization, size, form, consistence. Color of a skin above nodes - hyperemia, cyanosis. Presence of ulcers, fistulas, pathologic discharge.

Muscular system: degree of development - normal, weak, atrophy, hypertrophy. Muscular force. Morbidity and a tone of muscles - normal, increased, lowered; spasmes (convulsions) - tonic, clonic.

Osteoarticular apparatus: Bones - morbidity at palpation, deformation. Periostitis, a curvature of fingers- «drum-type fingers». Morbidity in a backbone and sacroiliac joints. Form of bones presence of deformation or defiguration.

Joints: deformation, swelling, fluctuation, redness, hyperemia of skin in the area of joints Local temperature. Mobility, infringement of function. Morbidity at palpation and symmetry of affection of large or small joints. Volume of active movements (full, limited) Volume of passive movements. A crunch, defiguration, anchyloses, contractions. Atrophy of muscles.


2. RESPIRATORY SYSTEM

Breath through the nose: free, complicated, features.

Inspection of the chest:

1. Static: the form - (normosthenic, hypersthenic, asthenic, emphysematous, paralytic). Deformations of the thorax:scaphoid (navicular), « chicken breast», «breast of the shoemaker» (funnelled chest). Asymmetry of the thorax, protrusion, retraction. Spinal curvature (lordosis, kyphosis, scoliosis). Supraclavicular and subclavian fossae are pronounced, smoothed from both sides, on the one hand). Intercostal intervals are smoothed, protruding, involved, wide, narrow. Scapulae (attached to a thorax or lag behind). Position - on one level or not.

2. Dynamic: Respiratory movements of the thorax: evenness, symmetry of respiratory movements of both sides of the thorax. Type of breath (chest, abdominal, mixed). Rhythm of breath – regular, irregular (Cheyne-Stokes respiration, Biot's respiration, Kussmaul's respiration, Grokko). Depth of breath (normal, deep or Kussmaul's respiration, superficial). Number of respiratory movements per one minute (rate).

Palpation of the chest: morbidity (painfulness) at palpation ribs, intercostal intervals, scapulae. Elasticity, rigidity of the chest (diffuse or on the certain part).

Vocal fremitus: Vocal fremitus is equally pronounced from both sides, amplified{strengthened}, weakened (in which side). Sensation of friction of pleura. Presence of subcutaneous emphysema (localization).

Percussion of lungs: Comparative percussion - on symmetric sides above the lungs. Character of percussion sound (clear, dull, dulled, tympanic, bandbox, metal). Localization of the changed percussion sound.

DATA OF TOPOGRAPHICAL PERCUSSION

OF LUNGS


Height of

standing of

apecis of the

lungs

On the right

On the left

in front of

above

clavicle

cm. …

above

clavicle

cm. …

behind

at a level of

vertebra …

at a level of

vertebra…

width of areas of Кrenig’s

cm. …

cm. …

LOWER BORDER OF LUNGS


Topographical lines

On the right

On the left

parasternal







midclavicular







anterior axillary







midaxillary







posterior

axillary







scapular







paravertebral

thoracic vertebra

thoracic vertebra


RESPIRATORY MOBILITY OF THE

LOWER BORDER OF LUNGS

Topografic lines

Mobility of lower border of lungs

in cm.

Right lung

Left lung

ihalation

exhalation

total

ihalation

exhalation

total

mid clavicula



















mid

axillary



















scapula



















Auscultation of lungs

At auscultation of lungs it is necessary to observe some rules. First of all, it is necessary to emphasize that method of auscultation determines the character of breath. Additional respiratory noises are listened, and also the research of bronchophony is carried out.

Character of breath - vesicular, bronchial, amphoric and so forth is determined in a usual breath of the patient on symmetrical parts of the lungs. Additional respiratory noises: (rattles, crepitation, noise of friction of pleura and etc. are better listened at the forced breath (deep and frequent). It is necessary to auscultate repeatedly the lungs after semicough of the patient.

For the determination of the latent bronchospasm the research at the forced exhalation is carried out. By this whistling dry rattles are determined.

Bronchophony - presupposes auscultation of leading of sound fluctuations at pronunciation by the patient of the words with sibilant sounds (church, chair, child) above the symmetric sites of lungs. Bronchophony is identical on its value to the voice trembling which is determined by palpation.

Character of vesicular breath: clear breath, amplified (strengthened), weakened, rigid, with the prolonged exhalation, saccadic. Bronchial breath (the place of auscultation amplified (strengthened), weakened, its versions - amphoric, metal, etc. Mixed or uncertain breath. Absence of vesicular and bronchial breath.

Additional respiratory noises: crepitation (sonorous, not sonorous). Dry rattles: whistling, buzzing. Damp rattles: largely, middling or small kind of bubbles, sonorous or not sonorous. Noise of friction of pleura. Noise of Hippocrat’s splash. Noise of a falling drop.

Bronchophony: amplified (strengthened), weakened, normal, not carried out.

At detection of auscultation changes at the patient it is necessary to specify their localization precisely.


3. CARDIOVASCULAR SYSTEM

Inspection of the area of the heart: not changed, a cardiac hump. Apex beat: localization, width, character (limited, poured), height, strength. Cardiac beat (push).

Inspection of peripheral vessels: swelling of cervical veins, their pulsation, positive venous pulse. Carotid pulsation, pulsation of large arteries and other parts of the body. Presence of curved vessels. Visible pulsation in other places of the thorax. Epigastric pulsation.

Palpation of the heart and vessels: Determination of properties of an apex beat at palpation: character, intensity, amplitude (strong, weak, limited, poured, resistance). Its localization, removability at the change of position of the body. Systolic or diastolic (presystolic) thrill (tremor) and its localization. Palpation of the pulse on a radial artery (symmetry of the size of the pulse from both sides, rhythm, frequency, form, size, filling and tension. Deficiency of the pulse (Jackson's symptom). Determination of the character of pulsation in epigastric area. Positions of vessels of the lower extremities, their pulsations.

Capillary pulse. Arterial pressure.

PERCUSSION OF THE HEART


Place of

determination

Relative

dullness

Absolute

dullness

Right







Left







Upper







Width of a vascular bundle … cm.

Configuration of the heart (aortal, mitral, trapez-like, cor-bovinum).

Transverse length of relative cardiac dullness …cm.

Auscultation of the heart and vessels

Consecutive auscultation of the valves of the heart: mitral - at a cardiac apex; aortic - in the second intercostal space on the right border at sternum; pulmonary valve - in the second intercostal space on the left border of a sternum, tricuspid – the area of attachment of xiphoid process to sternum, fifth point -auscultation of heart in Botkin's point.

Detemination of quality of heart tones: forces (weakening or strengthening of the first tone on the apex or tricuspid; on the second tone on the basis), timbre, tinge (loud or snapping tone, metal, rattle). Splitting or separation of tones (the first or the second). Rhythm of gallop, rhythm of a quail.

Endocardiac murmurs: the relation of murmur to separate phases of cardiac cycle (systolic, diastolic, presystolic, etc.). Force and character of murmur, conductivity, change at physical activity, and position of the body: standing, lying. The place of the best auscultation of murmur, change at breath (test of Valsalva). Heart rate.

Extracardiac murmurs: the murmur of friction of a pericardium, pleuropericardial murmur.

Auscultation of vessels: determination of Тraube’s double tone and double murmur of Vinogradov-Duroziez on femoral arteries; systolic top-like murmur on cervical veins.


4. DIGESTIVE SYSTEM

Inspection of the mouth (oral) cavity: condition of mucosa and its color (pale, pink, red). Pigmentation, exanthemata, haemorrhages, ulcerations, scars and other defects. Smell out of the mouth: fetor oris (stinking odor), putrefactive, acetone, ammoniac, rotten eggs. Gum: loosened, swelling, ulcerations, haemorrhages, reddening, grey border. Teeth: their condition; absence, (which of them quantity), peculiarity of the form. Tongue - dry, damp, clean, coated (the color of the coat), abrasion, fissure, color, condition of papilla, presence of impresses of teeth on the edges of the tongue.

Condition of pharynx and tonsils: color, form, presence of coats, purulent plug.

Inspection of the abdomen: form, protrusion (common, local), swelling (frog-like abdomen), retraction, involved abdomen. Movement of the abdomen wall at breath. Presence of visible peristaltic movements. Varicose veins of the abdomen wall. Postoperative scars on the skin of the abdomen. Presence of hernias (inguinal, femoral, umbilical, white line of the abdomen).

Palpation of the abdomen in lying and standing position of the patient:

a). Superficial, orientational palpation of the abdomen.

Detection of local or poured morbidity, painful points on the abdominal wall, common or local muscle tension of the abdominal wall, local induration. Shchyotkin-Blumberg's sign. Presence of free liquid in the abdominal cavity. Determination of ascites by method of fluctuation.

b). Profound, sliding, methodical consecutive palpation of the abdomen according to Obraztsov-Strazhesko.

Palpation of intestines: sigmoid, cecum, a fragmenton (part) of ileum, appendix with detailed characteristics - on what distance it is palpated, diameter of intestine, consistence (soft, elastic, dense), surface (smooth, tuberous, beaded). Morbidity at palpation (its localization), mobility of palpated areas of intestine, rumbling at palpation.

Palpation of transverse colon part of the intestine, descending and ascending parts, hepatic and splenic corners (at presence of enteroptosis). Determination of the lower border of the stomach by methods of auscultatory friction, auscultatory percussion and producing of splashing sound. Profound palpation of the body of the stomach: consistence, morbidity, its surface. Palpation of pylorus part of the stomach and duodenum.

Inspection of the liver.

Percussion. Detemination of relative and absolute dullness. Sizes of the liver according to Kurlov.

Palpation of the liver. Characteristics of the lower edge of the liver: localization (for how many sentimeteres it is lower than a costal arch), form (sharp, rounded, blunt). Consistence of the edge of the liver (soft, moderately dense, dense, very dense). Sensitivity, morbidity. Characteristics of the surface (smooth, granular, tuberous). Pulsation of the liver.

Palpation of the gall-bladder: form, mobility, consistence and morbidity. Symptoms: Zakharyin’s, Vasilenko’s, Murphy’s, Mussy- Georgievsky, Ortner’s, Courvoisier's. Points Boas. Morbidity of a choledocho-pancreatic zone - of Shofar (point Dejardin). Zone Hubergritz-Skulsky (points Hubergritz and Mayo - Robson's). Frenicus symptom.

Palpation of the pancreas. Whether the body or the head of the pancreas are palpated: morbidity, induration, its size.

Percussion of the spleen: determination of the upper and lower borders. Sizes of the spleen in sm. According to Kurlov (longitude and width).

Palpation of the spleen in horizontal and lateral position (on the right side). Sizes of the spleen. Consistence (dense, soft); surface (smooth , tuberous). Morbidity of the spleen, mobility; splenic incisure.

5. URINOEXCRETORY SYSTEM

Inspection of the area of kidneys: swelling, hyperemia.

Palpation: morbidity in the area of kidneys, at ureteral points, costovertebral points, in suprapubic areas, along the course of ureters, at the upper, middle and lower points of natural bends. Palpation of kidneys in horizontal and vertical positions by bimanual examination: determination of the lower pole of kidneys, their nephroptosis of different degrees consistence, morbidity, mobility.

Percussion - (light percussion with the edge of the hand in the area of kidneys) reveals positive (presence of morbidity) or negative symptom of Pasternatsky. Frequency of urination a day, presence of morbidity at urination, difficulties (free urination, complicated, by a thin faltering jet).

Auscultation of kidneys for exception of renovascular hypertension.

Daily diuresis.


6. ENDOCRINE SYSTEM

Inspection of area of thyroid gland: (if it is normal, if not- degree of enlargment).

Palpation of the thyroid gland: - uniformity of enlargement, tuberosity, morbidity, mobility at the act of swallowing.

Detection of symptoms of affection (lesion) of the thyroid gland: - exophthalmus (protruded eyeballs), symptoms: Graefe’s, Moebius’, Stellwag’s, Kocher’s, tremor of fingers of hands, etc. Dryness or sweating of the skin. Temperature of the skin. Greyish-brown pigmentation. Edematic, puffiness of the face. Giantism. Nanism. Adiposity (obesity). Cachexia.


7. NERVOUS SYSTEM ANDNEUROPSYCHIC CONDITION

Comes in contact easily, with difficulty); emotional lability (quiet, irritable, emotionally labile); relations at work and in the family (good, bad, nervous situation).

Memory – (good, reduced); attention (absent-minded, concentrated).

Sleep (deep, superficial, disturbing, interrupted sleep, difficulty to fall asleep).

Stability in pose (posture) Romberg’s, tendinous reflexes (alive, languid, absent). Reaction of pupils to the light – simultaneous, alive or not). Presence of pathological reflexes, paresis, paralyses. Faints, spasms, losses of consciousness.


8. HYPOTHETICAL (assumptive) DIAGNOSIS

Determination of hypothetical diagnosis is carried out on the basis of the results of the main methods of examination of patients (inquiry, general examination, palpation, percussion and auscultation).

Ways of logical thinking at diagnostics:

a) picking out the main diagnostical symptoms and syndromes.

b) determination of possible nosologic disease with the help of main symptoms.

c) determination of possible phase of the disease, its complications and clinical outcome with the help of main symptoms.

9. ADDITIONAL RESEARCHES

1. Сlinic-laboratory examinations (blood, urine, stool, sputum, gastric juice, duodenum contents- gall, pancreatic juice, pleural, ascitic liquids and so forth).

2. Biochemical examinations - sugar of blood, rest nitrogen, creatinine, bilirubin,total protein, albuminous fractions, cholesterol, amylase of urine.. Enzymes of blood serum (alanine aminotransferase -AlAT, asparaginase AsAT, lactate dehydrogenase- LDH, amylase etc.), coagulation test, C-reactive protein, haptoglobin, sialic acids, etc.

3. Instrumental methods of examination: X-ray examination (rontgenoscopy, rontgenography, tomography, nuclear magnetic resonance - tomography, electrocardiography-ECG, echocardiography and ultrasonic examination of internal organs, phonocardiography -PCG, gastrofibroscopy, flexible colonoscopy, proctosigmoidoscopy etc.

Besides, the conclusions of other specialists (oculist, neuropathologist, otolaryngologist, surgeon etc.), are included in the case history who are applied for specification of the character of changes on the part of the corresponding organs which are in developing therapeutic diseases. The special temperature list is also filled in where besides data of temperature, rate of the pulse and breath are also marked.


10. JOURNAL OF SUPERVISION (monitoring)

After a daily round the doctor writes in the case history «report of supervision». In some cases, during recovery of the patients or inspection of recruits entry of the report every other day is admitted.

In the report of supervision complaints for the last day, dynamics of the objective data, respireatory rate, pulse, arterial pressure, and also the data of laboratory - instrumental methods are marked.

One shouldn’t write «Complaints to the heartache …., etc. » i.e. to repeat the complaints at hospitalization of the patient. It is necessary to concretize them according to the time of occurrence.

For example: « For the last day the patient marks pains in the area of the heart of compressing character which disturbed the patient for 10 minutes approximately at 7 p.m. Pains have passed on reception of nitroglycerine. Slept well at night.

The data of objective examination should also be described in dynamics though they to a lesser degree are exposed to changes. On getting the results of additional methods of examination the doctor should give them an estimation in a riport. Usually the riport comes to an end with it. For example: «clinical analysis of blood is received, moderate leukocytosis is marked (9,6х10 9), increase of ESR till 30 mm / hour).

In the training case history it is necessary to write 2-3 reports.

Here is the list of received treatment with the instruction of a dosage and frequency of reception.

RIPORTS OF SUPERVISION


(examples of registration)

Date

Pulse, AP

T 0C

Riport of supervision

Treatment

10.11.04

Puls-82 per 1 min

AP-180/110

mm/Hg

T-36.7

In the evening at 6 o'clock p.m. during 1 hour the pains in the heart of aching and shooting character disturbed the patient which passed on reception of nitroglycerine. Headaches were present in the morning at 7 o'clock, but soon passed without reception of medicines.

Objectively: general condition of moderate severity. Skin’s color is usual, there are no hypostases. Near lower boder of the lungs crepitation is heard. Borders of the heart are displaced to the left, tones are muffled, rhythmical, accent of the II nd tone on the aorta. Rhythmical intense pulse 82 beats per 1 minute. The stomach is painless, the liver is not increased. The stool and diuresis was not disturbed.

Diet № 10

1. Enap 1t.x 2 (twice) a day.

2.Sol. Papaverini 2%-2.0 intramuscularly 2 times a day

3. Extract of the valerian

1t. х 3 time a day.

4. To make an electrocardiogram.

5. Clinical analysis of blood

6. Consultation of the oculist.

12.11.04

Puls-76 per 1 min

AP-165/100

mm/Hg

T-36,6


The pain in the heart for the last day did not occur, at night slept badly. The headache appeared by the morning which passed on reception of analginum and enap.

Objectively: the general condition remains to be of moderate severity. In the lungs crepitation has somewhat decreeased.Tones of the heart rhythmical, the accent of the II- nd tone on the aorta has decreeased. Pulse

76 beats per 1 min. Stomach is painless. The liver is not increased. The stool and diuresis are normally expressed. On the received ECG there are signs of hypetrofy of the left ventricle moderately expressed focal

hypoxia of the back wall of myocardium.

Tne applied to treatment should be added:


1. Enap 1t.x 2 (twice) a day

2. Nitroglycerine at pains in the heart.




11. SUBSTANTIATION OF THE CLINICAL DIAGNOSIS


The substantiation of the clinical diagnosis should be carried out by each doctor not later than the third day of stay of the patient in a hospital. On a face sheet of the case hystory the diagnosis and the date of its establishment are written down, and «the substantiation of the clinical diagnosis» is written in the case history on this day instead of a diary of observation.

Here the doctor consistently and logically states his ideas concerning the diagnosis established by him. For this purpose the doctor involves the data of all carried out researches which confirm the diagnosis (complaints, the anamnesis of disease, the anamnesis of the life, data of objective, laboratory and instrumental methods of examination).

It is the most complex section of the case history, not each doctor is able to prove the diagnosis competently, convincingly and consistently.

A plenty of mistakes is especially made by students in this section for the sake of which as a matter of fact all previous sections of the case history were written.

The most typical mistakes in the writing of substantiation of the diagnosis is not the statement of the ideas confirming the diagnosis, but drawing up of the simple list of all complaints, the anamnesis of disease and life, the objective and laboratory data, at the end of which the diagnosis is written down, more often it is one sentence on 2-3 pages making no sense.

At substantiation of the diagnosis the following rules should be observed:

1. The diagnosis should be proved in parts. For example, the diagnosis « Hypertonic disease II stage, hypertonic crisis, is proved in the following order.

At the beginning the presence of hypertonic disease is proved, then the data proving the II stage of disease and then presence of hypertonic crisis are stated.

2. It is not necessary to state at once, that there is this disease. According to complaints and the anamnesis it is possible to come out with the assumption, the objective data can confirm the assumption, and the data of additional research can finally convince of it.

3. We do not recommend to begin substantiation of the diagnosis with the words « On the basis … » or « taking into account … » since, as a rule, ideas are expressed not clearly, sentences are unfinished or simply wrongly formulated.

We count more successful is enumeration of separate symptoms with the indication of their possible connection with prospective disease. Then we should consistently involve new symptoms revealed at objective research, connecting them in a single whole the diagnosis.

4. For substantiation of some diseases it is necessary to use the criteria developed by scientists. So, for substantiation of the diagnosis "rheumatism" it is necessary to use Jones-Nesterov's criteria.

5. The substantiation of the diagnosis ends with generalization and formulation of the full diagnosis.

Before starting substantiation of the diagnosis, it is necessary to formulate it precisely and correctly. At difficulty it is necessary to resort to the help of the teacher.

As an example of substantiation of the diagnosis here is the substantiation of hypertonic disease presented by 3-year student in the training case history.

Clinical diagnosis: «Hypertonic disease of II stage, hypertonic crisis.

Complaints of headaches in occipital area, dizzinesses, increase of systolic and diastolic pressure which are indications of psychological overstrain besides hypertonic disease in the father, available in the anamnesis of a life corresponds to hypertonic disease.

Absence of changes on the part of kidneys, affections of other organs at which the level of arterial pressure increases convince us that the patient has a hypertonic disease. Duration of the disease is11 years, stable increase of arterial pressure up to 220/110 mm. Hg. Arterial blood pressure doesn’t decreas to normal figures as a result of treatment, and also some changes on the part of heart developed (displacement of border of the heart for 1,5 sm to the left from midclavicular line, X-ray study - increase in the sizes of the heart due to the left ventricle). The left type of an electrocardiogram, attributes of a hypertrophy of the left ventricle (negative wave Т in I and V5-6, leads V1-6 > 35), the narrowing of arteries and expansion of veins of an eye bottom convincingly speak about the II stage of hypertonic disease.

Sharp deterioration of condition, significant amplification {strengthening} of a headache, dizziness, nausea, instability at walking, «flashings in front of the eyes» - specify the presence of hypertonic crisis.

Presence of dyspnea in the patient and tachycardia at walking, cough with rare allocation of mucous sputem. At comparative percussion a bandbox sound is heard. At auscultation separate dry whistling rattles and damp small bubbles – like rattles which are not sonours are heard above the lungs and all this speaks about the presence of the development of stagnation in a small circle of blood circulation (a stagnant bronchitis) in the patient with the II A stage of heart insufficiency ( HI II A).

Principles of substantiation of the diagnosis in various diseases (bronchites, pneumonias, ischemic disease, gastrites, a stomach ulcer, nephritis, etc.) are covered at the lectures on propaedeutics of internal diseases.


12. EPICRISIS

Epicrisis is a final part of the case history which is its brief content. In epicrisis in the compressed form all data on the beginning of disease or exacerbation, the anamnesis of disease and a life, data of objective examination (basically pathology), the results of additional examinations, treatments, its efficiency should be stated. Besides, in epicrisis concrete recommendations on the further treatment, work capacity, sanatorium treatment, necessity of constant dispensary supervision are specified, as well as recommendations on a diet, work and rest, practising physiotherapy exercises.

It is necessary because epicrisis is the document, which not only remains in the case record but it is pasted as a copy with the signature of the doctor and a seal in an out-patient card and is directed to a medical establishment which has directed the patient.

Schematically epicrisis looks in this way:

First name, middle initial, last name _____________ (completely) was on hospitalization in therapeutic or other department _________ of the hospital from _____ to ________.

In the department the clinical diagnosis was difined________ (the full developed clinical diagnosis with complications, functional part and accompanying diseases).

At hospitalization to the department showed complaints of _________.

Was ill with the present disease for the first time or not, the disease began (sharply, gradually).

Patient was ill from __________, was treated on a regular basis, under dispensary supervision or not.

Last exarcebation took place _______ in connection with _______.

In the anamnesis of a life there are indications on the carried diseases, traumas, operations, harmful habits, heredity factors and so forth. Only what could affect the development or exarcebation of the disease should be specified.

At objective research it is revealed: _____________ (to describe only the pathological data).

The following additional researches are carried out: (to bring in all data with a pathology and without changes).

1. Clinical analysis of blood: date ________ 2. Clinical analysis of urine: date ____

3. Biochemistry of blood date ________ 4. Rontgenoscopy (rontgenography) date ________ and all examinations which were given to the patient. At the presence of two and more examinations to specify one with the expressed changes and the last, made before discharge.

4. The patient is examined by experts: ENT (ear, nose, throat) the oculist, the surgeon, etc. (to note the conclusion with recommendations).

During a stay in clinic the treatment is carried out ___________. To specify all kinds of treatment, a dosage and term of application.

As a result of the carried out treatment the condition of the patient has improved (despite the carried out treatment - has not improved). Complaints have disappeared of: __________ have decreased ____________, however continues to disturb __________.

There have appeared some changes at objective examination: ___________, parameters (blood, an electrocardiogram, functional tests and so forth) have improved.

Discharged with recommendations:

1.а) the Patient is able-bodied, does not require further medicamentous treatment.

b) The patient is temporarily invalid, to continue treatment in out-patient conditions. It is recommended to take ____________ (to list the names of medicines, dozes, frequency rate of reception a day on hours and terms of application, exercise therapy, physiotherapy, etc.);

c) Work capacity is sharply limited, requires employment, which is not connected with (physical loading, work at night, professional insalubrity and so forth). In case of loss in earnings is subject to a direction to Medical Labor (Working) Expert Commission for an establishment of group of physical disability;

d) The patient is invalid, is subject to a direction to Medical Labor (Working) Expert Commission for determining the group of physical disability.

2. Requires dispensary supervision with carrying out of scheduled inspection and treatment at the therapist on a residence (work).

3. It is necessary to observe day regimen (depending on a disease: work and rest, nourishment within the limits of the diet № ______ on Pevzner, to avoid overcooling and stay on drafts and so forth).

4. In ______ months after the control inspection can continue treatment in sanatoria: ____________ in the seasons of the year.

5. The physiotherapy exercises (at school of health, visiting a swimming -pool, morning hygienic gymnastics, run and so forth) is recommended.

6. The medical certificate from ____ to ______ is given. It is discharged to work.

The patient is still ill. Visit to the doctor of a polyclinic _________ 200 __.


Chief of department

Physician

Curator the 3 rd year student, group number____.

It’s not necessary to make sentences in this particular way however, the sequence and depth of a statement should be observed according to suggested recommendations.


NORMAL BLOOD COUNTS

Haemoglobin:




men

130.0-160.0 g/1

women

120.0-140.0 g/1

Erythrocytes:




men

4.0-5.0 x 1012 per 1 1

women

3.9-4.7 x 1012 per 1 1

Colour index

0.85-1.05

Haemoglobin content of one erythrosyte

30-35 pg

Reticulocytes

2—10%

Thrombocytes

180.0-320.0 x 10 9 per 1 L

Leucocytes

4.0-9.0 x 10 9 per 1 L

Neutrophils:




stab [bond]

1-6%

segmented [segmentonuclear] leukocyte

47-72%

Eosinophils

0.5-5%

Basophils

0-1%

Lymphocytes

19-37%

Monocytes

3-11%

(ESR):




men

2-10 mm/h

women

2-15 mm/h



Biochemical components of a system


of a human being’s organism

1. Blood (B), plasma (P), serum (S) blood

Total protein 65-85 g/l-adults, 56-85 children till 6 years old, 53-89 g/l newborns.

Albumin 35-50 g/l

Globulins 23-35 g/l

Albumin – globulin coefficient А/G 1.5-2.3

albumins -58-68 %

globulins: α 1-2,5-7 %

α 2-6 - 8 %

β - 8-12 %

γ -12-18 %

Immunoglobulins (P)

G 50-112.5 micromole/l (800-1800 mg / 100 ml)

A 5.62-28.12 micromole/l (90-450) mg / ml

M 0.62-2.5 micromole/l (60-250 mg / 100 ml)

E 0.3-30 nanomole/l (0.006-0.6 mg / 100 ml)

Alanine aminotransferase (АlАТ) of S - 0.1-0.68 millimole/(h.ml)

Aspartate aminotransferase (АsАТ) of S -0.1-0.45 millimole/(h.ml)

Amylase of B - 12-32 mg / (h.ml)

Creatine kinase of S - 0-6 micromole/ (min.l)

Lactate dehydrogenase LDG 220-1100 nanomole/ (s.x l) or 0.8-4 micromole/(h.ml)

Phosphatase sour S - 67-167 nanomole/(s x l) or 4-10 micromole/(min.l)

Phosphatase alkaline S - 278-830 nanomole/(s x l) or 1-3 micromole/(h.ml).

Cholinesterase S - 45-95 micromole/ (s x l) or 160-340 micromole/ (h.ml)

Hormones of blood:

Adrenocorticotropic hormone, ACTH - 10-80 nanogram /l

Somatotropin – 0.3 – 6.5 mkg / l

Cortisol -138-432 nanomole/l

Corticosterone -12-53 nanomole/l

11-oxycorticosterone-306-695 nanomole/l

Aldosterone -55-832 nanomole/l

Adrenaline - 1.9 -3.8 nanomole/l

Noradrenaline - 0-7.7 nanomole/l

Thyroxin -51.5-141.6 nanomole/l

Triiodothyronine -2- 4.3 nanomole/l

Parathormone -0.3 – 0.8 mkg /l

Nitrogen residual -14.3 -28.5 millimole/l (20-40 mg / 100 ml)

Creatinine of S- 0.044- 0.088 millimole/l- women; 0.044 – 0.1 millimole/l- men

Bilirubin total in S – 8.5-20.5 micromole/l (0.5-1.2 mg / 100 ml) from which 75 % free and

25 % connected bilirubin.

Urea of S – 2.5- 8.3 millimole/l (15-50 mg / 100 ml)

Uric acid of S: 0.24-0.5 millimole/l (4.4-8.5 mg / 100 ml) – men; 0.16-0.4 millimole/l (2.8-7.5 mg / 100 ml)- women

Indican of S – 1.19-3.18 micromole/l

Ascorbic acid of P 34.1-90.8 micromole/l

Glucose of S –

3.1-5.5 millimole/l (55-100 mg / 100 ml)- glucose-oxydase method

3.3-6.1 millimole/l (60-110 mg / 100 ml) - ortho- toluidine method

Galactose of S - 111-943 micromole/l (2-17 mg / 100 ml)

Fructose -5.55-27.75 micromole/l (0,1-0,5 mg / 100 ml)

Lactic acid:

Arterial 0.33-0.78 millimole/l (3-7 mg / 100 ml)

Venous 0.55-2.22 millimole/l (5-20 mg / 100 ml)

Pyruvic acid 34.07-102.2 micromole/l (0.3-0.9 mg / 100 ml)

Sialic acid of S 2-2.4 millimole/l (620-730 mg / ml)

C- reactive protein - negative.

Antistreptolisine -О - up to 250 units.

Anti- hyaluronidase -up to 300 units.

Diphenylamine test – 0.18 – 0.2 units.

Thymol (turbidity) test 0-4 units.

Seromucoid - 0.13-0.20 units.

Total lipids in S – 3.5-8 g/l

Phospholipids of S – 1.5-3.6 g/l; on phosphorus 2-4.6 millimole/l

nonesterification acids (0.28-0.71 millimole/l)

Lipoproteins of P:

high-density lipoprotein (HDP) – 1.25-4.25 g/l- men; 2.5-6.5-g/l- women

intermediate density lipoprotein -3-4.5 g/l

low-density lipoprotein (LDL) – 0.8-1.5 g/l

Cholesterol of S total – 3.9-5.2 millimole/l (150-250 mg / 100 ml) from them

70 % -esterificated, and 30 % - free

Histamine in B -180-900 nanomole/l (2-10 mkg / 100 ml)

Serotonin in B -230-460 nanomole/l (4-8 mkg / 100 ml)

Acid-base balance:

Bicarbonate standard (P) 21-25 millimole/l

Parameter of hydrogen (рН):

Arterial – 7.36-7.42

Venous – 7.26-7.36

Iron nonhemin of P- 12-32 micromole/l (65-175 mkg / 100 ml)

Potassium (K) of P -3.4-5.3 millimole/l (13.6-20.8 mg / 100 ml)

Calcium of S – 2.3-2.75 millimole/l (9-11 mg / 100 ml)

Magnesium of S – 0.7-1.7 millimole/l (1.7-2.8 mg / 100 ml)

Copper of S or P -11-22 micromole/l- men; 13.4-24.4 micromole/l- women

Sodium of P -130-157 millimole/l (300-360 mg / 100 ml)

Phosphorus inorganic of P or S- 1-2 millimole/l (3-6 mg / 100 ml)

Chlorine of S or P - 97-108 millimole/l

Coagulogram:

Prothrombin index - 80-100 %

Recalcification time -60-120 sec.

Heparin tolerance of plasma -7-12 mines

Thrombotest -9-12 mg / ml

Plasma fibrinogen – 2-4 g/l or 200-400 mg / 100 ml

Fibrinogen B - negative

Fibrinolytic activity of plasma -3h.30min - 4h.30min.

2. Urine

Relative density 1016-1022

Protein - 50-150 mg /day

Alpha - Amylase up to 44 mg / (s.l) or up to 120 mg / l (h. x ml.)

Creatinine -4.4-17.6 millimole/day (0.5-2 g/day)

Urea 330-580 millimole/day (20-35 g/day)

Uric acid 1.6-3.54 millimole/day

Glucose about 0.72 millimole/day

17- oxycorticosteroids

Free 0.11-077 micromole/day (0.04-0.28 mg/day)

Total 4.1-13.7 micromole/day (1.5-5 mg/day)

Chlorine 150-250 millimole/day

Gastric contents

рН-1,5-2,5

General acidity 40-60 millimole/l

Free hydrochloric acid 20-40 millimole/l

Connected hydrochloric acid 10-15 millimole/l

Hydrochloric acid discharge (output)

free НСI-1-4 millimole/h (basal secretion)

6.5-12 millimole/h (submaximal)

16-24 millimole/h (maximal)

Pepsin – 0.57-1.29 millimole/l (21-45 g/l)


Схожі:

Methodical directions for the i-st III- rd year students iconObstetrics and gynaecology department №2 Methodical recommendations for students of 4th year of stomatological faculty for practical lessons in obstetrics

Methodical directions for the i-st III- rd year students iconFor the Foreign Students of Medical Faculty for the III term 2012 – 2013 academic year

Methodical directions for the i-st III- rd year students iconFor the 4-year students of pharmaceutical faculty 2012-2013 academic year

Methodical directions for the i-st III- rd year students icon3-year students of medical faculty 2012-2013 academic year

Methodical directions for the i-st III- rd year students iconFor the 3-year students of medical faculty 2012-2013 academic year

Methodical directions for the i-st III- rd year students iconPractical classes timetble for 3 rd year foreign students on fall semester 2010-2011 academic year

Methodical directions for the i-st III- rd year students iconPractical classes timetble for 3 rd year foreign students on fall semester 2012-2013 academic year

Methodical directions for the i-st III- rd year students iconThe time table the lectures and practically lessons for the four-year foreign students of medical faculty of surgery for the VII session 2010-2011 academic year

Methodical directions for the i-st III- rd year students iconCalendar Plan Practical Lessons in Neurology for iv-year students General Practitioner Faculty VII semester 2012-2013 Academic Year module 1

Methodical directions for the i-st III- rd year students iconSchedule of the lecture of the 5th course of the Internetional Medical Faculty (16, 17, 20 groups) students in the first half-year term 2009-2010 academic year at the Departmen of the Internal Medicine N3

Methodical directions for the i-st III- rd year students iconSchedule of the lecture of the 5th course of the Internetional Medical Faculty (16, 17, 20 groups) students in the first half-year term 2009-2010 academic year at the Departmen of the Internal Medicine N3

Додайте кнопку на своєму сайті:
Документи


База даних захищена авторським правом ©zavantag.com 2000-2013
При копіюванні матеріалу обов'язкове зазначення активного посилання відкритою для індексації.
звернутися до адміністрації
Документи