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Ministry of public health of ukraine

Bukovinian state medical university


on the cathedral meeting of the

Department of patient care and higher nurse education


minute № ____

Head of department

Associate professor Plesh I.A.

Methodical guidelines

for 3rd – year students of the medical faculty

Module 2

The main duties and professional skills of nurse

at the surgical department

Semantic module 3

Surgical infection



Acute purulent diseases of a hand

Subject: Nursing practice

3rd-year students of Medical faculty

Speciality: "General medicine" – 7.110101

7.110104 – "Pediatrics"

Duration - 2 hours

Methodical guidelines composed by:

Professor R.I. Sydorchuk

Assoc. professor O.Y. Khomko

Assistant R.P. Knut

Chernivtsi – 2008

AIM: To learn a symptomatology of different forms of panaritiums and phlegmons of a hand, to seize their diagnostics. To acquire questions of prophylaxis and modern principles of treatment. To learn to distinguish a symptomatology of osteomyelitis. To acquire modern methods of diagnostics, principles of treatment and prophylaxis of occurrence of purulent diseases of bones and joints.

To learn to distinguish and estimate value of syndromes in early diagnostics of a tetanus, to carry out complex prophylaxis and treatment. To acquaint students with clinical displays of anthrax, a diphtheria of wounds, to methods of prophylaxis and treatment.

^ PROFESSIONAL MOTIVATION: Hand - the basic organ of work, organ of influence of the person on an environment. Values of a brush in human life induces physicians to concern with special attention to prophylaxis and treatment of its diseases and traumas.

Almost 2 % of the population is sick on acute purulent diseases of a hand and fingers which in polyclinic surgical practice occupy one of the first places. That is all 1/3 patients on different purulent diseases which for the first time have addressed in a polyclinic, make persons with purulent-inflammatory diseases of a hand and fingers.

Purulent diseases of a hand are the important social problem in connection with high frequency of occurrence, a plenty lost operating time, the material inputs connected to payment of a temporary disability, and by adverse results. They demand of the doctor of a profound knowledge and skills in questions of diagnostics and medical tactics.

Necessity of illumination of problem of osteomyelitis caused by insufficient studying of a pathogeny, difficulty of diagnostics, late hospitalization, absence of unity of views on a choice of methods of diagnostics, rational volume of operation, conducting the postoperative period.

The tetanus continues to remain one of 10 main reasons of mors of the population. Extremely long conservation of spores of the originator of anthrax in ground will cause of constant vigilance and knowledge of all aspects of this illness dangerous to the person. Important value gets also the professional factor. At cattlemen, shepherds, workers of the leather industry possible antrax, and at diggers, workers of an agriculture - a tetanus.


Hand Infections

Paronychia. This condition starts as a subcuticular or intracutaneous infection, with exudate developing in a localized area, which eventually spreads around under the base of the fingernail, elevating it from the nail matrix and eventually the nail bed (Fig. 1).

Fig. 1 Paronychia:. 1. The pus collections near the nail;

2. The pus spreading under nail

If a small collection of purulent material cannot be localised "and expressed, complete drainage is indicated as early as possible by an incision that allows the lateral and proximal folds of the nail to be exposed. This may be done under digital block anaesthesia without the use of epinephrine in the anaesthetic. A pointed knife blade is inserted between the skin and the nail in order to incise the eponychium from within outward, on either side of the base of the nail. This allows the skin flap to be turned upward for adequate drainage. Wet dressings, petrolatum gauze, antibiotic ointments, and regular reopening of the drainage area will prevent the skin from adhering until infection has been controlled. If more extensive drainage is needed for a deeper abscess, the incisions are extended the skin fold, the skin edges are raised upward along with the dorsal skin over the nail bed, and the proximal end of the fingernail is excised. A small segment of nail, rather than the entire fingernail, can be removed. The infection, if chronic and severe, may be sufficient to destroy the nail matrix, the nail bed, and ultimately the phalanx. Thus, in order to avoid loss of bone and even the phalanx, treatment should be complete, aggressive, and early. Incisions adjacent to the eponychium should be avoided, as the remaining skin flaps may necrose. Also, the incisions over the extensor tendons should be avoided, since these may cause direct extension of the inflammatory process. The nail matrix should not be damaged while the fingernail is being removed. When the new nail forms it may be somewhat irregular, and several months will elapse before a smooth nail regenerates. Chronic paronychia, particularly in the female, may be due to Candida or Manilla. Local treatment by ointments should be initiated; however, appropriate cultures should be obtained prior to extensive antibiotic therapy, if local treatment appears to be unsuccessful.

Infection of the terminal pulp space (syn. Felon).

Felon (Latin, fel-gali). An abscess near the nail. Pulp-space infection is the second most frequent infection of the hand (about 25 per cent of all cases). The index finger and the thumb are affected most often. The origin of the infection is usually a prick.

Surgical anatomy. The deep fascia, which is attached to the thin skin of the distal flexion crease, fuses with the periosteum just distal to the insertion of the deep flexor tendon, thereby closing the terminal pulp compartment at its proximal end. Through the space, which is filled with compact fat, feebly partitioned by fibrous septa, run the terminal branches of the digital arterv. Thrombosis of these vessels accounts for the frequency with which osteomyelitis complicates infection of this closed space. The basal plate of the epiphysis is rarely involved.

Clinical features. Dull pain, worse when the hand is dependent, and swelling are the first symptoms. Forty-eight hours later there are severe noctual exacerbations of throbbing pain, interfering with sleep. Light pressure over the affected pulp increases the pain. Frequently, the corresponding regional lymph node is enlarged and tender. If the pulp is indurated and has lost its normal resilience, pus is present. Untreated, the abscess tends to point towards the centre of the pulp beneath a patch of devitalised skin. A collar stud abscess then occurs; if still untreated, the abscess bursts. Neglected cases suffer serious loss of pulp tissue leading to a markedly scarred finger tip.

In the early stages when there is no localisation, large doses of flucloxacillin may bring about resolution. Once pus is present, operation without delay is the rule. A short incision is made through the skin at the point of greatest tenderness. The beginner is warned not to be beguiled by entering only the superficial loculus of a collar stud abscess. Removal of slouch, which is frequently present, is most desirable, but great care must be taken not to traumatise the periosteum.

Osteomyelitis of the terminal phalanx may be a sequel of terminal pulp-space infection. That part of the bone without blood supply will become a sequestrum and separate some weeks after the abscess has been opened, in which event the wound continues to discharge. Repealed radiographs and probing (revealing rough bone) will indicate when the sequestrum has separated. Only then must it be removed, after which healing will proceed apace. In the case of a child, regeneration of the diaphysis is possible, provided the periosteum is relatively undamaged. In the adult, no regeneration occurs, and the patient is left with a shortened phalanx covered by an ugly, curved nail.

Subcutaneous infections and abscesses can occur on the dorsal and volar surfaces at various levels. The volar surface of the hands of manual workers is often covered with greatly thickened epithelium. Especially in such individuals, a subcutaneous abscess may burst through the dermis and extend in the layers of the epidermis, in which event it is impossible to differentiate it from a purulent blister until the deeper loculus has been discovered at operation.

Treatment. The abscess is opened (Fig. 2). The resulting undermined flaps are cut away with scissors. The unroofed cavity is swabbed free from pus, which is examined by culture for the identification Of the bacteria and for tests of their sensitivity to various antibiotics. Then it is explored for a sinus leading to a deep loculus. If one is found, the communicating channel is stretched by inserting and opening the jaws of a small haemostat.

Fig. 2. Incisions for drainage of an abscess of the distal closed space.

1. Hockey - slick incision, which can he employed when the abscess is demonstrated definitely to lie in the lateral side of the space;

2. Fish-mouth or horseshoe incision, which gives the most adequate drainage.

3. Through -and- through type of incision for drainage of the distal closed space

Pyogenic arthritis of the finger

This type of infection occurs from extension of infection from soft tissues around the joint like infection of the middle or proximal segment of the finger or suppurative tenosynovitis (Fig. 3). Only very rarely pyogenic arthritis of the finger may occur from perforating wound of the finger.

The infection is first localised in the synovial membrane and in this stage if treatment is done, disability may be avoided. But unfortunately enough the articular cartilages and capsular ligaments are very quickly involved resulting in stiffness of the finger, if not properly treated.

Fig. 3. Pyogenic arthritis of the finger: pus

Pyogenic arthritis of a finger is suspected, when following a wound, the region of the knuckle becomes very painful and movement of the joint increases the intensity of pain. Crepitus is a late sign. When this condition is not associated with an external wound, one must estimate the blood sugar level to exclude diabetes mellitus.

When an external wound is present to show the cause of pyogenic arthritis, immediate exploration should be carried out under antibiotic cover. The extensor expansion on either side is transversely incised and a clear view of the joint should be obtained by mobilising the tendon towards the opposite side. The pus is drained and a search should be made for any loculated collection of pus within the joint as is always done to drain any abscess cavity. Loose fragments of cartilage and necrotic tissues are removed. The joint is irrigated with first normal saline and then with antibiotic solution. The capsule and the extensor expansion are repaired with fine sutures of nylon or polypropylene. The skin wound is closed. It should be left open if the wound is more than 6 hours old and the wound is very much contaminated. The hand is immobilised in optimum position till the infection has completely subsided.

When pyogenic arthritis is not associated with an external wound, conservative treatment should always be tried first. An intensive antibiotic therapy should be started immediately and the fingers and the hand are immobilised in the optimum position. In most of the cases, the infection subsides with this treatment. But in some cases operative drainage may be required.

^ Suppurative tenosynovitis

Surgical anatomy. The synovial sheaths of all the fingers extend up to the distal interphalangeal joints. Proximally, the sheaths of the index, middle and ring fingers end in a cul-de-sac at the distal palmar crease. The sheath of the thumb is continuous with the radial bursa, which surrounds the tendon of the flexor pollicis longus and extends proximally to a point about I inch above the crease at the wrist (Fig. 4 ). The synovial sheath, covering the flexor tendon of the little finger, sometimes has direct communication with the ulnar bursa or common palmar sheath, which surrounds all the flexor tendons to the four fingers. The ulnar bursa also extends proximally up to 1 inch proximal to the crease at the wrist. At times, the radial and ulnar bursae intercommunicate each other, while they lie in the carpal tunnel, flexor tendons to the four fingers. The ulnar bursa also extends proximally up to 1 inch proximal to the crease at the wrist. At times, the radial and ulnar bursae intercommunicate each other, while they lie in the carpal tunnel.

These sheaths are often infected from a puncture wound in one of the digits. There will be swelling of the Finger concerned, but this swelling will be much less than what is found in infection of the middle or the proximal volar space of the finger. The digit will be held in semiflexed position and will be rigid. This rigidity in flexion may disappear due to spontaneous rupture of the sheath. Passive extension will lead to acute pain. Tenderness will be present all throughout the extent of the sheath, but will be maximum over the flexor creases and over the proximal cul-de-sac of the sheath.

When the synovial sheaths of the flexor tendons become infected with pyogenic organism and ultimately pus forms within these sheaths, the condition is called suppurative tenosynovitis.

Fig. 4. Suppurative tenosynovitis:

collection of pus at the tendon sheath

Aetiology. This condition occurs:

a) directly from a puncture wound e.g. a pin-prick, a needle prick or sharp object penetrating the tendon sheath;

b) indirectly, due to spread from neglected subcutaneous infections (middle or terminal or proximal volar space) or injudicious incision for drainage of such abscesses.

Pathology. The infecting organism is usually Staphylococcus aureus or Streptococcus pyogenes. As soon as the infection enters the sheath, a reactive effusion occurs which spread for the whole extent of the sheath. Gradually pus forms within the sheath. The sheath gets swollen. Pressure within the sheath along with virulent infection will cause damage to the flexor tendon inside the sheath. Ultimately stiffness of the finger will ensue.

Clinical features. This is an infection of the flexor tendon sheath.

The infection is mainly a direct one from a prick of a needle, a thorn or a dorsal fin of a fish. The prick is obviously through the skin overlying the tendon sheath, mostly through a digital flexion crease as at this part the skin surface is remarkably nearer to the sheath. Sometimes this condition may develop from injudicious incision for drainage of the distal pulp space or from spread of infection from the middle and proximal volar spaces. The whole sheath is rapidly involved. The patient feels throbbing pain in the affected digit, the finger becomes red and swollen and the patient's temperature rises. Infection of the thumb or little finger spreads up to the palm to involve the radial or ulnar bursa respectively. The cardinal features of this condition are:

1. Uniform swelling of the whole finger except the terminal segment where there is no tendon sheath,

2. Typically the finger is held in flexed position which is classically known as "Hook" sign. This is an early sign.

3. Tenderness over the anatomical disposition of the sheath. To determine the area of tenderness the end of a match stick serves the purpose admirably. Accurate localisation of tenderness is not possible with the examiner's finger tip which covers too wide an area. Usually the tenderness is most marked at the proximal ends of the sheaths in case of the index, middle and ring fingers. In case of ulnar bursa, a point of maximum tenderness is obtained over the part of the bursa lying between the two transverse palmar creases — Kanavel' s sign.

4. The patient is asked to move the fingers. Slight movement of the metacarpophalangeal joint by contraction of the lumbrical and interosseous muscles may be possible but movement of the interphalangeal joints is completely restricted.

5. Any attempt to straighten the finger actively or passively causes exquisite pain.


1. Necrosis of the tendon and adhesion of the tendon with the sheath result in permanent stiffness of the finger in flexed position.

2. Spread of infection from one tendon sheath to another is not impossible since the ulnar and radial bursae inter-communicate in 80% of cases and occasionally the tendon sheath of the index or the middle or the ring finger communicates with the ulnar bursa.

^ Infection of the ulnar bursa

This is probably the most serious of all infections in the hand. The infection may result from a direct spread from tenosynovitis of the 51h finger. The clinical features of this condition are:

1). Flexion of mainly the little finger and other fingers if the sheaths of their tendons communicate with the ulnar bursa, but if the sheath has already ruptured this finding may not be present;

2). Fullness of the palm;

3). Maximum tenderness towards the ulnar side between the two palmar creases (Kanavel's point);

4). Oedematous swelling of the dorsum of the hand.

^ Infection of the radial bursa

In fact true synovitis of the flexor pollicis longus always brings about this condition. This is evident by the fact that swelling of thumb is seen to extend into the thenar eminence. The thumb is held flexed. Swelling may be seen just proximal to the flexor retinaculum on the lateral side.

Treatment. This should be treated immediately with intensive chemotherapy, immobilisation and elevation of the hand. If alter 24 hours of conservative treatment, there is not much improvement of pain, swelling, tenderness and if the temperature continues to be high, operation should be performed without delay.

Operation. For the index, middle and ring fingers, a small transverse incision is made on the proximal cul-de-sac of the tendon sheath to allow both decompression of the sheath as well as irrigation with antibiotics. After the pus has been evacuated, plastic cannula or a ureteric catheter of suitable calibre is introduced into the sheath. The sheath is irrigated with antibiotic solution. Dry dressing is applied and the hand is immobilised and elevated in a piaster splint. If pain, tenderness and fever continue to be present, it seems that the drainage site has become blocked. In this case exploration and irrigation should be repeated without delay. As soon as the infection has been controlled, active exercises should be commenced, but antibiotic therapy should be continued for a few days more, as there is a chance of relapse as soon as the movement of the finger is started.

If the tendon is seen to have sloughed and non-viable, amputation of the finger through its base should be considered. If a small portion of the tendon has become sloughed one can try to replace this by a graft provided the function of the finger is still maintained.

For the little finger. The danger of suppurative tenosynovitis in this finger lies in the fact that tendon sheath here often communicates with the ulnar bursa and infection spreads to the ulnar bursa if treatment is not started early. Sometimes there is a constriction in the sheath at the level of the metacarpophalangeal joint which may prevent spread of infection to the ulnar bursa in early stage. Whenever the response to conservative treatment is not satisfactory, no time should be lost in draining the sheath of the little finger by the methods described for other fingers above.

For radial bursa, three incisions may be necessary for proper drainage. One at the midlateral line of the proximal segment of the thumb which lies just in front of the digital vessels and nerve. The second on the perithenar crease and this incision should not extend further than a finger's breadth distal to the flexor retinaculum, which is located by the scaphoid tubercle, since a branch of the median nerve to the muscles of the thenar eminence may be injured. Lastly a transverse incision may be made just proximal to the flexor retinaculum on the radial bursa. After drainage, irrigation may be done with thin polythene cannula.

In ulnar bursa, incision may be made just in front of the metacarpophalangeal joint of the little finger. The ulnar bursa is opened. A ureteric catheter may be passed both proximally and distally for proper irrigation. But a transverse incision 1 cm proximal to the distal crease of the wrist joint is more often required for proper drainage. Sometimes even after two incisions, drainage may not be satisfactory. In these cases, the flexor retinaculum has to be divided through an incision from the proximal incision carried distally for a short distance which skirts the thenar eminence.

Complications i>f suppurative tenosynovilis.

1. Involvement of the forearm. When the radial or ulnar bursa becomes distended with pus, it may burst and pus travels proximally in the forearm between the flexor profundus tendons anteriorly and pronator quadralus and incrosscous membrane dorsally. This is the space known as Parana's space. Pus in this space will not show much swelling, but there will be brown induration above the wrist in the flexor surface of the forearm. The pus here is drained by making incision on the lateral or medial border of the forearm and by pushing a haemoslat through this incision. The jaws of the haemostat are opened and the pus is drained by Hilton' s method. A corrugated drain is then inserted.

2. Suppurative arthritis. This occurs very rarely as a complication of suppurative tenosynovitis. This condition may call for amputation except the thumb.

3. Continuation of suppuration is possible when there is sloughing of tendon or bone necrosis.

4. Stiffinger is possible if the condition is not detected in time and treatment instituted.

5. Involvement of median nerve is possible due to compression of the Carpal-Tunnel by distension of ulnar or radial bursa. Both the bursae may be distended due to the existent communication.

  1. ^

    Objectives for Students’ Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

  1. To teach anatomico-physiological features of a structure of a hand.

  2. Classification, features of clinic and treatment of a panaritium.

  3. Classification, surgical approach and treatment of phlegmons of a hand.

I.Tests and Assignments for Self – assessment

Multiple Choices.

Choose the correct answer/statement:

  1. Patient A., 22 years old, has addressed for medical aid with complaints to a pain of constant character in a site of the right palm which amplifies at movements by fingers, the general delicacy, subfebrile temperature. Objectively: at the basis of the third finger of the right hand on a palmar surface it is marked callosity skins around of which the edema and hyperemia of skin are observed. Through epidermis the purulent exudation is visible. A palpation of a place of defeat morbid, violation of function of fingers and brushes. It is possible to think of what pathology?

    1. A hypodermic panaritium of the basic phalanx IIIrd finger of the right hand.

    2. A dermal panaritium of the basic phalanx IIIrd finger of the right hand.

    3. A phlegmon of median checkered space of the right hand.

    4. Subcallosal abscess.

    5. Articular panaritium of the IIIrd finger of the right palm.

  2. Patient G., 28 years old, has addressed for medical aid with complaints to a pain of constant character in a region of IInd finger of the left hand, infringement of function of a finger. Objectively: on a dorsum of the basic phalanx of the IInd a finger of the left brush the inflammatory infiltrate 1,5Ч2 сm with a necrotic hinge in center is determined . What disease takes place in the patient?

    1. A skin panaritium.

    2. A subskin panaritium.

    3. A carbuncle.

    4. A furuncle.

    5. Erizipelid.

  3. Patient A., 26 years old has received a microtrauma (puncture) of a nail phalanx of the IInd finger of the left hand. 5 days later has addressed in a polyclinic where the diagnosis was exposed: a hypodermic panaritium of nail phalanx of the IInd finger of the left hand. Under what anesthesia it is expedient to execute disclosing of a panaritium?

    1. Local infiltrative anaesthesia.

    2. An intravenous narcosis.

    3. Intraosseous anaesthesia.

    4. A conduction anaesthesia by Oberst-Lukachevitch.

    5. Intubation narcosis.

  4. Patient M., 60 years old, admit in surgical department 10 days later from the beginning of disease with complaints to pains in a region of the IInd finger of the left hand, infringement of function of a finger, the general delicacy, a fervescence up to 38°С. Objectively: a condition of the patient satisfactory, pulse 90 per 1 minutes, arterial pressure - 120/80 mm Hg., a body temperature 38°С, IInd finger of the left hand dwarfed, deformed, a skin hydropic, cyanotic. In the field of an average phalanx on a palmar surface - is a fistula up to 0,3 sm with purulent discharges. Flexion contracture of finger. Active movements are absent. On a roentgenogram a destruction of a bone of middlephalanx is determined.

What disease at the patient?

    1. A bone panaritium.

    2. A pandactylitis.

    3. Tendovaginitis.

    4. A subskin panaritium as "cuff link".

    5. A thecal whitlow.

Real-life situations to be solved:

  1. Patient E., 35 years old, was treated during 3 days concerning a thecal whitlow of the fifth finger of the left hand. On given time of the complaint for a pain in a hand, infringements of a flexion of the Ist and Vth fingers. Objectively: expressed edema and morbidity in the field of the Ist and Vth fingers, rise in temperature up to 38°C. What complication was developed in the patient?

  2. Patient K., 18 years old, has addressed in surgical department with complaints to a throbbing pain in the field of the thumb of the right hand. From an anamnesis it is known, that 2 days later has received insignificant wound in time of nails paring. Objectively: nails platen is swollen in lateral side, hyperemia is observed. From under it is allocated insignificant quantity of white pus.

Diagnose. Your tactics.

II.Answers to the Self-Assessment:

    1. D;

    2. D;

    3. D;

    4. B;

    5. U-like phlegmon of the left hand.

    6. Diagnosis: paronychia of the thumb of the right hand. Tactics: to raise with the help of a scalpel the nail platen for pus discharge.


Essential reading:

  1. Gostishchev V.K. General surgery /The manual. – M.: GEOTAR-MED, 2003. – 220p.

  2. Lectures prof. B.I. Dmitriev from Odessa State Medical University.

  3. Surgery: Text-book for English medium medical students / S.I. Shevchenko, O.A. Tonkoglas, I.M. Lodyana, R.S. Shevchenko. – Kharkiv: KSMU, 2001. – 344p.

  4. Kushnir R. Ya. General surgery /Lectures.- Ternopil, Ukrmedknyha, 2005.- 308 p.

  5. Butyrsky A. General surgery /The manual.- Simpheropol: publishers CGMU, 2004.- 478 p.

Further reading:

  1. Oxford handbook of clinical surgery / Edited by G.R. Mc Latchie, D.J. Leaper, 2002.- 930 p.

IV.Students’ Practical Activities:

    • Work 1. To distinguish the basic clinical attributes of acute purulent diseases of fingers and hands;

    • Work 2. To leaddiagnostics of an acute purulent pathology of fingers and hands on its kind and localization;

    • Work 3. To prove the plan of individual treatment (conservative and surgical);

V.Seminar Discussion Of Theoretical Questions And Practical Work:

VI.The initial level of knowledge and skills is checked by the decision of situational problems (tasks) from each theme, answers to tests such as "Step", constructive questions etc.

Students must know:

    • Definition, classification of a panaritium, a phlegmon of hand;

    • A clinical picture of a panaritium, a phlegmon of a hand;

    • Diagnostics and treatment of a panaritium, a phlegmon of a hand.

    • An etiology, a pathogeny acute hematogenous osteomyelitis;

    • Diagnostics and medical tactics of purulent diseases of bones;

    • Kinds of operative treatment;-

    • Chronic forms of osteomyelitis, their treatments;

    • An etiology, a pathogenesis, methods of diagnostics, the basic clinical attributes of a tetanus, antrax, diphtherias of wounds;

    • Methods of specific prophylaxis and treatment of an acute specific surgical infection.

Students should be able to:

    • to collect an anamnesis;

    • to lead objective inspection of the patient;

    • to distinguish the basic clinical attributes of purulent diseases of fingers and hands;

    • to lead diagnostics of an acute purulent pathology of fingers and hands on their kind and localization;

    • to prove the plan of individual treatment (conservative and surgical);

    • to give the reference on an aftertreatment of patients.


Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

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