Summary: Why is it necessary to know the history of your Fatherland. Dependence of society on nature. surgical pathology of the abdominal organs
Since the appearance of society on Earth, three kinds of processes have taken place: properly natural, specifically social, and mixed.
As society develops, its direct dependence on nature decreases, and indirect - the geographical environment intensifies, which has an important impact on the development of society. Human history is a clear example of how environmental conditions and the outlines of the planet's surface contributed to or, on the contrary, hindered the development of mankind.
A qualitatively different natural environment of his life is the sphere of all living things - the biosphere, which includes the upper part of the earth's crust inhabited by organisms, the waters of rivers, lakes, seas and oceans, as well as the lower part of the atmosphere. Its structure and energy-information processes are determined by the past and present activities of living organisms. It is under the influence of cosmic as well as deep underground influences: it is a giant natural biophysical and biochemical laboratory for the conversion of solar energy through the green cover of the planet. As a result of a long evolution, the biosphere has developed as a dynamic, internally differentiated equilibrium system. But it does not remain unchanged, but, being self-organizing, it develops along with the evolution of the Universe and all living things. The history of life on our planet shows that deep transformations have already taken place more than once and a qualitative restructuring of the biosphere has led to the disappearance of various species of animals and plants and the emergence of new ones. The evolutionary process of the biosphere is irreversible.
The concept of "noosphere" was introduced by Vernadsky, the creator of anthropocosmism, representing in unity the natural (cosmic) and human (social-humanitarian) sides of objective reality, studied the problem of the transition of the biosphere into the noosphere. In the past, man's use of the forces of nature and its resources was predominantly spontaneous: he took from nature as much as his own productive forces allowed. But the scientific and technological revolution confronted man with a new problem - with the problem of limited natural resources Global problems of our time. the problem of ecology - the preservation of peace - the exploration of outer space and the oceans - the food problem - the problem of population - the problem of overcoming backwardness - the problem of raw materials.
Features of global problems.
1) They have a planetary, global character and affect the interests of all peoples of the world.
2) They threaten the degradation and death of all mankind.
3) They need urgent and effective solutions.
4) They require collective efforts of all states, joint actions of peoples.
In general, global problems are a complex system that includes three main groups of interrelated problems. The first group is intersocial problems expressing contradictions between countries and groups of countries. The first of the intersocial problems and the most important of all global problems at this stage is the problem of maintaining peace between the leading powers and preventing thermonuclear war. No matter how serious dangers for mankind may be accompanied by all other global problems (environmental, demographic, raw materials, etc.), they are even in the aggregate incomparable with the disastrous consequences of a world thermonuclear war. It can lead not only to the direct death of many hundreds of millions of people, but also to an irreversible ecological catastrophe. According to experts, even 5% of the currently available nuclear weapons (if used) will be enough to cause irreversible environmental consequences: the soot that has risen from incinerated cities and forests will create a screen impenetrable to sunlight and lead to a drop in average temperature by tens of degrees. , so that even in the tropical zone there will come a long polar night. As a result, not only all of humanity will perish from such a “nuclear winter”, but, apparently, all biological species, with the exception of the simplest ones.
The second of the intersocial problems is overcoming the gap in the level of economic and cultural development between the developed countries of the West and the developing countries of Asia, Africa and Latin America, eliminating hunger, poverty and illiteracy of millions of people in the latter. More than 75% of the world's population lives in underdeveloped countries, and this vast region is a constant source of social explosions, environmental disasters and epidemics. The particular danger posed by these countries lies in terrorism and the possibility of their use of nuclear weapons.
The second group of global problems is problems in the "man-society" system. These include health and demographic issues. Despite the general improvement in living conditions and the development of medicine, the number of diseases such as alcoholism, drug addiction, malignant tumors, hypertension, AIDS, which threaten to undermine the working capacity of society, is growing on the planet. In developing countries, millions of people do not have medical care, and epidemics often occur. Due to the spread of chemical and radioactive mutagens in the environment, the genetic burden of the human population is growing.
A serious problem on the planet is the "population explosion". At the beginning of our era, the number of mankind was about 200 million people, in 1850 - 1 billion, in 1930 - 2 billion, in 1960 - 3 billion, in 1987 - 5 billion, in 1999 - 6 billion people. With modern technologies and agricultural techniques, the Earth will allow to support about 6 billion people at the average American food consumption standards. But population growth continues. The severity of the situation lies in the fact that over 80% of population growth falls on developing countries, as a result of which their share in the world population is steadily growing due to the increase in the gap in population growth in developing countries and the growth in the production of material goods is exacerbated by instability in the global economy and politics. In these countries, over 90% of the world's number of hungry, illiterate, underemployed.
Not demographically prosperous and developed countries. There is a decrease in the birth rate, an aging of the population, the proportion of pensioners in the total population and, accordingly, an increase in the cost of their maintenance. Therefore, the demographic policy in developing countries is aimed at reducing the birth rate, and in developed countries - at its increase. In our country, against the background of ongoing cataclysms, mortality exceeds the birth rate, and the population of Russia is decreasing.
The third group of global problems is problems in the "society - nature" system. These include environmental, raw material, energy and food problems. About the first of them, which, apparently, in its severity after the military problem, is in second place among all global problems. Here we note that in the foreseeable future, humanity will exhaust traditional raw materials and energy sources (coal, oil, gas, uranium, etc.). Intensive technologies deplete soil fertility. Due to population growth, the average area under grain crops per person has decreased over the past 30 years by one third. Since 1984, world grain production (which is used not only for human food, but also serves as feed for beef and dairy cattle) has increased annually by only 1% - 2 times slower than population growth. Therefore, the number of hungry people on the planet is not decreasing, but increasing.
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Sentences with "decreases"
We found 50 sentences with the word "decreases". See also synonyms for "decreases".
Meaning of the word
- This means that the meager tonnage that the Black Sea Fleet possesses is continuously decreases.
- Well, maybe someone remembers, only from year to year the number of such grateful citizens sharply decreases, steadily tending to zero.
- The risk of getting cancer in any form decreases if you increase your intake of fruits and vegetables.
- This had to be taken into account when calculating the draft ages (the number of mobilized as a result of this decreases).
- The success of imitation depends on the vigilance of the first enemy you meet and decreases proportional to the distance from the center.
- I thought that over the years this collection would stop: decreases the number of valences for friendship, for love.
- Familiarity with the situation is growing, but our uncertainty does not decreases, but, on the contrary, increases.
- Risk of death with age decreases.
- But with the denial of the ontological status of reality and the being of others decreases own ontological security.
- The free volume of the station gradually decreases, since trucks bring more equipment than astronauts throw away with waste.
- Having already crossed the vertical, I looked at the speed indicator and saw that it was quickly decreases.
- Accordingly, Army Group A, advancing on the Caucasus, decreases from 60 to 29 divisions.
- Very often the impression of the film is enhanced or decreases who you are next to while watching.
- From here the depth gradually decreases and in the upper or eastern mouth it reaches only a foot and a half, and sometimes there is no water at all.
- The general composition of the members of the foreign delegation slowly but gradually decreases.
- When the submarine is about to sink, its buoyancy decreases by blowing the cylinders to a certain level.
- As decreases the number of kilometers to the target, something comes to consciousness more and more clearly.
- True, their number is gradually decreases.
- Since with height the pressure decreases The air we breathe no longer contains enough oxygen.
- Over time, the significance of his figure not only decreases, but also, as it sometimes seems, on the contrary, increases.
- Time is running, just about it will be necessary to look at the next batch of information, a stack of documents decreases, and at the door Martov and Nikitenko.
- A great visionary, he believed that the amount of the vital fluid known as "will power" decreases with every desire.
- Urban population decreases and soon should not exceed a million people at all.
- The doctor treated this area in some way and was glad that gradually it decreases.
- Greg watched with satisfaction as decreases the number of uncrossed lines.
- Therefore, if decreases food intake, then even more decreases consumption of other products.
- The water in the ponds is decreases also from a watering place in them a herd of horses, cattle and sheep.
- Terrestrial magnetism decreases when approaching the poles.
- Suddenly, anti-aircraft fire significantly decreases and a bright light captured us.
- And the number of those wishing to set foot on the same dangerous path is something decreases with time.
- Unfortunately, it is impossible to determine instrumentally to what extent the pitching, due to the overflow of water in the tank, decreases.
- Your interest seems to decreases as mine grows.
- Sometimes he eats a lot, and sometimes he does not see food at all for two or three days, although his physical activity is by no means decreases.
- There are no reefs anywhere, and the depth to the shore decreases gradually.
- If the source is moving towards you, the wavelength decreases(frequency increases), so that its spectrum is shifted to a bluer part.
- interest in Stalin decreases, then increases, but there has not yet been a case that it disappeared completely.
- Kustov spoke with restraint about the results: “The level of chaos decreases with enough dynamics.
- The feeling of modesty of the participants in the war and military conflicts decreases as they move away from the front line.
- Number of atrocities decreases, although, unfortunately, they never completely disappear.
- When going on planing abruptly decreases movement resistance.
- Only one thing pleased us: we noticed that the thickness of the ice floes gradually decreases.
- In America, the glory of Horowitz is not decreases.
- Thereby decreases the risk of losing something from the property, as it is concentrated in one place.
- Some kind of weakness seized me, it was felt that the internal tension was gradually decreases.
- It happens that within five minutes a move from 10 knots decreases up to 1 knot and again rises to 10 knots.
- During the offensive, the active resistance of the enemy gradually decreases.
- Sometimes I could not stand it and roared sobbing because nothing came, and the uterus was still decreases and decreases by ultrasound results.
- Unfortunately, when I read newspapers now, I constantly see that decreases livestock, labor productivity declines.
- Almost simultaneously they reported from the stern: “Distance to the coast decreases».
- Usually the number of troops in stories about battles or decreases, or increases according to circumstances, and you can’t believe everything.
Source - introductory fragments of books from LitRes.
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with acute pathology of the abdominal organs
(Manual for students and teachers)
The order of investigation of patients with suspected
surgical pathology of the abdominal organs:
Complaints at the time of inspection;
Medical history;
Anamnesis of life.
2. Inspection.
3. Auscultation.
4. Percussion.
5. Palpation.
6. Additional research methods:
Laboratory;
R-logical;
Instrumental.
Interrogation (questioning) of the patient
First of all, it is necessary to establish contact with the patient, to gain confidence in him, to try to catch the peculiarities of the patient's character and intellect. It is necessary to question the patient methodically, in detail, clearly imagining a plan for questioning and further examination. Do not rush the patient, interrupting his story. If the patient answered your question inaccurately, repeat this question, changing its wording. When formulating your questions, take into account the patient's vocabulary, speak "his language", because the use of special medical terminology, professional jargon, may be incomprehensible to the patient.
You should not comment on the patient's story - it should be analyzed at the end of the examination.
When talking with the patient, it is necessary to observe maximum tact, goodwill, interest in the fate of the patient - only then does the contact necessary for the treatment of the patient arise.
First of all, we find out complaints patient at the time of examination.
In surgical diseases of the abdominal organs, the most common complaint is PAIN.
Assessing the pain syndrome, we must establish the following points:
1. Localization of pain (where does it hurt?).
2. Irradiation of pain (where does the pain spread, ''give away''?)
3. The nature of the pain (how does it hurt?)
4. Intensity of pain (strong, moderate, insignificant).
5. Persistence of pain.
6. What is the pain associated with (when and from what it arises, disappears, intensifies or decreases)
7. The duration of the pain syndrome.
8. Have there been similar painful episodes before, how were they resolved.
pain localization
Often, having heard the question “where does it hurt?”, The patient can answer: “in the stomach”, “in the liver”, etc. It is better for the paramedic to ask the patient to show the area of pain on the anterior abdominal wall.
It is very important to ask about the area of primary localization and the possible displacement of pain to another area.
radiation of pain
There are options for typical irradiation that allow you to immediately navigate the diagnosis (for example, “upper right” is typical for biliary tract pathology, irradiation to the back is for pancreatic diseases, etc.)
character of pain.
Often patients find it difficult to determine the nature of the pain, especially during the first pain episode. The paramedic can offer possible answers to the question: “How does it hurt?” - “Noet. Tunic. Cuts. Compresses…” (the list goes on). Sometimes the patient will give a completely unexpected answer as a result.
pain intensity.
Answers to the question "does it hurt a lot?" must be critically evaluated. In one case, the patient will indicate a strong, “dagger” pain, and in another case, the patient will say that it hurt a lot, but he slept at night.
The paramedic will have to make a conclusion about the intensity of pain himself.
pain persistence.
The pain can be constant, with periodic intensification, or paroxysmal, disappearing without an attack. There are constant pains associated with inflammation, a growing tumor.
Paroxysmal pain indicates the spastic nature of the disease or a connection with some periodically occurring processes in the body (for example, intestinal motility, stomach, ureters).
what causes the occurrence, increase or disappearance of pain.
The connection of the pain syndrome with intestinal peristalsis, the coincidence of the maximum of pain with the maximum of peristalsis, first of all, indicates the possibility of intestinal obstruction.
Increasing pain in a certain position of the patient often indicates a diagnosis. For example, increased pain in the right iliac region when lying on the left side indicates acute appendicitis. Increasing pain in the supine position and reducing it in the sitting position indicate an intraperitoneal rupture of the bladder or intraperitoneal bleeding. "Hungry" pain or pain after eating occurs with peptic ulcer, and a rapid decrease in the intensity of pain during an exacerbation of peptic ulcer or even the disappearance of pain may be a manifestation of gastroduodenal ulcer bleeding that has begun.
7. The duration of this pain episode and its comparison with the previous ones are more important when collecting an anamnesis of the disease.
The second most common after pain syndrome in diseases of the abdominal cavity is - dyspeptic syndrome.
The dyspeptic syndrome includes:
Nausea;
Belching;
Disorders of gas separation;
Disorders of defecation;
We specify:
Persistence of heartburn;
Belching - what?;
Nausea-constancy, connection with food intake, head position, from which it passes.
Very rich information can be obtained to establish the diagnosis from clarifying the nature of vomiting.
What interests us?
1. frequency of vomiting.
In surgical diseases, there are a variety of options: from 1-2 times vomiting in acute appendicitis to repeated vomiting in acute cholecystitis, acute pancreatitis, intestinal obstruction.
2. The nature of the vomit , their number.
Sometimes the diagnosis can be suspected by examining the vomit. For example, coffee grounds-colored vomiting suggests bleeding from the upper gastrointestinal tract (gastroduodenal bleeding); vomiting with an admixture of bile indicates a pathology of the biliary tract, vomiting with a putrid odor indicates a violation of the passage of food through the intestines. Abundant vomiting of a "fountain" with an admixture of food eaten the day before makes one think of a violation of the patency of the outlet section of the stomach, i.e. about some kind of stenosis (ulcerative, cicatricial, tumor).
3. Does vomiting provide relief??
In some diseases, for example, with stenosis of the outlet section of the stomach, in the early stages of intestinal obstruction, after vomiting, there is such a clear relief that the patients themselves induce vomiting. Vomiting with a perforated ulcer, rupture of hollow organs increases pain and causes a deterioration in well-being.
In acute appendicitis, cholecystitis, pancreatitis, vomiting does not cause relief.
When questioning the patient, be sure to pay attention to bowel movement process , i.e. gas and defecation. A feeling of bloating, fullness indicates either flatulence due to increased gas formation, or intestinal paresis and non-exhaustion of gases.
An important symptom of dyspeptic syndrome is defecation disorder . Therefore, by collecting an anamnesis, we find out the following:
1. Was there a chair? (If there is no stool, then we find out when there was a previous bowel movement).
2. If there was a chair, how many times since the onset of the disease?
3. The nature of the feces, the presence of pathological impurities in the feces.
Lack of defecation, non-excretion of gases indicate a violation of the passage of food through the intestines, i.e., intestinal obstruction. At the same time, frequent loose stools are possible in surgical diseases (some forms of appendicitis, cholecystitis).
Pathological impurities in the feces often help to navigate the diagnoses:
Discolored "clay" feces - obstructive jaundice;
Black "tarry" feces - gastroduodenal bleeding
Bright pink stool - "raspberry jelly" - intussusception
In acute surgical diseases of the abdominal cavity often occurs dysuric syndrome . Questioning the patient, it is necessary to identify the following:
1. Did the patient urinate?
2. Is there a change in the frequency of urination? (May be both increased and decreased urination).
3. How much urine? (possible: polyuria, oliguria, anuria).
4. Has the quality of urine changed? (color, transparency, presence of sediment, stones, flakes, smell).
Finding out the patient's complaints, it is necessary to find out whether the patient has intoxication syndrome (deterioration of well-being, decrease in general vitality, sleep and appetite disorders, increased t °, chills, sweating, headaches and muscle pains, hallucinations, delirium, etc.)
Finding out the medical history it is necessary to find out in detail the development of this disease, its course, treatment and the effect of the measures taken.
Attention should be paid to family history, heredity, for example, metabolic disorders: diabetes, gallstone and urinary stone disease. Ask in detail about the presence and course of concomitant diseases.
We end the question by asking anamnesis of life . It is necessary to find out how the patient grew and developed. In women, find out a gynecological history (the course of the menstrual cycle, the number of pregnancies, their course, the number of births and abortions; past illnesses and operations, the course of the postoperative period are especially important). This may affect the development of such surgical diseases as adhesive disease with intestinal obstruction, postoperative hernia.
It is necessary to pay attention to the harmful effects of the environment (professional hazards, the nature of work, bad habits). When talking with a patient with a pathology of the abdominal organs, it is necessary to find out the diet, the nature of nutrition, the tendency to overeat, addiction to fatty, spicy, spicy foods, alcohol.
Completing the survey, you should ask about the dynamics of the patient's weight.
Physical examination methods
Features of the physical examination of a surgical patient with acute pathology of the abdominal organs are explained severity of pain syndrome in such patients. Therefore, it is more reasonable and humane to start the study with the most benign methods, gradually moving to coarser ones that increase the pain of the patient. It is more logical to use the following order of research:
1. General examination of the patient;
2. Examination of the oral cavity;
3. Inspection of the anterior abdominal wall;
4. Auscultation of the abdomen;
5. Percussion of the abdomen;
6. Palpation of the abdomen;
7. Additional research methods.
General examination of the patient.
First of all, we evaluate the position, consciousness and condition of the patient.
The position of the patient:
active;
Passive;
Forced.
Particular attention should be paid to the forced position of the patient / for example, the position on the right side is typical for acute appendicitis, on the back with the legs brought to the stomach - for a perforated ulcer, the knee-elbow position - for intestinal torsion, etc.
A passive position always indicates a serious condition of the patient.
Consciousness of the patient
The consciousness of the patient is assessed during the interview of the patient. We solve the following issues:
Is there consciousness?
Is the patient excited, does he have euphoria?
/This may be a manifestation of intoxication./
Is the patient retarded?
How does he get in touch?
How does he answer questions?
Is he oriented in himself and the environment, is criticism preserved?
The unconscious state of the patient indicates severe intoxication and a serious condition of the patient.
Patient status is evaluated taking into account the activity of vital organs / circulatory and respiratory systems /.
To do this, the paramedic must:
3. Look for signs of heart failure.
5. Assess the color of the skin and mucous membranes / oral cavity and conjunctiva of the lower eyelid \, skin moisture, turgor, the presence of hemorrhages, etc.
Pay special attention to the foci of purulent-inflammatory diseases, assess the condition of the lymph nodes.
Examination of the digestive organs always begins with the oral cavity
Language research
"Language is the mirror of digestion."
Assessing the language:
- dry or wet?
/ In acute pathology of the abdominal organs, the tongue is dry “like a brush” /.
- is there a flight?
/ In diseases of the digestive system - white or yellowish plaque; after vomiting of bile - bright yellow; after vomiting with gastroduodenal bleeding - brown-brown, almost black, dense /.
Assessing the oral mucosa:
Color, presence of sores, abrasions, rashes, bleeding.
Assess teeth and gums:
The number of healthy and carious teeth, the condition of the gums, their swelling, bleeding, color.
Assessing the floor of the mouth:
Soft palate, arches, posterior pharyngeal wall, tonsils.
Abdominal examination
Inspection of the anterior abdominal wall should be from the costal arches to the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis (upper and lower borders of the abdomen). The lateral border of the abdomen is a vertical line connecting the end of the 11th rib with the iliac crest (Lesgaft line). The Lesgaft line separates the abdomen from the lumbar region. The height of the abdominal cavity significantly exceeds the length of the anterior abdominal wall due to the domes of the diaphragm and subcostal subdiaphragmatic spaces and the pelvic cavity.
Areas of the abdomen (diagram)
Inspection anterior abdominal wall should be methodical and consistent.
We evaluate:
1. Belly shape(correct or incorrect).
In the presence of free fluid in the lateral parts of the abdomen - a "frog" stomach, with a twisting of the intestinal loops - an irregularly shaped stomach, etc.
2. Symmetry belly a (axis of symmetry - white line of the abdomen). The abdomen is asymmetric with muscle tension, with intestinal obstruction, with formations of the anterior abdominal wall and abdominal cavity.
3. We examine the typical places of the exit of the game g (linea alba, umbilical ring, Spigellian lines, inguinal-iliac regions and inguinal-femoral regions). To identify defects in the aponeurosis, we suggest that the patient, lying on his back, simultaneously raise his head and legs, without leaning on his hands. At this time, we palpate the linea alba, Spigelly's lines.
4. Evaluate participation of the anterior abdominal wall in the act of breathing(whether and whether all departments are equally actively involved in breathing). With severe muscle tension or severe intestinal paresis (peritonitis), the anterior abdominal wall does not participate in breathing. The lag of some sections in breathing indicates the presence of a pathological process in the corresponding sections of the abdominal cavity.
5. Decide swollen or not swollen abdomen. If in the position of the patient on the back the anterior abdominal wall is below the costal arch, the stomach is not swollen; at the level of the costal arch - moderately swollen; above the costal arch - significantly swollen.
6. Carefully examining the skin anterior abdominal wall.
Can be found:
Scars from previous surgeries;
Traces of traumatic injuries (hemorrhages, wounds);
Pigmentation of the skin from the use of heating pads;
Cyanotic "marble" rings in the umbilical region and in the lateral sections of the abdomen (with acute pancreatitis);
Asymmetry of the hypochondrium or iliac fossae (with muscle tension);
Visible peristaltic wave (with intestinal obstruction);
Expansion of the veins in the navel (such as the "head of a jellyfish");
With a thin abdominal wall, you can see the gallbladder or appendicular infiltrate in the form of a formation in the right hypochondrium or in the right iliac region.
Auscultation of the abdomen
On auscultation we decide:
1. Is there intestinal peristalsis? (increased peristalsis is manifested by rumbling, audible at a distance with the naked ear, for example, with intestinal obstruction). Listen to peristalsis with a stethoscope or phonendoscope. Best of all, at the Kümmel point (2 cm to the right and below the navel).
2. Define lower border of the stomach using auscultofriction.
3. Exploring splash noise.
It can be determined with intestinal obstruction (splashing noise in the intestines) or the stomach 3-4 hours after a meal (with stenosis of the gastric outlet).
4. With mechanical intestinal obstruction, it is possible with auscultation
detect noise "falling drop"(symptom of Sklyarov).
With intestinal paresis, including with peritonitis, intestinal peristalsis
not defined.
Percussion of the abdomen.
When starting percussion of the abdomen, it must be remembered that percussion of the abdomen over the pathological focus sharply increases pain in the abdomen; therefore, before percussion, you need to ask the patient to indicate the zone of maximum pain and start percussion outside the zone of pain.
1. When tapping the anterior abdominal wall (clockwise around the navel) according to Razdolsky, you can find zones of pain sensitivity:
The zone of maximum pain identified in this way allows you to navigate the diagnosis.
2. Tapping along the costal arches .
Soreness when tapping along the right costal arch is observed in acute cholecystitis (Ortner's symptom).
3. Definition of hepatic dullness .
Hepatic dullness disappears with a perforated ulcer, rupture of a hollow organ and severe intestinal paresis.
4 . Percussion reveals fluid in the free abdomen. To do this, we produce percussion from the white line to the lateral parts of the abdomen. Percussion dullness in the lateral sections indicates fluid in the free abdominal cavity (internal bleeding, peritonitis, perforated ulcer).
5. With intestinal obstruction, it can be detected with percussion Waal sign(high tympanitis adjacent to dullness).
Palpation of the abdomen
We produce first superficial palpation, then deep.
With superficial palpation, we can find:
1. Muscle tension :
Local (local, limited).
In the right hypochondrium (o. cholecystitis).
In the right iliac region (o. appendicitis).
In the projection area of the pancreas - transverse resistance (Kerte's symptom) - in acute pancreatitis.
2. Pathological formations(tumors, hernial protrusions).
When a tumor is detected, it is necessary to establish its mobility (displacement), connection with surrounding tissues and consistency.
When a hernial protrusion is detected, it is necessary to decide:
Does it fit into the abdominal cavity;
Are hernial gates determined;
Whether the symptom of a cough impulse is determined;
Soft or tense hernial protrusion, whether it is painful on palpation.
3. On superficial palpation, we determine zone of maximum pain.
With deep palpation (sliding deep methodical palpation according to Obraztsov and Strazhesko), pathological formations of the abdominal cavity (tumors, cysts), enlarged organs (for example, the gallbladder), swollen intestinal loops (with volvulus of the intestines), intussusceptions, appendicular infiltrates, etc. d.
In addition, deep palpation reveals symptom Shchetkin-Blumberg (the most convincing of the symptoms of peritoneal irritation) and symptoms characteristic of various diseases of the abdominal organs.
Additional research methods
1. Rectal examination:
a) measurement of rectal temperature;
b) digital examination - examination of the anus (possible pathological discharge, gaping of the anus and spontaneous outflow of intestinal contents with diffuse peritonitis);
c) detection of overhanging and soreness of the walls of the rectum (with peritonitis);
d) detection of pathological formations in the rectum and abdominal cavity.
2. Laboratory tests of blood, urine, bile, digestive juices.
3. R-logical examination of the abdominal cavity.
4. Instrumental research methods:
a) laparoscopy, ultrasound. FGS, colonoscopy, biopsy, computed tomography, etc.
Symptoms characteristic of various diseases of the abdominal organs.
Acute appendicitis
| The initial localization of pain in the epigastrium, above the navel; after some time (from several hours to a day), the pain will mingle in the right half of the abdomen, and then in the right iliac region. | S-m Kocher (anamnestic) | |
| Increased pain in the right iliac region in positions on the left side. | St. Sitkovsky | |
| Soreness on palpation of the caecum increases in the position of the patient on the left side. | St. Bartomier - Michelson. | |
| Pain, muscle tension and hyperesthesia of the skin in the right iliac region. | Triad Dieulafoy | |
| The patient is in the prone position; The paramedic presses the abdominal wall at the Kümmel point with a finger and, without removing it, offers to stand up. An increase in pain indicates appendicitis, a decrease indicates salpingo-oophoritis. | St. Zhendrinsky | |
| In patients in sitting positions, when raising the straightened right leg, pain occurs (or intensifies) in the right iliac region. | S-m Zatler | |
| Soreness with pressure at the cervical point of the right phrenic nerve. | St. Iliescu | |
| Increased pain in the right iliac region during rotation of the right thigh. | S. Coupe. | |
| The appearance or intensification of pain in the right iliac region when examining the external opening of the right inguinal canal with a finger. | S. Krymov. | |
| Tightening of the right testicle (or both), occurring spontaneously or on palpation of the anterior abdominal wall. | S-m Laroka | |
| The difference between axillary and rectal temperature is more than 1 degree. | St. Lenander | |
| Painful point on the border of the middle and outer third of the line connecting the right anterior iliac spine with the navel. | Mac Burney Point | |
| When percussion of the right iliac region with four fingers in a row, the usual tympanic sound is absent. | St. Murphy | |
| Soreness in the right iliac region during percussion according to Razdolsky. | St. Razdolsky | |
| With your left hand, press on the abdominal wall in the left iliac region (corresponding to the location of the descending part of the colon). Without taking away the pressing hand, with the right hand to make a short push through the anterior abdominal wall to the overlying segment of the colon. Appendicitis causes pain in the right iliac region. | St. Rovzinga |
perforated ulcer
| 1. | Sharp sudden pains in the abdomen that occur in the midst of complete well-being (“a stab in the stomach with a dagger”). | St. Dieulafoy |
| 2. | In the middle part of the abdomen, at the location of the rectus muscles, retracted transverse stripes are visible. | C-m Dzbanovsky-Chugaev |
| 3. | Shortening of the percussion sound in the right lateral canal and the right iliac region (due to the draining of the contents of the stomach into the right lateral canal). | St. Kerven |
| 4. | Sharply tense abdominal wall with simultaneous pulling of the testicles to the inguinal openings. | St. Trendelenburg |
| 5. | "The Cry of Douglas Space". | St. Cullenkampf |
| 6. | With perforation of a gastric ulcer into the retroperitoneal space, pain from the epigastrium radiates to the shoulder blades and lower back. | S-m Levin |
internal bleeding
Acute pancreatitis
| 1. | Peri-umbilical "marble" darkening of the skin - about. pancreatitis | s-m Cullen (Cullen) |
| 2. | Areas of limited "marble" cyanosis on the lateral surfaces of the abdomen. | s-m Gray-Turner |
| 3. | Transverse resistance (muscle tension) in the projection area of the pancreas. | s-m Körte |
| 4. | The appearance of ecchymosis around the navel (local toxic vascular damage). | s-m Grunwald |
| 5. | Petechiae on the buttocks. | s-m Davis |
| 6. | The disappearance of the pulsation of the abdominal aorta in the epigastrium. | s-m Resurrection |
| 7. | Facial cyanosis, Abdominal pain, signs of peritoneal irritation, decreased blood pressure. | Mondor's syndrome |
| 8. | Pain on palpation in the left costovertebral angle. | s-m Mayo-Robson |
Acute cholecystitis
Intestinal obstruction
One of the first and most difficult tasks of a paramedic is to make a diagnosis. Emergency care, paramedic tactics and, ultimately, the fate of the patient depend on this. Surgical diseases of the abdominal organs, leading to a catastrophe in the abdomen, are the most difficult to diagnose.
Knowledge of the procedure for examining a patient with suspicion
on the “acute abdomen”, the ability to use all the methods of physical examination, knowledge of individual symptoms of diseases, the ability to analyze, conduct differential diagnostics allows the paramedic to correctly navigate the diagnosis, the volume of emergency care and determine the correct tactics in relation to such complex patients, most often in need of emergency help.
Syndrome "Acute" abdomen
"ACUTE" ABDOMEN - a symptom complex that occurs in acute surgical pathology of the abdominal organs.
1. Abdominal cavity. Its boundaries:
Front and sides - the front and side walls of the abdomen;
Behind - the lumbar region;
Above - the diaphragm;
Below - a conditional plane that defines the cavities of the large and small pelvis.
2. Areas of the abdomen: select 9 anatomical areas:
Two vertical lines (through the pubic tubercles along the outer edge of the rectus abdominis muscles);
Two horizontal lines (through the lower points of the ribs of the arches (upper) and through the anterior upper axes of the iliac bones (lower)).
I. Epigastrium (right and left hypochondrium and epigastric proper).
II. Mesogastrium (right and left lateral + umbilical).
III. Hypogastrium (right and left iliac + pubic).
3. The abdominal cavity is a narrow labyrinth of spaces between its walls and organs located in it, as well as between individual organs.
Tightness of the abdominal cavity:
Men are sealed
In women, it is leaky, because. communicates with the external environment through the fallopian tubes, uterine cavity and vagina.
4. The peritoneum is a serous membrane covered with a flat epithelium, lining the walls of the abdominal cavity from the inside and covering the surface of the internal organs (perietal and visceral). The total surface of the peritoneum - 2 wk.m
5. Content. In the abdominal cavity, up to 20 ml of clear liquid is normal and single cells (torn off epithelium, macrophages, etc.)
6. Layers of the peritoneum:
a) mesothelium - a single-layer squamous epithelium, the cells of which are tightly pressed to each other;
b) border (basal) - a network of thin fibers and vitreous intermediate substance, the largest amount of which is concentrated on the border with the mesothelium (basement membrane);
c) fibrous - collagen and elastic fibers tightly adjacent to each other.
innervation:
a) the innervation of the parietal peritoneum is carried out by somatic nerves (branches of intercostal nerves), therefore, the parietal peritoneum is sensitive to any type of influence (mechanical, chemical, etc.), and the resulting somatic pains are clearly localized;
b) the visceral peritoneum has autonomic innervation (sympathetic and parasympathetic) and practically does not have somatic, therefore, visceral pains arising from its irritation are not localized;
c) the parietal peritoneum of the pelvis does not have somatic innervation, this explains the absence of protective tension in the muscles of the anterior abdominal wall during inflammatory processes in the small pelvis.
7. Hemolymph formation.
The blood and lymphatic vessels for most of the length of the peritoneum are located in the deep layers of the fibrous layer, with the exception of the lymphatic vessels of the diaphragm, which are directly adjacent to the mesothelium.
8. Floors of the abdominal cavity.
The mesentery of the transverse colon divides the abdominal cavity into two floors.
Right and left sides outside the canal.
The peritoneum is a semi-permeable, actively functioning membrane that performs a number of functions:
1. Resorptive - within an hour, the peritoneum can absorb an amount of fluid equal to 8% of body weight.
2. Exudative - the ability to secrete fluids and fibrin.
3. Barrier function:
a) mechanical
b) protection against infection using humoral (complement, free antibodies) and cellular (macrophages, granulocytes) mechanisms.
Peritonitis
Peritonitis - inflammation of the peritoneum, accompanied by local and general symptoms
Frequency:
Primary - 1%.
Secondary - complications of acute surgical diseases and injuries of the abdominal organs.
Mortality in severe forms of peritonitis is 25-30%, with the development of multiple organ failure - 85-90%.
Surgeons returned to the positions that were formulated by S.I. Spasokukotsky back in 1926:
“With peritonitis, surgery in the first hours gives 90% of recovery, on the first day - 50%, after the third day - 10%.”
Etiology:
1. Bacterial peritonitis.
2. Aseptic (abacterial, toxic-chemical) peritonitis (exposure to aggressive agents, aseptic necrosis of internal organs).
Pathogenesis
Started as a local process, peritonitis quickly turns into a life-threatening disease of the whole organism, leading to intoxication, hypoxia, profound metabolic disorders, immune defense and multiple organ failure.
I. The rate of development of the clinical picture of peritonitis is determined by the following points:
a) insufficient protection mechanisms;
b) high virulence of the infection;
c) volume and rate of contamination of the abdominal cavity;
d) inadequate treatment.
II. Violation of hemodynamics - proceeds in phase, characterized by a successive change of hyper- and hypodynamic syndromes:
a) cardiovascular syndrome is formed from three simultaneously occurring processes:
Decreased contractile function of the myocardium;
Violation of vascular tone with a progressive decrease in CVP;
BCC change.
b) violation of microcirculation:
1. In the early stages - vasoconstriction, increased permeability of the vascular wall for protein and water, development of procapillary edema. This disrupts the supply of oxygen to tissues and the removal of metabolites from them.
2. As the process progresses, precapillaries and venules expand, blood flow slows down in them, and arterial blood is discharged into the venous system through arteriovenular shunts. The rate of blood flow in the tissues slows down, aggregates of formed elements form in the lumen of small vessels, stasis and hemolysis of erythrocytes are noted.
3. Violation of metabolic processes leads to the development of tissue hypoxia, acidosis, increased blood clotting, the occurrence of DCC - a syndrome with consumption coagulopathy.
III. Gastrointestinal dysmotility:
a) intestinal atony, which occurs at the very beginning of the development of peritonitis as a protective reaction to the inflammatory focus in the abdominal cavity, can delimit the inflammatory process;
b) under the influence of the action of toxins on the neuromuscular apparatus of the intestine, circulatory disorders in its wall, metabolic disorders in the muscle fibers and nerve cells of the intestine, persistent paresis of the gastrointestinal tract occurs (paralytic ileus);
c) increasing ischemia in the intestinal wall makes it permeable to microorganisms.
4. Violation of the body's immune defenses
As peritonitis progresses, immunosuppression develops.
5. Hypovolemia.
Losses of blood and plasma range from 20% to 50% of the BCC. The increase in hypovolemia is provided by:
Exudation and trasudation into the lumen of the gastrointestinal tract, into the free abdominal cavity of the tissue of the whole organism;
Loss of fluid during vomiting, breathing, evaporation from the skin.
Hypovolemia is accompanied by significant disorders of hemodynamics, water-electronic balance and acid-base balance.
6. Syndrome of polyhedral insufficiency
Hypoxia causes cascade damage to the function of the lungs, liver, kidneys, intestines, heart, brain. In these organs, there is a decrease in intraorganic blood flow, an increase in intravascular resistance, and the development of dystrophic and necrobiotic processes.
PATANATOMY
The inflammatory process on the peritoneum is already noticeable in the early stages:
1. Hyperemia.
2. Reduced gloss (dull peritoneum).
3. Fibrin deposits
4. Liquid exudate
5. Edema and infiltration of omentums, mesentery, intestinal walls
CLASSIFICATION
By clinical course:
· spicy;
chronic.
By the nature of the exudate:
· serous;
fibrinous;
purulent;
hemorrhagic;
putrefactive.
By prevalence:
Delimited (abscess, infiltrate);
Diffuse (local, widespread, general);
By phase of development:
reactive (the first 24 hours) - the phase of the body's hyperergic reaction to an extreme peritoneal stimulus;
toxic (24-72 hours) - the phase of increasing intoxication. Equivalent to the concept of "endotoxic shock".
· terminal (over 72 hours) - a phase of deep disturbances of metabolic processes and vital functions of the body. Equivalent to the concept of "septic shock".
DIFFERENTIAL DIAGNOSIS
It is carried out mainly in the reactive phase (the duration of the disease is short, there are many common symptoms).
1. Pseudo-dominal syndrome can occur in more than 70 diseases:
a) diseases of the lungs and pleura (pneumonia, pleurisy, damage to the lungs and pleura, hemo- and pneumothoraxes);
b) sepsis disease (angina pectoris, myocardial infarction, atherosclerosis, myocarditis, etc.);
c) dissection of an aneurysm of the abdominal aorta;
d) chronic ischemia of the digestive organs;
e) rheumatic peritonitis;
f) in case of heart failure, abdominal pain associated with congestive liver is stopped by diuretics and cardiac drugs;
g) diseases and damage to the nervous system;
h) decompensation of diabetes mellitus;
i) severe thyrotoxicosis;
j) infectious diseases:
· food toxicoinfections;
Viral hepatitis
Influenza, scarlet fever;
· dysentery;
· typhoid fever;
k) diseases of the genitourinary organs:
· renal colic;
pyelitis.
l) diseases and injuries of the anterior abdominal wall.
A special form of peritonitis
Gonococcal peritonitis is usually seen in young women. Approximately 15% of patients with gonorrhea develop pelvioperitonitis.
Pathogens enter the abdominal cavity through the vagina, uterine cavity, fallopian tubes. Identical lesions cause chlamydia.
Clinic
Intense pain in the lower abdomen, tenesmus, loose stools, fever. The abdomen is moderately swollen in the lower sections, soft. Symptoms of peritoneal irritation are sharp (+), the tongue is wet.
Diagnosis
With a digital examination of the rectum or vagina - signs of inflammation of the pelvic peritoneum. Purulent discharge from the vagina. Symptom Lenander (+).