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KURSK STATE MEDICAL UNIVERSITY

General Surgery Department

EDUCATION MANUAL
ON THE COURSE OF «GENERAL SURGERY»
FOR INTERNATIONAL FACULTY STUDENTS

Kursk - 2015
УДК: 617=111 (075.8) Печатается по решению
ББК: 54.5 я73 редакционно-издательского
М 54 совета ГБОУ ВПО КГМУ
Минздрава России

Education manual on the course of “General Surgery” for foreign faculty


students // under edition of Professor B.S. Sukovatykh. – Kursk: KSMU, 2015. –
257 p.

Authors:
Professor Dr. B.S. Sukovatykh MD, PhD
Associate professor M.B. Sukovatykh, MD
Professor Dr. Yu.Yu. Blinkov, MD
Assistant E.G. Andryuhina, MD
Assistant A.Yu. Orlova, MD
Assistant N.M. Valuyskaya, MD
Assistant O.V. Alymenko, MD

The offered manual covers the questions of self-preparation for classes in


the General Surgery course and includes three main units: the general questions
of surgery (asepsis, antisepsis, bleeding and hemostasis, principles of blood
transfusion, critical and terminal states, pain and anesthesia); the basics of the
clinical surgery (suppurative, vascular, oncologist diseases, mechanical and
thermal injuries); the stages of the surgical treatment (first medical aid,
ambulatory and hospital surgery). Each topic is added with necessary tests for
the self-control and basic clinical situations in the form of clinical tasks
including questions and answers.

ISBN: 5-7487-0588-0 ББК: 54,5 я73

© Collective of authors KSMU 2015

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КУРСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ

КАФЕДРА ОБЩЕЙ ХИРУРГИИ

УЧЕБНОЕ ПОСОБИЕ ПО КУРСУ


«ОБЩАЯ ХИРУРГИЯ»
ДЛЯ СТУДЕНТОВ МЕЖДУНАРОДНОГО ФАКУЛЬТЕТА

Курск 2015

3
УДК: 617=111 (075.8) Печатается по решению
ББК: 54,5 я73 редакционно-издательского
М 54 совета ГБОУ ВПО КГМУ
Минздрава России

Учебное пособие по курсу «Общая хирургия» для студентов


международного факультета // Под редакцией профессора Б.С. Суковатых.
– Курск: КГМУ, 2015. – 257 с.

Авторы:
профессор, д.м.н. Б.С. Суковатых
доцент, к.м.н. М.Б. Суковатых
профессор, д.м.н. Ю.Ю. Блинков
ассистент, к.м.н. Е.Г. Андрюхина
ассистент, к.м.н. А.Ю. Орлова
ассистент, к.м.н. Н.М. Валуйская.
ассистент, к.м.н. О.В. Алименко

В предлагаемом учебном пособии освещены вопросы подготовки к


занятиям по общей хирургии по трем основным разделам: общие вопросы
хирургии (асептика, антисептика, кровотечение и гемостаз, принципы
переливания крови и кровезаменителей, критические и терминальные
состояния, боль и обезболивание); основы клинической хирургии
(гнойных, сосудистых, онкологических заболеваний, механических и
термических повреждений); этапы лечения хирургического больного
(первая медицинская помощь, амбулаторная и стационарная хирургия). К
каждой теме предлагаются тесты для самоконтроля, а также основные
клинические ситуации в форме практических задач, включающих вопросы
и ответы.

ISBN: 5-7487-0588-0 ББК: 54,5 я73

©Коллектив авторов КГМУ 2015.

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CONTENT
For topic option, press and hold a «Сtr» button, followed by a mouse click

TOPIC 1 INTRODUCTION INTO SURGERY. HISTORICAL ASPECTS


OF SURGERY ...............................................................................................................9
Tests ..................................................................................................................................... 10
Clinical tasks ....................................................................................................................... 12
TOPIC 2 DESMURGY ...............................................................................................14
Tests ..................................................................................................................................... 15
Clinical tasks ....................................................................................................................... 17
TOPIC 3 DESMURGY. TEMPORARY STABILIZATION .................................19
Tests ..................................................................................................................................... 20
Clinical tasks ....................................................................................................................... 22
TOPIC 4 NON-OPERATIVE SURGICAL TECHNIQUES ..................................24
Tests ..................................................................................................................................... 26
Clinical tasks ....................................................................................................................... 27
TOPIC 5 ASEPSIS ......................................................................................................29
Tests ..................................................................................................................................... 31
Clinical tasks ....................................................................................................................... 32
TOPIC 6 ANTISEPSIS ...............................................................................................34
Tests ..................................................................................................................................... 35
Clinical tasks ....................................................................................................................... 37
TOPIC 7 FLUID-ELECTROLYTE AND ACID-BASE DISORDERS IN
SURGICAL PATIENTS AND PRINCIPLES OF INFUSION THERAPY ..........39
Tests ..................................................................................................................................... 40
Clinical tasks ....................................................................................................................... 42
TOPIC 8 BLEEDING AND HEMOSTASIS ............................................................44
Tests ..................................................................................................................................... 46
Clinical tasks ....................................................................................................................... 47
TOPIC 9 TRANSFUSION THERAPY .....................................................................50
Tests ..................................................................................................................................... 51
Clinical tasks ....................................................................................................................... 53
TOPIC 10 HEMOSTATIC DISTURBANCES IN SURGICAL PATIENTS .......55
Tests ..................................................................................................................................... 56
Clinical tasks ....................................................................................................................... 58
TOPIC 11 TERMINAL CONDITIONS. PRINCIPLES OF
RESUSCITATION. SHOCK .....................................................................................60
Tests ..................................................................................................................................... 61
Clinical tasks ....................................................................................................................... 63
TOPIC 12 CRITICAL CONDITIONS IN SURGICAL PATIENТS ....................65
Tests ..................................................................................................................................... 66
Clinical tasks ....................................................................................................................... 68
TOPIC 13 ENDOGENOUS INTOXICATION SYNDROME. MODS .................71
Tests ..................................................................................................................................... 72
Clinical tasks ....................................................................................................................... 74
TOPIC 14 PAIN AND ANESTHESIA ......................................................................76
Tests ..................................................................................................................................... 78
Clinical tasks ....................................................................................................................... 79
TOPIC 15 WOUNDS AND WOUND HEALING....................................................81

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Tests ..................................................................................................................................... 83
Clinical tasks....................................................................................................................... 85
TOPIC 16 GENERAL ASPECTS OF SURGICAL INFECTION.
PURULENT DISEAESES OF THE SKIN, SUBCUTANEOUS TISSUES
AND GLANDULAR ORGANS ................................................................................ 87
Tests ..................................................................................................................................... 89
Clinical tasks....................................................................................................................... 90
TOPIC 17 PURULENT DISEASES OF HAND AND FOOT ............................... 93
Tests ..................................................................................................................................... 95
Clinical tasks....................................................................................................................... 97
TOPIC 18 SPECIFIC SURGICAL INFECTION. TUBERCULOSIS OF
BONES AND JOINTS. ACTINOMYCOSIS. ANTHRAX .................................... 99
Tests ................................................................................................................................... 100
Clinical tasks..................................................................................................................... 102
THE LIST OF PRACTICAL SKILLS QUESTIONS .......................................... 104
5TH SEMESTER GENERAL SURGERY .............................................................. 104
Desmurgy ........................................................................................................................... 104
Hemostasis ......................................................................................................................... 104
Miscellaneous .................................................................................................................... 105
Interviewing skills ............................................................................................................. 105
TOPIC 19 PURULENT DISEASES OF CELLULAR SPACES......................... 107
Tests ................................................................................................................................... 109
Clinical tasks..................................................................................................................... 110
TOPIC 20 PURULENT DISEASES OF BONES AND JOINTS ........................ 113
Tests ................................................................................................................................... 115
Clinical tasks..................................................................................................................... 117
TOPIC 21 ANAEROBIC SURGICAL INFECTIONS......................................... 119
Tests ................................................................................................................................... 121
Clinical tasks..................................................................................................................... 123
TOPIC 22 PURULENT DISEASES OF SEROUS CAVITIES ........................... 125
Tests ................................................................................................................................... 127
Clinical tasks..................................................................................................................... 129
TOPIC 23 SURGICAL SEPSIS AND SEPSIS SYNDROME ............................. 131
Tests ................................................................................................................................... 133
Clinical tasks..................................................................................................................... 134
TOPIC 24 SURGICAL PATIENT EXAMINATION .......................................... 137
Tests ................................................................................................................................... 138
Clinical tasks..................................................................................................................... 140
TOPIC 25 ARTERIAL DISORDERS .................................................................... 142
Tests ................................................................................................................................... 143
Clinical tasks..................................................................................................................... 145
TOPIC 26 VENOUS AND LYMPHATIC DISORDERS .................................... 147
Tests ................................................................................................................................... 149
Clinical tasks..................................................................................................................... 150
TOPIC 27 THERMAL INJURIES ......................................................................... 153
Tests ................................................................................................................................... 155
Clinical tasks..................................................................................................................... 156
TOPIC 28 GENERAL TRAUMA .......................................................................... 158
Tests ................................................................................................................................... 160

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Clinical tasks ..................................................................................................................... 162
TOPIC 29 TRAUMA OF THE HEAD, CHEST, AND ABDOMINAL
ORGANS ....................................................................................................................164
Tests ................................................................................................................................... 167
Clinical tasks ..................................................................................................................... 169
TOPIC 30 BASIC PRINCIPLES OF SURGICAL ONCOLOGY .......................171
Tests ................................................................................................................................... 173
Clinical tasks ..................................................................................................................... 175
TOPIC 31 BASIC PRINCIPLES OF PLASTIC SURGERY AND
TRANSPLANTATION.............................................................................................177
Tests ................................................................................................................................... 178
Clinical tasks ..................................................................................................................... 180
TOPIC 32 BASIC PRINCIPLES OF SURGICAL MALFORMATIONS ..........182
Tests ................................................................................................................................... 183
Clinical tasks ..................................................................................................................... 185
TOPIC 33 BASIC PRINCIPLES OF PARASITIC INFECTION SURGERY ..187
Tests ................................................................................................................................... 188
Clinical tasks ..................................................................................................................... 190
TOPIC 34 OUT-PATIENT SURGERY. PREOPERATIVE PERIOD.
SURGICAL OPERATION ......................................................................................192
Tests ................................................................................................................................... 196
Clinical tasks ..................................................................................................................... 198
TOPIC 35 POSTOPERATIVE PERIOD. NUTRITION OF SURGICAL
PATIENTS .................................................................................................................200
Tests ................................................................................................................................... 202
Clinical tasks ..................................................................................................................... 204
TOPIC 36 FINAL CLASS (EXAMINATION OF PRACTICAL SKILLS) .......206
THE LIST OF QUESTIONS OF PRACTICAL SKILLS ....................................207
6TH SEMESTER GENERAL SURGERY ...............................................................207
Desmurgy ........................................................................................................................... 207
First aid and transport stabilization .................................................................................. 208
Hemostasis ......................................................................................................................... 208
Miscellaneous .................................................................................................................... 209
Interviewing skills .............................................................................................................. 210
Test answers ...............................................................................................................211
TASK ANSWERS .....................................................................................................212
TOPIC 1 INTRODUCTION INTO SURGERY. HISTORICAL ASPECTS
OF SURGERY. ..........................................................................................................212
TOPIC 2 DESMURGY 1 ..........................................................................................212
TOPIC 3 DESMURGY 2. TEMPORARY STABILISATION .............................213
TOPIC 4 NON-OPERATIVE SURGICAL TECHNIQUES ................................214
TOPIC 5 ASEPSIS ....................................................................................................216
TOPIC 6 ANTISEPSIS .............................................................................................217
TOPIC 7 FLUID-ELECTROLYTE DISTURBANCES .......................................218
TOPIC 8 BLEEDING AND HEMOSTASIS ..........................................................219
TOPIC 9 TRANSFUSION THERAPY ...................................................................220
TOPIC 10 HEMOSTATIC DISTURBANCES IN SURGICAL PATIENTS .....221

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TOPIC 11 TERMINAL CONDITIONS. PRINCIPLES OF
RESUSCITATION. SHOCK .................................................................................. 223
TOPIC 12 CRITICAL CONDITIONS .................................................................. 224
TOPIC 13 ENDOGENOUS INTOXICATION SYNDROME............................. 225
TOPIC 14 PAIN AND ANESTHESIA ................................................................... 227
TOPIC 15 WOUND HEALING.............................................................................. 228
TOPIC 16 GENERAL ASPECTS OF SURGICAL INFECTION.
PURULENT DISEASES OF THE SKIN, SUBCUTANEOUS TISSUES,
AND GLANDULAR ORGANS .............................................................................. 230
TOPIC 17 PURULENT DISEASES OF HAND AND FOOT ............................. 232
TOPIC 18 SPECIFIC SURGICAL INFECTION. TUBERCULOSIS OF
BONES & JOINTS. ANTHRAX. ACTINOMYCOSIS. ...................................... 233
TOPIC 19 PURULENT DISEASES OF CELLULAR SPACES......................... 235
TOPIC 20 PURULENT DISEASES OF BONES AND JOINTS ........................ 236
TOPIC 21 CLOSTRIDIAL MYONECROSIS. TETANUS. NECROTIZING
FASCIITIS ................................................................................................................ 238
TOPIC 22 PURULENT DISEASES OF SEROUS CAVITIES ........................... 239
TOPIC 23 SURGICAL SEPSIS AND SEPSIS SYNDROME ............................. 241
TOPIC 24 SURGICAL PATIENT EXAMINATION .......................................... 243
TOPIC 25 ARTERIAL DISORDERS .................................................................... 244
TOPIC 26 VENOUS AND LYMPHATIC DISORDERS .................................... 245
TOPIC 27 THERMAL INJURIES ......................................................................... 246
TOPIC 28 GENERAL TRAUMA .......................................................................... 247
TOPIC 29 HEAD, CHEST, AND ABDOMINAL TRAUMA .............................. 248
TOPIC 30 BASIC PRINCIPLES OF SURGICAL ONCOLOGY ...................... 249
TOPIC 31 MALFORMATION SURGERY .......................................................... 250
TOPIC 32 PLASTIC SURGERY AND TRANSPLANTATION ........................ 251
TOPIC 33 PARASITIC INFECTION SURGERY ............................................... 252
TOPIC 34 OUT-PATIENT SURGERY. PREOPERATIVE PERIOD.
SURGICAL OPERATION...................................................................................... 254
TOPIC 35 POSTOPERATIVE PERIOD. NUTRITION OF SURGICAL
PATIENTS ................................................................................................................ 255

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TOPIC 1 INTRODUCTION INTO SURGERY. HISTORICAL ASPECTS
OF SURGERY

Following social and cultural competences of a student have to be formed after


preparation of the topic:
 Ability to carry out scientific analysis of basic socially important problems and
processes, political events and trends; understanding of driving forces and common regularity
of historical process.
 To be able to practice ethical issues of medical relationships in communication
with colleagues, auxiliary and junior medical personnel, people of different age groups,
patient‟s relatives and parents.

I. Motivation of the goal:


Before studying of the certain surgical diseases, it is necessary to comprehend the
historical pathway of surgery development, organization of surgery study of at a medical
university, people health care service, and to get acquainted with the ethical principles in
surgery (deontology). Knowledge of such aspects allows a doctor to avoid mistakes inthe
treatment of surgical patients, avoid malpractice and torts and create a healthier working
environment at the medical institution.

II. The goal of self-preparation:


To get acquainted with the basic periods of surgery development, organization of
surgery study, people health care service, and ethical principles in surgery (deontology).

III. Studying purposes.


Know:
 basic periods of surgery development;
 principles of people health care service;
 organization of surgery study at a medical university;
 ethical principles of surgery (deontology) ;
 common mistakes in treatment of surgical patients;
 basic degrees of an iatrogenic outcomes in surgery;
Be able to:
 properly converse with a patient taking into account the moral aspects of his/her
confession (Muslim, Christian etc) ;
 properly converse with patient's relatives taking into account principles of
confidential information in medicine.
Practice and demonstrate:
 Skills of communication with colleagues, auxiliary and junior medical personnel,
people of different age groups, patient‟s relatives and parents.

IV. The initial level of knowledge:


For successful mastering of the given topic, it is necessary to repeat achievements of
original and foreign scientists from the course "History of medicine» who had a paramount
impact on the development of surgery.

V. The plan for the topic studying.


1. Characteristic of basic periods of surgery development.
2. Principles of people health care service.
3. Organization of surgery study of at a medical university.
4. Modern scientific surgical schools.
5. Basic ethical principles of surgical service (deontology).

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6. Types of malpractice and torts in treatment of surgical patients.
7. Characteristic of degree of iatrogenic outcomes of surgery.

VI. The recommended literature:


Suggested readings:
1. Lecture materials
2. SURGERY. Basic science and clinical evidence. USA., 2000., Pp. 3-21.
Supplemental materials:
1. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991., Pp. 1-19.

VII. Questions for the self-control.


1. What most prominent surgeons of "beginning of surgery development of " do you
know?
2. When and where were the first surgical schools organized?
3. Whose medical works played the most prominent role in the second period of
surgery development?
4. Whose medical works played the most prominent role in the third period of
surgery development?
5. What surgical departments are presented at the medical university?
6. What sorts of surgical aid concerning depending on its urgency do you know?
7. What kinds of surgical aid concerning to its volume do you know?
8. What surgical wards are presented at the hospital?
9. What questions are studied by surgical deontology?
10. What ethical principles have to be taken into account while working at a surgical
hospital?
11. What is the meaning of the term "iatrogenic"?
12. Why do mistakes treating surgical patients happen?

VIII. Tasks for self-preparation:


1. Present the characteristic of the first period (until introduction of anesthesia and
antisepsis) of surgery development.
2. Present the characteristic of the second period (until introduction of antibiotics) of
surgery development.
3. Present the characteristic of the third period (last fifty years) of surgery
development.
4. Present the characteristic of the fourth period (recent years) of surgery
development.
5. Describe the kinds of surgical aid according to the term it should be provided to a
patient.
6. Describe the kinds of surgical aid according to the volume it should be provided to
a patient.
7. List the basic ethical principles in the work of a surgeon.
8. Describe the ethical principles of the work of auxiliary medical personnel.
9. Write classification of iatrogenic mistakes in surgery.
10. Present the characteristic of the different kinds of iatrogeny.

Tests

1. which ancient civilization was renowned for their great skill in plastic surgery (choose
right)
a) Greek

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b) Roman
c) Indian
d) European
e) China

2. who were most Greek medical works written by? (choose right)
a) Celsus
b) Vesalius
c) Galen
d) Hippocrates
e) Paracelsus

3. "De medicine» is the oldest important medical document which provides cumulative
knowledge of early Roman medicine and surgery. It was written by (choose right)
a) Celsus
b) Vesalius
c) Galen
d) Hippocrates
e) Paracelsus

4. the classical description of inflammation: redness and swelling, with heat and pain at
first was done by the following person (choose right)
a) Celsus
b) Vesalius
c) Galen
d) Hippocrates
e) Paracelsus

5. one of the most famous physicians of the Roman period in second century A. D. (129-
199) was the following (choose right)
a) Celsus
b) Vesalius
c) Galen
d) Hippocrates
e) Paracelsus

6. which name is closely related to introduction of general anesthesia (choose right)


a) Celsus
b) Vesalius
c) Kocher
d) Claude Bernard
e) William Morton

7. who was the germ theory of disease proposed by?(choose right)


a) Josef Lister
b) Bassini
c) Louis Pasteur
d) Claude Bernard
e) Kocher

8. the first antiseptic to be used with a particular aim to kill bacteria was the following one
(choose right)

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a) furacillin
b) carbolic acid
c) H2O2
d) chlorhexidine
e) boric acid

9. the discovery of X-rays by Roentgen dates from following years (choose right)
a) 1720
b) 1875
c) 1885
d) 1865
e) 1895

10. the point of maximal tenderness at acute appendicitis was named in honor of that
surgeon (choose right)
a) Mc Burney
b) Bassini
c) Josef Lister
d) William Halsted
e) Alexis Carrel

11. new method of blood vessels reconnection by means of end-to-end suture for which he
was awarded the Nobel Prize in 1912 was proposed by (choose right)
a) Josef Lister
b) Esmarch
c) Alexis Carrel
d) William Halsted
e) Guillaume Dupuytren

12. that surgeon at first was awarded with Nobel Prize in 1909 in honor of his
achievements in surgical treatment of goiter (choose right)
a) Josef Lister
b) Kocher
c) Bassini
d) William Halsted
e) Guillaume Dupuytren

Clinical tasks

Task № 1
Clinical scenario: A 34 year old male person was injured by a moving vehicle. A
doctor of a paramedic team has diagnosed an open fracture of the left calf.
Questions:
1. What type of the medical aid is given to the patient?
2. What does the medical aid consist of?
3. What medical institution the patient has to be transported to?
4. What type of surgical aid according to urgency is given to the patient?

Task № 2
Clinical scenario: A 45 year old male has been admitted into the reception ward of
the emergency hospital. He complains of a pain in the right inguinal area and vomiting. The
patient‟s condition is satisfactory. A primary diagnosis is an acute appendicitis.

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Questions:
1. What medical document is recorded in the reception ward?
2. What examination and treatment is fulfilled by a nurse assistant?
3. What ward will the patient be transported to further?
4. How is the patient transported into the ward?

Task № 3
Clinical scenario: A 45 year old male is transported into the reception ward of the
emergency hospital. He complains of a repeated vomiting with blood and dark stool. He has
had a history of gastric ulcer for more than 3 years. The onset of symptoms was sudden with
loss of consciousness. Condition of the patient is severe, the peripheral pulse is not detected,
blood pressure is 60/0 mm of mercury.
Questions:
1. What complication of gastric ulcer has resulted in shock?
2. Does the patient need common treatment fulfilled by a nurse assistant in the reception
ward?
3. Where and how is the patient transported further?
4. What type of medical aid according to urgency is to be given to the patient?

Task № 4
Clinical scenario: A 32 year old male is transported into the reception ward of the
emergency hospital. He was stricken by a fist into the lower jaw. He complains of a pain in
the lower jaw, inability to open the mouth, and bloody saliva.
Questions:
1. What specialist has to treat the patient?
2. What basic diagnostic tool is used in the case?
3. What ward will the patient be transported to further?
4. What type of the medical aid according to urgency is to be given to the patient?

Task № 5
Clinical scenario: An unconsciousness person was found in a street and transported
into the reception ward of the emergency hospital. A condition of the patient is severe, the
patient is unconscious. There is a lacerated wound 5х4 with a clotted blood in the occipital
area. Blood pressure is 100/60 mm of mercury, pulse is 100 beats per minute.
Questions:
1. What specialist has to treat the patient?
2. What basic diagnostic tool is used in the case?
3. What treatment is done by a nurse assistant?
4. How is the patient transported further?
5. What ward is the patient treated further?

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TOPIC 2 DESMURGY
Following professional competences of a student have to be formed after preparation of
the topic:
 Ability to recognize basic pathologic symptoms and signs of traumatic injuries,
and provide first aid using dressing and bandaging for different body parts.

I. Motivation of the goal:


The skill to put bandages is one of the general medical practical skills, and it is widely
applied in surgery, traumatology and orthopedics. Desmurgy (from the Greek desmos –
connection, bandage and ergon – business) is an art of putting bandages.
The art of fixing dressing material relates to the most ancient skills in the development
of medical science. There are numerous data on the use of a rubber adhesive plaster, a pitch, a
canvas as fixative materials (Hippocrates, Cornelius, Celsius, Galen). Later on, the technique
of putting bandages developed gradually, new kinds and types of bandages, new kinds of
dressing materials were suggested, the indications for their application extended. The above
given facts dictate the necessity of profound study of desmurgy, including the classification of
dressing materials, bandages, the indications and methods of their application.

II. The goal of self-preparation:


To study the classification of bandages, different kinds of dressing materials, to
acquire the skills of putting soft bandages on head, neck, and trunk.

III. Studying purposes.


After self-contained studying of the topic a student must.
Know:
 the definition of "desmurgy";
 the definition of concepts "bandage" and "dressing";
 modern dressing materials;
 the classification of bandages based on their nature and indications;
 types of fixative materials for putting bandages;
 general rules of putting bandages;
 basic kinds of soft bandages;
 the instructions for use of an individual dressing kit;
 the rules of putting an occlusive dressing on the thoracic wall;
 the rules of putting slings.
Be able to:
 put typical soft bandages on the head;
 put typical soft bandages on an eye, both eyes, four-tail bandaging of the nose and
chin;
 put soft bandages on a breast, both breasts, thoracic cage;
 use an individual dressing kit;
 put an occlusive dressing on the chest wall;
 put slings;
 correctly fix bandages using different methods;
Practice and demonstrate:
 Skills of dressing and bandaging of surgical patients of different age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat anatomy of joints
of upper and lower extremities, places of the superficial location of main vessels (arteries,
veins) and nervous trunks from a course of normal anatomy.

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V. The plan for studying the topic.
1. The definition of "desmurgy".
2. The principle differences between the concepts of “bandage" and "dressing".
3. The brief historical data on bandages.
4. The medical value of bandages.
5. The characteristic of the basic modern dressing materials.
6. Types of bandages according to the kind of material and a method of application.
7. Soft bandages, general rules of putting soft bandages.
8. Types of bandaging.
9. Special dressing agents used in modern medicine.
10. The technique of putting simple bandages on head, neck, and thorax.

VI. The recommended literature:


Suggested readings:
1. General surgery the manual, V.K. Gostishev., 2003. Pp. 103-109.
2. "The nurse assistant" - Joan F. Donovan. Chapter 19 (pp. 278-286).

VII. Questions for the self-control.


1. The definition of “desmurgy”.
2. The principle differences between the concepts of “bandage" and "dressing".
3. The classification of bandages based on the kind of the material used for their
application.
4. The classification of bandages according to the purpose of their application.
5. Types of bandages depending on the method of application.
6. Types of immobilization bandages.
7. Basic kinds of plaster bandages.
8. Basic requirements for dressing materials.
9. Types of bandages.
10. Typical bandages put on the head, neck, and chest.

VIII. Tasks for self-preparation:


1. Write the classification of basic kinds of bandages.
2. Draw the scheme of putting the “Hippocrates‟ cap”.
3. Draw the scheme of putting the “head gear”.
4. Draw the scheme of putting a bandage on the right eye.
5. Draw the scheme of putting a bandage on the left eye.
6. Draw the scheme of putting a bandage on both eyes (binocular bandage).
7. Draw the scheme of a Barton bandage on a chin and lower jaw.
8. Draw the scheme of putting a four-tail bandage on the chin and nose.
9. Draw the scheme of putting a bandage on the right breast.
10. Draw the scheme of putting a bandage on the left breast.
11. Draw the scheme of putting a bandage on bothbreasts.

Tests

1. the following methods of applying bandages are recognized (choose right)


a) spiral
b) figure-of-nine
c) tubular
d) figure-of-eight
e) circular

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2. what may bandages be used for?(choose right)
a) to hold dressing in place
b) to reduce edema
c) to stabilize a fracture
d) to control bleeding
e) to control vomiting

3. what may bandages be used for?(choose right)


a) protect surgical wounds against infection
b) to support a limb or joint
c) to correct a deformity
d) to hold dressing in place
e) all the above mentioned

4. what bandages may be made of?(choose right)


a) gauze
b) flannel
c) woven cotton
d) elastic webbing
e) all the above mentioned

5. what material is most frequently used in bandaging? (choose right)


a) gauze
b) flannel
c) woven cotton
d) elastic webbing
e) all are equally used

6. what bandaging material is best to distribute even pressure over varicose veins?(choose
right)
a) gauze
b) flannel
c) woven cotton
d) elastic webbing
e) all are equally used

7. what bandaging material is the most stretchable? (choose right)


a) gauze
b) flannel
c) elastic webbing
d) woven cotton
e) all are equally used

8. what kind of bandage is easy to apply and stay in a place better (choose right)
a) roller bandage
b) handkerchief bandage
c) tubular bandage
d) triangle bandage
e) tailed bandage

9. what is the best way to prevent stagnation of blood in the patient’s veins (choose right)
a) roller bandage

16
b) handkerchief bandage
c) elastic stockings
d) triangle bandage
e) tailed bandage

10. in spiral bandaging, each turn overlaps approximately(choose right)


a) one-third of the preceding turn
b) one-fourth of the preceding turn
c) one-fifth of the preceding turn
d) two-thirds of the preceding turn
e) all the above mentioned

11. always apply the bandage starting with the following point (choose right)
a) farthest away from the head
b) farthest away from the lung
c) farthest away from the arm
d) farthest away from the heart
e) farthest away from the leg

12. the following methods of securing bandages are known (choose right)
a) tying
b) pinning
c) sewing
d) adhesive taping
e) all are used

Clinical tasks

Task № 1
Clinical scenario: You are on the scene of a road traffic accident. A patient has a head
injury. During the examination the following data are found. There is a wound 10х6 cm in the
temporal area with mild bleeding and edema, palpation is tender. There are no obvious
deformities and pathologic movements in the skull area. Blood pressure and pulse rate are
normal.
Questions:
1. What causes this state of the patient?
2. Does the patient need dressing?
3. If needed, what types of bandaging can be used?
4. Does the patient need qualified medical aid?
5. If needed, what medical institution does the patient have to be transported to?

Task № 2
Clinical scenario: You are on the scene of an accident. A person was stricken by a
foot into the lower jaw. During the examination the following data are found. The chin is
shifted rightwards, the mouth is slightly open. There is edema, hyperemia, and severe
tenderness in the lower jaw area. Any attempts to open or close the mouth cause severe pain.
The pathologic movements and deformation are visible in the lower jaw area.
Questions:
1. What is the state of the patient?
2. Does the patient need transportation stabilization?
3. If needed, what type of transportation stabilization is required?
4. Does the patient need admission to a hospital?
5. If needed, what medical institution does the patient have to be transported to?

17
Task № 3
Clinical scenario: A person had an injury of the face with a blunt object. The patient
wore glasses. During the examination the following data are found. There are multiple
scratches, edema, hyperemia, and tenderness in the right eye area. The right eyelid is closed
and very tender on opening. The right eye cornea is hyperemic with numerous petechia.
Questions:
1. What causes this state of the patient?
2. Does the patient need dressing?
3. If needed, what types of bandaging can be used?
4. Does the patient need qualified medical aid?
5. If needed, what medical institution does the patient have to be transported to?

Task № 4
Clinical scenario: A person has jumped into a pool landing on the bottom with his
head. During the examination the following data are found. The patient complains of
moderate pain in the posterior neck area that is worsened by head turning and body
movements. The pain radiates into the back. The back muscles are strained. The neck part of
the spine is deformed and very tender on palpation. The pathologic movements are noticed on
the part.
Questions:
1. What is the state of the patient?
2. Does the patient need transportation stabilization?
3. If needed, what type of transportation stabilization is required?
4. Does the patient need admission to a hospital?
5. If needed, what medical institution does the patient have to be transported to?

Task №5
Clinical scenario: You have arrived to the scene of an accident. There is a patient with
a right chest knife injury. During an examination, there is 1х3 cm wound of the right chest in
the 5th intercostal space in the midclavicular line. The wound has mild venous bleeding. On
each inspiration the wound sucks the outside air into the chest, whereas each expiration
pushes the air through the wound outside with little bubbling blood.
Questions:
1. What is the state of the patient?
2. What type of dressing must be used in the situation?
3. What does the dressing consist of?
4. What is its action principle?

18
TOPIC 3 DESMURGY. TEMPORARY STABILIZATION
Following professional competences of a student have to be formed after preparation of
the topic:
 Ability to recognize basic pathologic symptoms and signs of traumatic injuries,
and provide first aid using temporary stabilization of different body parts.

I. Motivation of the goal:


After studying the basic data on the technique of putting bandages, the indications for
their application and having studied the main kinds of dressing materials, it is necessary to
master the technique of putting bandages on the selected parts of the body: shoulders, upper
and lower extremities. These are the indispensable skills for a doctor of any specialization.

II. The goal of self-preparation:


To study the technique of putting soft roller bandages on shoulders, upper and lower
extremities.

III. Studying purposes.


After self-contained study of the topic a student must
Know:
 the classification of bandages;
 the purpose and the area of bandages application on the upper and lower
extremities;
 technical and clinical advantages and disadvantages of different bandages;
 the rules of putting bandages on shoulders;
 the rules of putting bandages on the upper extremities;
 the rules of putting bandages onthe lower extremities;
 technique of temporary stabilization of upper extremities;
 technique of temporary stabilization of lower extremities;
 technique of temporary stabilization of different parts of the vertebral column;
 technique of temporary stabilization of pelvic bones;
 transfer technique in patients with different forms of injuries.
Be able to:
 put a Desault's bandage;
 put a Velpeau's bandage;
 put a spica bandage on a shoulder;
 put a handkerchief bandage;
 put soft bandages on a hand;
 put a tortoise bandage on an elbow and a knee joint;
 put a cross bandage on a foot;
 put a reverting bandage on a stump of an extremity;
 temporary stabilize the upper extremities;
 temporary stabilize the lower extremities;
 temporary stabilize the different parts of the vertebral column;
 temporary stabilize the pelvic bones.
To practice and demonstrate:
 Skills of dressing, bandaging, and temporary stabilization in traumatic injuries of
different age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to revise the anatomy of
upper and lower extremities from a course of normal anatomy.

19
V. The plan of the topic studying.
1. The technique of putting bandages on shoulders.
2. The technique of putting bandages on upper extremities.
3. The technique of putting bandages on lower extremities.

VI. The recommended literature:


Suggested readings:
1. General surgery the manual, V.K. Gostishev., 2003. Pp. 103-109.
2. "The nurse assistant" - Joan F. Donovan. Chapter 19 (pp. 278-286).

VII. Questions for self-control.


1. The classification of bandages.
2. The technique of putting a Desault's bandage.
3. The technique of putting a Velpeau's bandage.
4. The technique of putting a spica bandage on a shoulder.
5. The technique of putting a "figure-of-eight" bandage on a forearm.

VIII. Tasks for self-preparation:


1. Draw the scheme of putting a Desault's bandage.
2. Draw the scheme of putting a Velpeau's bandage.
3. Draw the scheme of putting a handkerchief bandage
4. Draw the scheme of putting a cross bandage on a foot.
5. List the indications for putting a Desault's bandage.
6. List the indications for putting a Velpeau's bandage.
7. Represent the positions of a bandage when putting a tortoise bandage on a knee
joint.
8. List the steps of putting a mitten bandage on a hand.
9. List the steps of putting a "figure-of-eight" bandage on a forearm.
10. Draw the scheme of putting a spica bandage on the thumb.
11. Draw the scheme of a gauntlet (glove) bandaging for the fingers.
12. List the steps of putting a reverting bandage on a stump of an extremity.

Tests

1. when removing a bandage, it is cut at the following point (choose right)


a) closest to the heart
b) closest to the wound
c) farthest away from the wound
d) farthest away from the heart
e) all are right

2. what binders may be used for? (choose right)


a) to give support for a body part
b) to apply pressure
c) to limit motions
d) to hold dressing in its place
e) all are used

3. what binder is used to hold a dressing after hemorrhoidectomy? (choose right)


a) four-tailed binder
b) breast binder
c) T- binder

20
d) scultetus binder
e) abdominal binder

4. the following binders are known (choose right)


a) four-tailed binder
b) breast binder
c) T- binder
d) scultetus binder
e) all are right

5.what is necessary during dressing? (choose right)


a) scissors
b) gauze sponges and squares
c) forceps
d) cotton pads
e) all are necessary

6. what is done with a soiled dressing and bandages after dressing? (choose right)
a) left in the ward
b) left in the patients unit
c) transferred outdoor
d) burned in the incinerator
e) placed into the wastebasket

7. a bandage material that is heavier and firmer than cotton gauze is (choose right)
a) polyester
b) flannel
c) woven cotton
d) elastic webbing
e) muslin

8. a material that is placed under splints because it is soft is (choose right)


a) polyester
b) flannel
c) woven cotton
d) elastic webbing
e) muslin

9. continuous strips of material in various lengths and widths are called (choose right)
a) tailed bandages
b) oblong bandages
c) tubular bandages
d) square bandages
e) roller bandages

10.tailedbandages are used to (choose right)


a) dress wounds
b) apply pressure
c) hold splints in a place
d) stabilize fracture
e) hold dressing in a place

21
11. what binder is used to secure dressings on the nose and chin? (choose right)
a) four-tailed binder
b) breast binder
c) T- binder
d) scultetus binder
e) abdominal binder

12. a roller bandage consist of the following parts (choose right)


a) tail
b) nose
c) head
d) leg
e) all are right

Clinical tasks

Task № 1
Clinical scenario: A male slipped on ice and fell onto the straight right hand. After
that he felt severe pain in the right clavicle area. During the examination the following data
were found. There was moderate edema, hyperemia, and severe tenderness in the middle of
the right clavicle. Bleeding is absent. Pathologic movements have been noticed in the area.
Questions:
1. What kind of trauma does the patient have?
2. Does the patient need transportation stabilization?
3. If needed, what type of transportation stabilization is required?
4. Does the patient need admission to a hospital?
5. If needed what medical institution does the patient have to be transported to?

Task № 2
Clinical scenario: You have arrived to the scene of the accident. A builder has fallen
from a 3meter height roof onto a left hand. During the examination the following data are
found. There are severe edema, tenderness and deformation in the upper third of the left
humeral bone. Active and passive movements in the left hand are impossible due to extreme
pain. There is a crepitation in the upper third of the left humeral bone.
Questions:
1. What causes this state of the patient?
2. Does the patient need transportation stabilization?
3. If needed, what type of transportation stabilization is required?
4. Does the patient need admission to a hospital?
5. If needed what medical institution does the patient have to be transported to?

Task № 3
Clinical scenario: Having taken a ball a goalkeeper has experienced a severe pain in
the left thumb area. During examination, the following data have been found. There is
moderate edema and bruising in the left thumb area. Active movements in the thumb are
limited due to pain, palpation causes severe pain.
Questions:
1. What kind of trauma does the patient have?
2. Does the patient need transportation stabilization and what type of stabilization is
required?
3. What kind of bandaging has to be used?
4. Does the patient needqualified medical care?

22
5. What medical institution does the patient have to be transported to?
6. What pathologies have to be suspected? What investigation tool helps in diagnosis?

Task № 4
Clinical scenario: While skating a 25 year old girl twisted her right foot inwards. It
accompanied by a severe pain in a right ankle area. During examination, edema and bruising
in the area were found. The lateral side of the joint was tender. Active movements in the joint
were limited due to the pain. Punching of a right heel was painless.
Questions:
1. What kind of trauma does the patient have?
2. What type of stabilization is required?
3. What kind of bandaging has to be used?
4. What position should the foot be stabilized in?
5. Does the patient need qualified medical care?
6. What possible complication has to be considered? What investigation tool helps in
diagnosis?

Task № 5
Clinical scenario: A 45 year old male has an exema in a dorsum of a right palm and
fingers. A topical application of medical ointments is administered onto the affected surface
each next three days.
Questions:
1. What kind of bandaging is required to secure a dressing on the hand?
2. What are the features of right and left hand bandaging?
3. What kind of bandaging can also to be used?
4. What wrist function may partially be preserved when applying the bandage?
5. What type of bandaging is used to achieve it?

23
TOPIC 4 NON-OPERATIVE SURGICAL TECHNIQUES

The following professional competences of a student have to be formed after preparation


of the topic:
 Ability to recognize basic pathologic symptoms and signs of studied disorders, and
provide first aid using bleeding control and injection of medicines.

I. Motivation of the goal:


Non-operative surgical manipulations such as injections, infusions, draining hollow
organs through natural openings, and punctures of cavities and joints are especially important
in surgery, although they are also used in other clinical disciplines. That is why knowledge
and skill of making these manipulations are necessary for a doctor of any specialization.

II. The goal of self-preparation:


To study the technique of parenteral injection of medicines: intravenous and intra-
arterial injections and infusions, diagnostic and medical punctures of cavities and joints.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 ways and methods of parenteral injection of drugs;
 indications for carrying out intravenous and intra-arterial infusions of drugs;
 the technique of puncturing peripheral and central veins;
 the technique of puncturing peripheral and central arteries;
 placement of the Shwan-Ganz (pulmonary) catheter;
 placement of theintraaortic balloon pump;
 features of drug infusions in children;
 the technique of intraosseous infusion of medicines;
 the technique of measurement of central venous pressure;
 the technique of puncturing the abdominal cavity;
 indications for carrying out and the technique of the thoracocentesis;
 the technique of puncturing hematomas of soft tissues and superficial abscesses;
 the technique of puncturing a cavity of pericardium;
 the technique of puncturing the bladder and Douglas pouch.
Be able to:
 making intradermal, subdermal and intramuscular injections of drugs;
 puncturing and cutting-down a peripheral vein;
 assembling a system for intravenous and intra-arterial injections of drugs;
 making intravenous injections of drugs;
 taking a blood specimenfrom a vein;
 measuring the central venous pressure;
 puncturing the abdominal cavity;
 making the thoracocentesis at hemothorax and pneumothorax;
 puncturing the hematomaof soft tissues and superficial abscesses;
 puncturing the bladder and Douglas pouch.
To practice and demonstrate:
 Skills of nonoperative surgical techniques in patients of different age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the structure of
cavities of a human organism, bones and joints, and also the anatomy of peripheral veins and
arteries from a course of normal anatomy.

24
V. The plan for the topic studying.
1. Routes of parenteral injection of drugs.
2. Intradermal and subcutaneous injections.
3. Intramuscular injections.
4. Intravenous injections and infusions.
5. Intra-arterial injection of drugs and blood.
6. Puncture of the abdominal cavity and laparocentesis.
7. Pleural puncture and technique of the chest draining in hemothorax and
pneumothorax.
8. Puncture of the pericardium cavity. Intracardiac injection of drugs.
9. Puncture of joints, breast bone and other bones.
10. Puncture of the hematoma of soft tissues and superficial abscesses.
11. Puncture of the bladder and Douglas pouch.

VI. The recommended literature:


Suggested readings:
1. Lecture materials.
2. "Manual of common bedside surgical procedures", 2000.
3. "Bedside procedures in the ICU"., 2012. Editor Dr. Florian Falter, M.D., FRCA,
FFICM, Ph.D. Department of Anesthesia and Intensive Care Medicine Papworth Hospital
Cambridge UK.
4. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp.-424-
428.
Supplemental materials:
1. "Basic surgical techniques" chapter № 6 pp. 138-178.
2. "Scientific American surgery" chapter II - 1 (cardiopulmonary monitoring)

VII. Questions for the self-control.


1. General technique of injections.
2. Preparation of instruments and a patient.
3. Anatomic basics in choosing places for injections.
4. Indications for venous and arterial catheterization, technique, complications.
5. Intraaortic balloon pump and pulmonary catheter: indications, technique,
complication.
6. Possible complications of parenteral injection of drugs and their prophylaxis.
7. Indications for a puncture of the abdominal cavity, technique, and possible
complications.
8. Indications for a thoracocentesis, technique, and possible complications.
9. Indications for a pericardiocentesis, technique, and possible complications.
10. Indications, technique of a puncture of the bladder, Douglas space.
11. Indications, technique of a puncture of joints, breast bone and other bones.
12. Technique of a puncture of the haematoma of mild tissues and superficial
abscesses. Principles and features.

VIII. Tasks for self-preparation:


1. List the conditions of a patient in which injections of drugs are restricted or
impossible.
2. Draw schematically the regions of a human body, where subcutaneous injections
are made.
3. Draw schematically the place for intramuscular injections in the buttock region.
4. List possible complications of intramuscular injections.
5. Draw schematically a system of intravenous blood transfusions.
6. Draw schematically common sites for central venous and arterial catheterization

25
7. Draw schematically the technique of Swan-Ganz and IABP placement.
8. Draw schematically the typical points for the puncture of the abdominal cavity on
the anterior abdominal wall.
9. Draw the typical points on the chest for the pleural puncture at hemothorax and
pneumothorax.
10. Draw schematically the points for the puncture of a knee joint.
11. Draw schematically the typical points for the pericardiocentesis through a diaphragm.
12. Draw schematically the typical point for the puncture of the bladder on an anterior
abdominal wall.

Tests

1. common indications for central venous catheterization are as follows (choose right)
a) monitoring of the central venous pressure
b) measurement of arterial blood gases
c) enteral nutrition support
d) long-term infusion of drugs
e) monitoring of the arterial pressure

2. the following vessels are used for central venous access (choose right)
a) short saphenous vein
b) cephalic vein
c) internal jugular vein
d) great saphenous vein
e) subclavian vein

3. the following vessels are used for peripheral venous access (choose right)
a) femoral vein
b) cephalic vein
c) internal jugular vein
d) great saphenous vein
e) subclavian vein

4. indications for radial artery cannulation are as follows (choose right)


a) monitoring of the central venous pressure
b) treatment of a sepsis
c) continuous hemodynamic monitoring
d) total parenteral nutrition
e) frequent assessment of arterial blood gases

5. Allen's test is used before the following procedures (choose right)


a) tracheotomy
b) cephalic artery cannulation
c) radial artery cannulation
d) great saphenous artery cannulation
e) subclavian vein cannulation

6. indications for pericardiocentesis are as follows (choose right)


a) continuous hemodynamic monitoring
b) to establish a diagnosis from pericardial fluid
c) placement of the Swan-Ganz catheter
d) cardiac tamponade
e) monitoring of the central venous pressure

26
7. possible complications of the pericardiocentesis are as follows (choose right)
a) infection
b) cardiac arrhythmias
c) air embolus
d) cardiac puncture
e) all the above listed are possible

8. which pressure suggests the final position of the Swan-Ganz catheter tip? (choose right)
a) pulmonary artery pressure
b) superior cava vein pressure
c) right ventricle pressure
d) pulmonary artery wedge pressure
e) inferior cava vein pressure

9. choose the right statements regarding a thoracocentesis to be performed (choose right)


a) lower border of the rib
b) scapular line
c) second intercostal space
d) midclavicular line
e) eighth intercostal space

10. indications for thoracocentesis are as follows (choose right)


a) to relieve dyspnea caused by pleural effusion
b) to establish a diagnosis from pericardial fluid
c) for diagnosis of pleural effusion
d) cardiac tamponade
e) monitoring of the central venous pressure

11. indications for paracentesis are as follows (choose right)


a) acute urine retention
b) diagnostic studies of the peritoneal effusion
c) for diagnosis of pleural effusion
d) cardiac tamponade
e) ascitis

12. choose the right site for puncture of the bladder (choose right)
a) two centimeters above the symphysis pubis
b) eighth intercostal space
c) either lower abdominal quadrant
d) midpoint between the symphysis and umbilicus
e) second intercostal space

Clinical tasks

Task № 1
Clinical scenario: Performing catheterization of the subclavian vein a surgeon has
punctured a subclavian artery.
Questions:
1. List possible reasons for mentioned complication.
2. What is a management of the complication?
3. What other complications of a subclavian vein catheterization do you know?
4. Explain the procedure of a subclavian vein catheterization.
5. What are the indications and contraindications for subclavian vein catheterization?

27
Task № 2
Clinical scenario: After radial artery cannulation a patient has developed the
following clinical signs: numbness, paresthesia, and coldness of the palm. Further, a severe
unbearable pain resulted with paresis of fingers.
Questions:
1. What complication is responsible for mentioned signs and what management must be
started?
2. What other complications of radial artery cannulation do you know?
3. Explain the procedure radial artery cannulation.
4. What are the indications and contraindications for radial artery cannulation?
5. What is the aim of the Allen‟s test and how is it done?

Task № 3
Clinical scenario: A 74 years old male has been operated under spinal anesthesia
because of acute superficial thrombophlebitis. In the early postoperative period, the patient
has developed signs of acute urinary retention. Placement of a urinary catheter is technically
unsuccessful.
Questions:
1. What is the management of urinary retention if catheterization is impossible to
perform?
2. List all possible reasons for acute urinary retention.
3. What reason is likely to be in our case?
4. Explain the procedure of puncture of the bladder and percutaneous suprapubic
cystostomy.
5. What are the complications of the cystostomy?

Task № 4
Clinical scenario: A victim of a motor vehicle accident has been admitted to the
hospital. The trauma of the chest was caused by steering wheel. A patient complains of severe
chest pain and dyspnea. He is anxious. A cyanosis, rapid and weak pulse, and low blood
pressure are found. Objective exam has revealed unequal expansion of the chest (right part),
bulging of ICS on the affected side, decreased vocal fremitus and hyperresonant percussion
note (right part). The heart and arch of the aorta are displaced toward left. Breath sounds are
absent (right part)
Questions:
1. What organ is likely to be damaged?
2. What is your preliminary diagnosis?
3. Explain the procedure of needle aspiration of the air from the pleural space.
4. Why the puncture is done exactly above the upper border of the rib and is not
performed along the parasternal line?
5. What are the complications of puncture of the pleural cavity?

Task № 5
Clinical scenario: a 56 years old patient has been admitted to the hospital with
complaints on dyspnea and heaviness in the right part of the chest. Plain AP chest radiograph
has revealed a level of fluid reaching up to 3rd right rib.
Questions:
1. What is your primary diagnosis?
2. List all indications to thoracentesis.
3. Explain the procedure of thoracentesis.
4. What are the complications of thoracentesis?

28
TOPIC 5 ASEPSIS
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to use aseptic techniques, stylize medical instruments, maintain a hygienic
environment in the medical and diagnostic facilities.
I. Motivation of the goal:
Before discovering the antiseptic method in surgery, almost every operation was
accompanied by the development of purulent and septic complications. The introduction of
the aseptic method as a system of actions directed towards preventing infection contamination
in a wound has risen surgery to a new level. The knowledge and practicing of an aseptic
technique in a surgical ward is necessary for a successful operative treatment of patients.

II. The goal of self-preparation:


To get acquainted with the work of an operation room and the application of aseptic
methods during surgery, to develop the basic skills of behavior in an operation theater.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 what asepsis is and what the differences between asepsis and antisepsis are;
 types of exogenous surgical infection and methods of its correction;
 methods of sterilization of surgical materials (linen, dressing material, instruments,
devices) ;
 main features and structure of a surgical block and its equipment;
 sanitary and hygienic conditions in an operating room.
Be able to:
 carrying out is scrubbing before surgery by different methods, control of sterility;
 prepping and draping a surgical area;
 changing the sterile gloves;
 placing dressing material, operational clothes, gloves in the sterilizer.
To practice and demonstrate:
 Skills of prophylactic measures against microorganisms penetration into a wound
in patients of different age groups.

IV. The initial level of knowledge:


A student should repeat:
1. Kinds and transmission routes of a saprophytic and pathogenic infection.
2. Quality monitoring of bacterial contamination.
3. History of surgery development.
4. Lois Pasteur‟s works devoted to the value of microorganisms in a process of
fermentation.
5. Methods of assessment of microorganisms‟ sensitivity to antibiotics.
6. Air disinfection by UV-radiation.

V. The plan for the topic studying.


1. Routes of infection penetration to a wound and methods of prophylaxis of
airborne, contact and inoculation infection transmission.
2. Sterilization of operational clothes, linen, dressing, suture materials, surgical
equipment, and drains.
3. Quality monitoring of bacterial contamination.
4. A surgical block, its features and equipment. The assignment of its rooms.
5. Features of work in an operation room, rules of behavior of the medical personnel,
preparation and carrying out surgical operations.

29
VI. The recommended literature:
Suggested reading:
1. Lecture materials.
2. "General surgery" the manual., V.K. Gostishev., 2003, Pp. 7-16.
Supplemental materials:
1. "Basic surgical techniques" 2001 Chapter 5 pp. 105-132
2. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 138-162
3. "Textbook of microbiology" chapter № 4 pp. 29-37

VII. Questions for the self-control.


1. What is asepsis? What are the differences between asepsis and antisepsis?
2. Sources of exogenous and endogenous surgical infection.
3. Methods of control of air-born infection transmission.
4. Methods of control of contact infection transmission.
5. Methods of control of implantation infection transmission.
6. Sterilization and its methods.
7. Sterilization of silk, kapron, lavsan (methods).
8. Sterilization of catgut (methods).
9. Sterilization in an autoclave.
10. Sterilization in a dry-heat oven.
11. Sterilization of cutting instruments.
12. Sterilization of fiber-optic instruments.
13. G-ray sterilization.
14. Sterilization of materials and instruments contaminated with anaerobic flora.
15. Monitoring of sterility.
16. Methods of prepping of an operation area.
17. List the rooms of a surgical block.
18. Name the zones of a surgical block.
19. Characterize the zones of an operation theater and location of personnel and
equipment.
20. List the equipment located in a preoperative room.
21. Name the kinds of cleaning of an operation room.
22. Characterize the basic requirements for an operation room.
23. Characterize the sequence of surgical operations in a general surgery department.
24. List the equipment of supplementary rooms of a surgical block.
25. Endogenous and exogenous routes of microbial transmission (contact (direct,
indirect), air, implantation).
26. Nosocomial infection in a surgical hospital.
27. Methods of control of microflora on the routes of air transmission.

VIII. Tasks for self-preparation:


1. Specify the chemicals which are used for sterilization and disinfection.
2. Draw the scheme of exogenous infection.
3. Draw the scheme of a surgical block.
4. Describe all stages of instruments sterilization.
5. Describe all stages of surgical linen and material sterilization.
6. Describe the direct and indirect methods of the sterility control.
7. Describe the procedure of silk sterilization.
8. Describe the procedure of catgut sterilization.
9. Describe the procedure of hands scrubbing, using modern methods.
10. Describe the procedure of prepping and draping of an operation area.

30
Tests

1. most important sources of surgical wound contamination in the surgical hospital are as
follows (choose right)
a) rodents
b) human carriers
c) carnivores
d) persons with overt signs of infection
e) persons in the incubating period of infection

2. the following antiseptics are used in surgery (choose right)


a) povidon-iodine
b) penicillin
c) mercury dichloride
d) alcohol 70%
e) formaldehyde

3. the following disinfectants are used in surgery (choose right)


a) povidon-iodine
b) chlorhexidine
c) mercury dichloride
d) alcohol 70%
e) formaldehyde

4. sterilization of instruments in a dry air oven is done in the following conditions (choose
right)
a) 60 minutes
b) temperature 1230 C
c) 10 minutes at 2 atmospheres
d) temperature 1800 C
e) 40 minutes at 3 atmospheres

5. sterilization of instruments in an autoclave is done in the following conditions (choose


right)
a) 20 minutes at 2 atmospheres
b) temperature 123,90 C
c) 10 minutes at 2 atmospheres
d) temperature 1800 C
e) temperature 132,90 C

6. composition of the washing solution for instruments is as follows (choose right)


a) 2,5% H202 - 200ml
b) washing detergent - 5
c) 2,5% H202 - 400ml
d) washing detergent - 25
e) water - 795ml.

7. the control of sterility is attained by means of the following direct methods (choose right)
a) thermometers
b) bacteriological tests
c) use of materials with specific melting point
d) culturing of germs from sterilized items

31
8. the control of sterility is attained by means of the following indirect methods (choose
right)
a) thermometers
b) bacteriological tests
c) use of materials with specific melting point
d) culturing of germs from sterilized items

9. composition of the c - 4 solution is as follows (choose right)


a) H202
b) acetaldehyde
c) carbolic acid
d) formic acid
e) boric acid

10. when cleaning the operation theatre the following chemicals are used for spilled body
fluids (choose right)
a) detergents
b) disinfectants
c) antiseptics
d) soap
e) Plain water

11. prepping of the operative field may be done by the following chemicals (choose right)
a) povidon-iodine
b) chlorhexidine
c) mercury dichloride
d) alcohol 70%
e) formaldehyde

12. the following types of cleaning of the operating theatre are used (choose right)
a) at the end of each day
b) at the beginning of each day
c) during each surgery
d) after each surgery
e) all are right
Clinical tasks
Task № 1
Clinical scenario: a 25 year old patient is planned for elective surgery due to right
inguinal hernia. As a part of preoperative preparation a patient has been advised to shave an
area of surgery in the evening time a day before the surgery. Next morning a patient has been
successfully operated. But on the second day after surgery, during dressing of the operative
wound the signs of postoperative wound infection have been found.
Questions:
1. What bacteria is likely responsible for postoperative wound infection?
2. What mechanism of infection spread has likely happened?
3. What is likely a possible reason for postoperative wound contamination?
4. What has to be done to prevent the complication?
5. What substances have to be administered for empirical therapy of the complication?

Task № 2
Clinical scenario: a surgeon with sore throat participates in surgery of a 36 year old
patient because of incarcerated hernia. To prevent intraoperative spread of infection the
surgeon has put on a double medical mask.

32
Questions:
1. Which mechanism of infection spread is possible?
2. What bacteria is likely responsible for sore throat?
3. What complication is likely possible in the postoperative period?
4. What should have been done by a surgeon?

Task № 3
Clinical scenario: in a single operation theater the following surgeries are to be done:
Incision of the postinjection abscess of the right buttock, uncomplicated inguinal hernia, and
resection of the upper lobe of the right lung due to peripheral lung cancer.
Questions:
1. How do you schedule the sequence of surgeries?
2. Why should these surgical procedures be scheduled in such a way?
3. Classify every given surgery, according to epidemiology.
4. What infection rate is possible after each mentioned surgery?

Task № 4
Clinical scenario: an operation performed in a patient suffering from gas gangrene has
been successfully finished. The instruments used during surgery are cleansed according to the
following scheme: washed immediately and then soaked in a special washing solution
composed of H2O2 2,5% – 200 ml; washing detergent – 5; water 795 ml during 15-20 min at
temperature 50 C0. After that 5 min washing with the brush is done in the same solution, it is
followed by 5 min rinsing in warm water; after that instruments are ready for sterilization.
Questions:
1. Have any mistakes been made in the process of cleansing instruments?
2. What mechanism of infection spread is possible in case of using these instruments?
3. If any mistakes have been done, please correct them.

Task № 5
Clinical scenario: after proper cleansing of organic deposits (blood) from plastic
tubes and catheters the last have been placed for sterilization in the autoclave. Sterilization of
materials lasts 20 min under the following regimen: at 120 C0, 1,1 atm. A special indicator to
control sterility has been placed into the sterilizer.
Questions:
1. Has a temperature regimen been properly chosen?
2. Has a time interval been properly chosen?
3. Can the listed materials be sterilized in the autoclave?
4. Will indicator of sterility change its color (successful sterilization)?

33
TOPIC 6 ANTISEPSIS
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to use antiseptic techniques and provide care for patients.

I. Motivation of the goal:


Before discovering the antiseptic method of surgical work almost each operation was
accompanied by the development of suppurative complications. An introduction of the
antiseptic method, as a system of different measures to avoid an infection in a wound, has allowed
to raise the surgery on the new quality level.

II. The goal of self-preparation:


To study different kinds of antisepsis which are used, to understand the difference
between antisepsis and asepsis, the concept of mechanical, physical, chemical and biological
antisepsis. Students should get the first skills at making dressings of wounds with antiseptic
solutions.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the influence of halogens, oxidants, alcohol, mercury, silver, aldehydes, phenols
and dyes on microorganisms;
 physical properties of water-absorbing gauze, capillaries, hypertonic solution;
 ways of physical antisepsis;
 basic kinds of biological antisepsis;
 methods of influence on the immune forces of a human organism.
Be able to:
 choose the method of antibioticadministration;
 make a dressing of a wound;
 carry out the pressurized pulsatile irrigation of a wound.
To practice and demonstrate:
 Skills of microorganism inactivation in patient‟s wounds of different age groups.

IV. The initial level of knowledge:


A student should know the basic physical and chemical properties of antiseptics.

V. The plan of studying the topic.


1. Studying the history of antisepsis.
2. Mechanical antisepsis: primary and secondary debridement of a wound.
3. Physical antisepsis: draining and packing of wounds, drying, aspiration, the
pressurized pulsatile irrigation of a wound, continuous irrigation. UV irradiation, laser irradiation,
hyperbaric oxygenation, ozone therapy.
4. Ways of chemical antisepsis.
5. Kinds and means of biological antisepsis.
6. Methods of influence on the immune forces of a human organism.

VI. The recommended literature:


Suggested readings:
1. Lecture materials
2. General surgery the manual, V.K. Gostishev., 2003. pp. 16-23.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 138-
162.

34
VII. Questions for the self-control.
1. The concept of a biological antisepsis.
2. What drugs have the direct effect on a microbial cell?
3. What drugs attack a microbial cell through the macroorganism?
4. What are the basic drugs of proteolytic enzymes used in surgery?
5. The mechanism of antiseptic action of proteolytic enzymes.
6. The technique of application of proteolytic enzymes in purulent wound treatment.
7. The groups of antibiotics.
8. The characteristics of semisynthetic antibiotics.
9. The mechanism of action of antibiotics on a microbial cell.
10. Ways of injection of antibiotics to an organism.
11. The basic principles of the rational antibiotic therapy.
12. The resistance of microbial flora to antibiotics, the conditions of its development and
extension of resistancy.
13. The classification of resistancy to antibiotics.
14. Overcoming of resistance to antibioticsof microbial flora in treating patients with a
surgical infection.
15. Errors of antibiotic therapy.
16. The basic complications of antibiotic therapy.
17. The prophylaxis of complications of antibiotic therapy.
18. The immune drugs used to fight a surgical infection (vaccines, serums,
bacteriophages, etc.).
19. The immune drugs used for raising the nonspecific reactivity treating patients with a
surgical infection.

VIII. Tasks for self-preparation:


1. Draw the scheme of endogenic infection development.
2. Draw the scheme of the pressurized pulsatile irrigation of a wound.
3. List the derivatives of nitrofuran, write the characteristics.
4. Write the characteristics of the basic drugs in the group of oxidants.
5. Introduce the characteristics of the drugs in the group of halogens and phenols.
6. Specify the basic drugs of the group of 5-Nitromidazolum.
7. Write the characteristics of basic groups of antibiotics used in surgery.
8. Specify the basic enzymes; introduce their characteristics.
9. Specify the drugs for an active immunization, introduce their characteristics.
10. Specify the drugs for a passive immunization, introduce their characteristics.

Tests

1. an antisepsis includes the following forms (choose right)


a) physical
b) surgical
c) biological
d) medical
e) mechanical

2. excision of necrotic tissues (necrectomy) and secondary surgical debridement are


referred to the following form of antisepsis (choose right)
a) physical
b) chemical
c) biological
d) combined
e) mechanical

35
3. hyperbaric oxygenation, incineration, destructive action of the laser and ultrasound are
referred to the following form of antisepsis (choose right)
a) physical
b) chemical
c) biological
d) combined
e) mechanical

4. passive and active draining of a wound, use of continuous irrigation of the suppurative
cavity are referred to the following form of antisepsis (choose right)
a) physical
b) chemical
c) biological
d) combined
e) mechanical

5. use of synthetic antimicrobial agents is referred to the following form of antisepsis


(choose right)
a) physical
b) chemical
c) biological
d) combined
e) mechanical

6. find the chemicals which are referred to the acid group (choose right)
a) furacilin
b) boric acid
c) H2O2
d) chlorhexidine
e) potassium permanganate

7. find the chemicals which are referred to the oxidants group (choose right)
a) furacilin
b) boric acid
c) H2O2
d) chlorhexidine
e) potassium permanganate

8. find the chemicals which are referred to heavy metal salts group (choose right)
a) furacilin
b) silver nitrate
c) H2O2
d) chlorhexidine
e) potassium permanganate

9. find antibiotics which are referred to penicillins (choose right)


a) cephaloridin
b) ciprofloxacin
c) methicillin
d) ofloxacin
e) oxacillin

36
10. find antibiotics which are referred to cephalosporines (choose right)
a) cephaloridin
b) ciprofloxacin
c) methicillin
d) cephotaxim
e) gentamycine

11. find antibiotics, which are referred to aminoglycosides (choose right)


a) cephaloridin
b) ciprofloxacin
c) methicillin
d) ofloxacin
e) gentamycine

12. which immune compound is used to create an active immunity against microbes?
(choose right)
a) specific antimicrobial serum
b) vaccines
c) antitoxin
d) toxoid

Clinical tasks

Task № 1
Clinical scenario: a teenage patient has been admitted to the hospital with the
lacerated wound of the scalp. The accident happened 3 hours before. There are no signs of
continuing bleeding and local inflammation in the injured area.
Questions:
1. What method(s) of antisepsis is (are) to be used?
2. List minimum 5 antiseptics possibly used in this situation
3. Explain the procedure of surgical debridement of the wound
4. Explain the procedure of pressurized pulsatile irrigation of the wound.

Task № 2
Clinical scenario:A 38 year old woman was operated due to chronic cholecystitis.
During operation, the gallbladder was removed and the operationcompleted with the
placement of the plastic drain into the area of removed gallbladder (subhepatic area).
Questions:
1. What is the purpose of the plastic tube left in the subhepatic space?
2. When is the tube commonly removed?
3. What complications may develop if the drain is not removed timely?
4. What are the general precautions dealing with drains?

Task № 3
Clinical scenario: a patient has been admitted to the hospital with a burn of the hip. A
doctor has started to use a topical application of carbolic acid for the wound care.
Questions:
1. What method of antisepsis has been chosen?
2. Is there any mistake done by the doctor?
3. What is a difference between antiseptic and disinfectant agent?
4. Which antiseptics are preferred for local care of the burnt area?

37
Task № 4
Clinical scenario: a patient was admitted to the hospital with two days old crashed
traumatic wound of the left hip. There is an exudate (a brownish and foul-smelling fluid),
skin discoloration (khaki color) and bullae formation at the left lower extremity. After
complex examination a gas gangrene of the left lower extremity was diagnosed.
Questions:
1. What antiseptic is preferred for irrigation during surgery?
2. Why is exactly this antiseptic preferred for irrigation during surgery?
3. What antibiotic must be administered parenterally?
4. Why is exactly this antibiotic preferred for treatment of the gas gangrene?

Task № 5
Clinical scenario: a 45 years old patient is admitted to the hospital due to a stab
wound of the abdominal wall. The wound penetrates into the abdominal cavity and
complicated by perforation of the bowel. The peritonitis is diagnosed.
Questions:
1. What antibacterial agent(s) is (are) to be administered?
2. Why is (are) exactly this (these) antibiotic(s) preferred?
3. When is an antibacterial therapy to be started?
4. Will you delay an antibacterial therapy until the results of culture and sensitivity to
antibiotics?
5. Can an antibacterial therapy be used as a substitute for surgical treatment of the
peritonitis?

38
TOPIC 7 FLUID-ELECTROLYTE AND ACID-BASE DISORDERS IN SURGICAL
PATIENTS AND PRINCIPLES OF INFUSION THERAPY
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize basic pathologic symptoms and signs of fluid and electrolytes
disorders;
 Ability to provide infusion therapy to surgical patients.
I. Motivation of the goal:
Surgical patients, especially postoperative one, have abnormalities of the fluid and
electrolytes balance. The causes are various: the basic disease, the surgical trauma, the
features of the surgery, the general condition of the patient, the age, the concomitant diseases.
The developing disorders of the fluid and electrolytes balance considerably worsen the
patient‟s state, are quite often the immediate causes of the lethal outcomes. Well-timed
diagnosis and correction of homeostasis disorders are important tasks.
II. The goal of self-preparation:
To study causes, clinical manifestations, basic principles of diagnosis and treatment of
the fluid and electrolytes disbalance in surgical patients.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 basic causes of the fluid and electrolytes disbalance in surgical patients;
 basic causes of the acid-base disorders in surgical patients;
 clinical and laboratory methods of investigation of the fluid and electrolytes
balance;
 indications, contraindications and methods of the infusion therapy;
 principles of the infusion therapy;
 main infusion solutions used for the correction of the fluid and electrolytes
disbalance;
 infusionprogram, basic (maintenance) and correction (existing deficit and ongoing
losses) infusion therapy;
 risks and complications of the plasma substitutes transfusion;
 first aid and treatment of infusion therapy complications(fluid resuscitation);
 basic records for the infusion therapy (fluid resuscitation).
Be able to:
 carry out the subjective examination of patients with the fluid and electrolytes
disbalance (complaints, anamnesis) ;
 reveal the clinical complex of symptoms of the fluid and electrolytes disorders;
 estimate the parameters of the pulse rate, the arterial pressure, the central venous
pressure, hourly urine output in the patient with the fluid and electrolytes disbalance;
 estimate the laboratory parameters: hemoglobin, hematocrite, the total protein
level, the nitrogen, sodium, chlorine, potassium of the blood in the patient with the fluid and
electrolytes disbalance;
 fill in the i.v. line;
 fill in the chart of infusion resuscitation therapy;
 provide the first aid had the complications of the infusion therapy have happened.
To practice and demonstrate:
 algorithm of indications and technique of infusion therapy in patients of different
age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic, a student should repeat physiology of the
fluid and electrolyte disbalance.

39
V. The plan of studying the topic.
1. Causes of the fluid and electrolytes disbalance in surgical patients.
2. Clinical and laboratory diagnosis of the fluid and electrolytes disbalance.
3. The characteristics of degrees of the dehydration in surgical patients.
4. Classification of solutions used for the infusion therapy.
5. Monitoring of the infusion therapy.
6. Risks associated with the infusion therapy and possible complications.
7. First aid and treatment of the infusion complications.
8. The basic records of the infusion solutions (fluid resuscitation).
VI. The recommended literature:
Suggested reading:
1. Lecture materials
2. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 74-102.
3. "Short practice of surgery" Bailey and Love's, 1996. Chapter 4 pp. 28-36.
4. SURGERY. Basic science and clinical evidence. USA., 2000, Pp. 151-161
Supplemental materials:
1. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991., Pp. 57-77
2. "Surgery" Bruce E. Jarrell, 1991. pp. 3-10.
3. Scientific American surgery 1997; Chapter I (Emergency care) : 5 (Life-
threatening Acid-Base Disorders) pp. 1-21.
VII. Questions for the self-control.
1. Kinds and forms of the dehydration.
2. The degrees of the hypertonic dehydration.
3. Normal parameters of electrolytes in the blood plasma.
4. The degrees of the isotonic dehydration.
5. What solutions are used for the infusion therapy in patients with the fluid and
electrolyte disturbances?
6. What are the basic (maintenance) and correction (existing deficit and ongoing
losses) infusion therapy?
7. How is the assessment of the fluiddeficiency carried out?
8. How is the test of the K and Nadeficiency carried out?
9. What are the complications of the infusion therapy and what is the first had the
complications occur?
VIII. Tasks for self-preparation:
1. Describe the clinical complex of symptoms of the each degree of dehydration.
2. Present the normal parameters of electrolytes in the blood plasma.
3. Write the formula for calculation of the fluid deficiency in the body.
4. Write the formula for calculating the Na deficiency in the body.
5. Write the formula for calculating the K deficiency in the body.
6. Write the composition of the lactated Ringer's solution.
7. Write the medicines and the solutions used for the correction of the fluid and
electrolyte disbalance.
8. Describe the causes and the pathology of the respiratory and metabolic alkalosis.
9. Describe the causes and the pathology of the respiratory and metabolic acidosis.

Tests
1. the total body water of 70 kg individual approximately composes the following volume
(choose right)
a) 12L

40
b) 36L
c) 52L
d) 42L
e) 24L
2. the maintenance requirements of a body in fluid are those necessary to cover obligatory
body fluid loses with urine, perspiration etc. Therefore they should be supplemented for any
person at the following volume (choose right)
a) 1L
b) 2L
c) 10 ml/kg
d) 35-40 ml/kg
e) 55-60 ml/kg
3. which persons have higher insensible fluid loses and require administration of additional
fluid? (choose right)
a) with decreased body temperature
b) febrile patients
c) those on artificial breathing support
d) with dyspnea
e) aged persons
4. which fluid losses are assumed as an insensible loses? (choose right)
a) obligatory urinary loses
b) cutaneous water loses (sweating)
c) gastrointestinal loses
d) respiratory water loses
5. the ongoing fluid loses at surgical patients are represented by the following (choose
right)
a) lost blood during operation
b) obligatory urinary loses
c) fistula loses
d) cutaneous water loses (sweating)
e) loses of fluid through drains
6. the third space fluid sequestration may be cause by the following (choose right)
a) lost blood during operation
b) obligatory urinary loses
c) excessive dissection (trauma) at the operative site
d) cutaneous water loses (sweating)
e) loses of fluid through drains

7. because of leakage of crystalloid solutions from an intravascular to an interstitial space


the lost plasma volume must be replaces by lactated Ringer's solution with a following ratio
(choose right)
a) 1 : 0,5
b) 1 : 1
c) 1 : 2
d) 1 : 3
e) 1 : 4

8. the usual practice at patients after GIT surgery who is not allowed to take fluids by
mouth is to maintain body fluids requirements with following i.v. administered solutions
(choose right)

41
a) albumin
b) hemodes (povidon)
c) dextrose 5% in water
d) red blood cells
e) Ringer's solution

9. replenishing fluids which were lost and considered as an ongoing loses the following
should be taken into account (choose right)
a) patient's weight
b) sex
c) composition of lost fluid
d) amount of losing fluid
e) patient's age

10. the following body parameters are frequently reassessed providing infusion therapy
(choose right)
a) arterial blood gases
b) urinary output
c) body temperature
d) central venous pressure
e) pupillary reflex

11. a patient which is in hypovolemic state may represent the following signs and symptoms
(choose right)
a) peripheral edema
b) dry mucous membranes
c) dilute urine
d) low urine output
e) polyuria

12. the following characteristic changes in the laboratory values are seen in the analyses of
a patient suffering by hypovolemia caused by fluid sequestration (choose right)
a) urine output ↑
b) urine output ↓
c) urine specific gravity ↑
d) urine specific gravity ↓
e) Ht ↓

Clinical tasks
Task № 1
Clinical scenario: a 70 kg woman has had an elective cholecystectomy.
Questions:
1. How much fluid (water) does she need at the first postoperative day?
2. How much sodium and potassium does she need daily?
3. What i.v. solution (s) is (are) to be ordered during the first postoperative day?
4. What i.v. solution (s) is (are) to be ordered during the second postoperative day if
circumstances are the same?
5. Is a potassium supplementation provided at first postoperative day?
6. Why is the patient given fluid i.v. but not orally?
Task № 2
Clinical scenario: a 100 kg man has had an elective resection of a part of the bowel.
The patient has developed paralytic ileus. To decompress the GIT a nasogastric tube is

42
inserted. Over the next 24 hours, there are 1000ml of nasogastric drainage. Serum electrolytes
are normal.
Questions:
1. What is a total volume of fluid needed at the first postoperative day?
2. How much fluid (water) does he need to cover maintenance daily requirements?
3. How much fluid (water) does he need to cover ongoing loses?
4. What i.v. solution (s) and how much is (are) to be ordered during the first
postoperative day?
5. What i.v. solution (s) is (are) to be ordered during the second postoperative day if the
circumstances are the same?
6. Is a potassium supplementation provided at first postoperative day?
7. Why is the patient given fluid i.v. but not orally?
Task № 3
Clinical scenario: a 100 kg man has had an emergency surgery - resection of 2/3 of
the stomach (Billirot II type of resection) due to peptic ulcer complicated by internal bleeding
(1000ml of blood have been lost). The patient has developed paralytic ileus. To decompress
the GIT a nasogastric tube is inserted. Over the next 24 hours, there are 500ml of clear
nasogastric drainage. Serum electrolytes are normal.
Questions:
1. What is a total volume of fluid needed at the first postoperative day?
2. How much fluid (water) does he need to cover maintenance daily requirements?
3. How much fluid (water) does he need to cover ongoing loses?
4. What i.v. solution (s) and how much are ordered to cover existing deficit?
5. What i.v. solution (s) and how much is (are) to be ordered during the first
postoperative day?
Task № 4
Clinical scenario: a 100 kg man has had an emergency surgery - resection of 2/3 of
the stomach (Billirot II type of resection) due to peptic ulcer complicated by internal bleeding
(1000ml of blood has been lost). Intraoopertively the blood loss was replaced with colloids.
The first postoperative day is managed with sufficient orders of fluid. Despite the proper
treatment the signs of paralytic ileus persist, and there are still 500ml of nonstained
nasogastric drainage. Please give orders at the second postoperative day.
Questions:
1. What is a total volume of fluid needed at the second postoperative day?
2. How much fluid (water) does he need to cover maintenance daily requirements?
3. How much fluid (water) does he need to cover ongoing loses?
4. How much fluid (water) does he need to cover existing deficit?
5. What i.v. solution (s) and how much is (are) to be ordered during second postoperative
day?
Task № 5
Clinical scenario: A 70 kg woman has been suffering by prolonged vomiting for two
days. She complaints of marked thirst. Examining the patient the following signs are found:
dry tongue, loss of skin turgor, increased heart rate, 90/60 mmHg blood pressure at upright
position, urine output is 200 ml/daily.
Questions:
1. What is a degree of dehydration?
2. What changes do you expect in hematocrit, level, urine osmolality, and CVP?
3. How much fluid (water) and what i.v. solution does she need to cover existing deficit?
4. How much fluid (water) should be given during a day?

43
TOPIC 8 BLEEDING AND HEMOSTASIS
The following professional competences of a student have to be formed after preparation
of the topic:
Ability to recognize eternal and internal bleeding;
Ability to manage external and internal bleeding in the extend of the skills of the medium
level medical worker;

I. Motivation of the goal:


Bleeding is a challenging part of the emergency surgery. This pathology is a direct
threat to the patient‟s life or an injured one and the patient's future depends on immediate
actions of a doctor. The knowledge of this theme is absolutely necessary for a doctor of any
specialty. Each doctor should be able to distinguish bleedings which do not always have
obvious manifestations and can be hidden under a mask of other diseases and states; to be
able to estimate a degree of hemorrhage; to master the methods to control bleeding.

II. The goal of self-preparation:


To study the kinds and clinical manifestations of bleedings, to acquire the basic
principles of diagnosis and methods of temporary and permanent hemostasis.

III. Studying purposes.


After self-contained studyingof the topic a student must
Know:
 the classification of bleeding;
 the characteristics of arterial, mixed, capillary bleeding;
 the general features of a hemorrhage;
 methods of a temporary control of external bleeding;
 the rules of tourniquet application;
 methods of a permanent control of bleeding;
 principles of the first-aid treatment at patients and injured after a significant
hemorrhage;
 the clinical manifestations of internal bleedings into the peritoneal,pleural,and
pericardial cavities;
 the procedure of diagnosis of a bleeding based on a circulating blood volume,
hematocrite, hemoglobin, a number of erythrocytes, a pulse rate, and, blood pressure;
 modern principles in treatment of bleeding.
Be able to:
 distinguish arterial, venous, capillary, mixed bleeding;
 carry out the temporary control of an external bleeding by application of a
compressing bandage;
 carry out the temporary control of a bleeding by tourniquet application;
 carry out the temporary control of a bleeding by digital compression of vessels;
 carry out the temporary control of a bleeding by putting a clamp;
 carry out the final control of a bleeding by ligation ofa vessel in a wound and on a
course, tamponade;
 carry out the final control of a bleeding by coagulation and cryosurgery;
 define a degree of a hemorrhage based on circulating blood volume, hematocrite,
hemoglobin, quantity of erythrocytes, pulse rate, blood pressure, central venous pressure;
 carry out the objective examination and reveal special symptoms at
hemoperitoneum;
 carry out the objective examination athemothorax and hemopericardium.
Practice and demonstrate:
 Skills of temporary hemostasis in patients of different age groups.

44
IV. The initial level of knowledge:
For successful mastering of the given topic it is necessary to repeat:
1. The topographical anatomy of the main blood vessels.
2. The physiological mechanism of a bleeding control and compensatory
mechanisms at hemorrhage.
3. The mechanism of a spontaneous bleeding control.

V. The plan of studying the topic.


1. The classification of bleeding.
2. The physiological response of an organism to an acute hemorrhage.
3. The clinical manifestations of external and internal bleedings.
4. Clinical and instrumental diagnosis of bleeding.
5. The estimation of a degree of a bleeding.
6. Methods of temporary and permanent bleeding control.
7. Modern principles of bleeding management.
8. Safe limits of hemodynamic.
9. The blood-saving technologies in surgery.
10. The transportation of patients with hemorrhage.

VI. The recommended literature:


Suggested readings:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. pp. 46-56.
3. "Short practice of surgery" Bailey and Love's, 1996. Chapter 4 pp. 40-42.
4. "Basic surgical techniques" 2001 Chapter 4:2 pp. 72-80.
Supplemental materials:
1. SURGERY. Basic science and clinical evidence. USA., 2000., Pp. 259-263.
2. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991, Pp. 85-103.

VII. Questions for the self-control.


1. The classification of bleeding.
2. Clinical manifestations of bleeding.
3. Clinical picture of bleeding.
4. Methods of diagnosis of a hemorrhage.
5. Clinical manifestations at hemothorax.
6. Clinical manifestations at hemoperitoneum.
7. Dangers and outcomes of bleeding.
8. Kinds of bleeding control, basic principles.
9. Methods of the temporary control of a bleeding.
10. Methods of the permanent control of a bleeding.

VIII. Tasks for self-preparation:


1. Write the classification of bleeding.
2. Draw the scheme of the typical points of digital compression of large vessels.
3. Make a plan of the patient's examination with hemoperitoneum.
4. Write the scheme of the process of formation of a fibrin in blood.
5. Draw the basic kinds of vascular suture.
6. Introduce the normal blood values (erythrocytes, hemoglobin, platelets,
hematocrite).
7. Write the chemical hemostatic agents.
8. Write the haemostatic drugs of local action.

45
9. Write the haemostatic drugs of general action.
10. List the drugs applied to control bleeding in patients with hemophilia.

Tests

1. classification of a bleeding type according to the source includes the following (choose
right)
a) capillary
b) arterial
c) internal
d) venous
e) external

2. which factor is the most important in the development of pathophysiologic changes in


response to blood loss (choose right)
a) patient‟s age
b) speed of blood loss
c) underlying pathologies
d) coexisting conditions
e) patient‟s position

3. clinical manifestation of acute hemorrhage includes the following changes (choose


right)
a) dry skin
b) malaise
c) fainting
d) rapid, weak pulse
e) drop of RBC

4. clinical presentation of the pulmonary bleeding is the following (choose right)


a) foamy blood
b) dark red color of the blood
c) bright red color of the blood
d) black color of a stool
e) escapes through the mouth

5. clinical presentation of the bleeding from the gastric ulcer is the following (choose right)
a) ground coffee-like color of vomiting masses
b) dark red color of the blood
c) bright red color of the blood
d) foamy blood
e) escapes through the mouth

6. clinical presentation of the bleeding from the bowel carcinoma is the following (choose
right)
a) escapes through the anus
b) dark red color of the blood
c) bright red color of the blood
d) black color of a stool
e) escapes through the mouth

46
7. examining a patient with hemoperitoneum the most valuable tools are the following
(choose right)
a) general examination with assessment of a local status
b) plain X-ray of the chest
c) laparoscopy
d) endoscopic esophgogastroscopy
e) ultrasound of the chest

8. examining a patient with hemopericardium the most valuable tools are the following
(choose right)
a) general examination with assessment of a local status
b) plain X-ray of the chest
c) contrast X-ray series of the chest
d) endoscopic esophgogastroscopy
e) colonoscopy

9. examining a patient with hemothorax the most valuable tools are the following (choose
right)
a) general examination with assessment of a local status
b) echocardiograph
c) laparoscopy
d) endoscopic esophgogastroscopy
e) plain X-ray of the chest

10. physical means of hemostasis are the following (choose right)


a) placement of the ice bag
b) ligation of a vessel
c) laser
d) fresh frozen plasma
e) cauthery (diathermy)

11. chemical and biological means of hemostasis are the following (choose right)
a) placement of the ice bag
b) aminocapronic acid
c) laser
d) fresh frozen plasma
e) cauthery (diathermy)

12. mechanical means of hemostasis are the following (choose right)


a) placement of the ice bag
b) ligation of a vessel
c) laser
d) fresh frozen plasma
e) vascular suture

Clinical tasks

Task № 1
Clinical scenario: A 36 year old victim of a road traffic accident was admitted to the
hospital. The trauma of the chest was caused by steering wheel. A patient complains of severe
chest pain and dyspnea. He is confused. A skin is pale and cyanotic. The vital signs are the
following: Pulse rate is 130, weak; arterial blood pressure is 90/50; respiratory rate is 35.

47
Examination of the respiratory system is done. There are no any wounds on the chest wall.
An unequal expansion of the chest (left part), bulging of ICS on the affected side, normal
vocal fremitus and dull percussion note over left chest part are found. The heart and arch of
the aorta are displaced towards right. Breath sounds are absent at the left side.
Questions:
1. What is your primary diagnosis?
2. What is a type of bleeding?
3. What percentage of circulating blood is lost?
4. What laboratory changes do you expect? List expected results.
5. How can you confirm diagnosis?
6. What methods of biological hemostasis can be used to improve hemostasis?

Task № 2
Clinical scenario: A half hour ago, a teenage boy was beaten in the street.
Immediately after an accident he noticed diffuse abdominal pain and general weakness. Due
to that, he was admitted to the hospital. The boy complains of abdominal pain and fainting.
He is anxious and prefers to lie still. The skin is clammy. The vital signs are the following:
Pulse rate is 110, weak; arterial blood pressure is 110/60; respiratory rate is 25. Examining the
GIT system there is a bruising and abrasions at the area of upper left quadrant. A moderate
rebound tenderness and voluntary muscle guarding are noticed over all anterior abdominal
wall. The peristalsis is diminished.
Questions:
1. What is your primary diagnosis?
2. What organ is likely to be injured?
3. What percentage of circulating blood has been lost?
4. What laboratory changes do you expect? List expected results.
5. How can you confirm diagnosis?
6. What methods of biological hemostasis can be used to improve hemostasis?

Task № 3
Clinical scenario: A teenage girl attempted to commit a suicide by cutting her forearm
veins open. In 20 minutes after an accident she is found. She is confused. The skin is clammy.
The pulse rate is 140, weak; arterial blood pressure is 90/40; respiratory rate is 35. There is an
incised wound 10/3 cm size at the left cubital area with slowly running dark non-pulsating
blood from completely transected basilic and cephalic veins.
Questions:
1. Classify the bleeding according to a) source of bleeding b) area of bleeding.
2. What percentage of circulating blood has been lost?
3. What laboratory changes do you expect? List expected results.
4. What methods of temporary hemostasis can be accomplished (at least five)?
5. What methods of permanent hemostasis is to be done at the hospital?

Task № 4
Clinical scenario: A 22 year old male has been stricken by the knife into the left
thigh. He was found 10 minutes later after an accident. The patient is confused. The skin is
clammy. The pulse rate is 150 very weak; arterial blood pressure is 50; respiratory rate is 35.
There is a stab wound 1/0,3 cm size of the left upper thigh with running pulsating bright red
blood.
Questions:
1. Classify the bleeding according to a) source of bleeding b) area of bleeding.
2. What percentage of circulating blood has been lost?
3. What laboratory changes do you expect? List expected results.

48
4. What methods of temporary hemostasis can be accomplished (at least five)?
5. What methods of permanent hemostasis is to be done at the hospital?

Task № 5
Clinical scenario: A 56 year old male patient has been suffering from continuous
vomiting for two days (15 times). According to the patient the vomiting was caused by
spoiled food. At the beginning the vomitus was of usual color. Last vomiting happened 1 hour
ago and was mixed with dark red blood. The patient is anxious. The skin is clammy. The
pulse rate is 110 very weak; arterial blood pressure is 120/80; respiratory rate is 25. A system
examination has not revealed any abnormalities of internal organs. The abdomen is soft and
slightly tender in the epigastric area.
Questions:
1. What is the source of bleeding? What is it caused by?
2. What percentage of circulating blood has been lost?
3. How can you precisely identify the source of bleeding?
4. How can the bleeding be controlled (offer at least three)?
5. What methods of biological hemostasis can be used?
6. When is an open suturing of bleeding vessel necessary?

49
TOPIC 9 TRANSFUSION THERAPY
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to determine indications to blood transfusion in surgical patients;
 Ability to do a blood transfusion in surgical patients under a surgeon‟s
supervision.

I. Motivation of the goal:


Hemotransfusion as a method of treatment occupies the special area in
transplantology. Hemotransfusion is the original transplantation of a living tissue that has a
multiple influence on the patient‟s organism and cannot be achieved by any other agents. The
knowledge of this theme is especially important for the students of the medical faculty
because a doctor of any specialty will inadvertently face hemotransfusion in the professional
work.

II. The goal of self-preparation:


To study the methods of blood typing, principles of the modern hemotransfusion
therapy, hemotransfusion complications and principles of treatment, modern methods of
preparation, preservation of blood and its components.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the history of hemotransfusion;
 basic characteristics and methods of blood typing;
 the indications to a hemotransfusion;
 the contraindications to a hemotransfusion;
 the duties of a doctor transfusing blood;
 the principles of the modern hemotransfusion therapy;
 hemotransfusion complications and reactions;
 the rules of the blood donor examination;
 modern methods of preparation and preservation of blood and its components.
Be able to:
 determine a blood type with the aid of standard serums and standard washed
erythrocytes with the known blood group;
 determine blood groups by means of coliclones anti-A and anti-B;
 carry out the tests on the individual compatibility of blood (cross-matching) ;
 carry out the tests of compatibility of bloodon the Rh factor;
 carry out the biological compatibility test at a hemotransfusion;
 assemble and prepare to work the line for a transfusion of blood and blood
substitutes;
 determine the suitability of blood for a transfusion.
Practice and demonstrate:
 algoritm of indications and technique of blood transfusion in patients of different
age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the cellular
composition of blood and the basic functions of blood from the course of normal physiology.

V. The plan of studying the topic.


1. The immunological bases of hemotransfusion.

50
2. Blood systems ABO and Rh. The methods of blood typing.
3. Modern rules of the blood transfusion.
4. The duties of a doctor transfusing blood.
5. Blood-compatibility tests of a donor and a recipient before transfusion.
6. The recording of a hemotransfusion.
7. Hemotransfusion reactions and complications: prophylaxis, diagnosis, and
principles of treatment.
8. The rules of examination of donors, the blood, and its components.
9. Modern methods of preparation and preservation of blood and its components.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 56-82.
3. "Surgery" Bruce E. Jarrell., 1991. Pp. 23-26.
Supplemental materials:
1. "Scientific American Surgery" I : 6 Pp. 1-20.
2. "Oxford textbook of surgery" Chapter 3.5.

VII. Questions for the self-control.


1. Blood systems ABO and Rh.
2. The indications to a hemotransfusion.
3. The absolute and relative contraindications to a hemotransfusion.
4. Method of blood typing to ABO and Rh-factor antigens.
5. Methods and procedure of hemotransfusion.
6. The complications of a hemotransfusion.
7. Preservation and storage of blood.
8. Determining the bloodsuitability for a transfusion.
9. Blood components and blood substitutes.

VIII. Tasks for self-preparation:


1. Draw the scheme of blood typing with the help of standard serums.
2. List the mechanisms of action of the blood after transfusion.
3. List the basic hemotransfusion solutions.
4. List the methods of hemotransfusion.
5. Draw the system for intravenoushemotransfusion.
6. Draw the system for intra-arterialhemotransfusion.
7. Draw the classification of hemotransfusion complications.
8. Draw the scheme of hemotransfusion shock treatment.
9. Draw the scheme of blood typing with the help of coliclones.
10. Make a record of hemotransfusion, in the patient's chart.

Tests

1. the following agent is used for preservation from clotting of a donated blood (choose
right)
a) saline solution
b) Na bicarbonate
c) K chloride
d) Na citrate
e) CaCl

51
2. what is the action of Na citrate at the clotting process? (choose right)
a) prevents formation of clotting factors by the liver
b) reduces absorption of Vit K by the bowel
c) binding of Ca ions
d) blocks the conversion of prothrombin to thrombin
e) blocks the conversion of fibrinogen to fibrin

3. the following blood component has level of Ht approximately equal to 70% (choose right)
a) fresh frozen plasma
b) cryoprecipitate
c) packed RBC
d) factor concentrate
e) albumin

4. which blood component is predominantly used to increase oxygen caring capacity of the
blood? (choose right)
a) fresh frozen plasma
b) cryoprecipitate
c) platelet concentrate
d) factor
e) packed RBC

5. which blood component is predominantly used during massive transfusion of packed


RBC and to maintain oncotic blood pressure? (choose right)
a) fresh frozen plasma
b) cryoprecipitate
c) packed RBC
d) factor concentrate
e) albumin

6. which blood component is predominantly used to correct factor abnormalities (liver


diseases, DIC)? (choose right)
a) platelet concentrate
b) cryoprecipitate
c) packed RBC
d) factor concentrate
e) fresh frozen plasma

7. which blood component is especially effective at hemophilic patients and states with
uncontrolled bleeding (DIC)? (choose right)
a) platelet concentrate
b) cryoprecipitate
c) packed RBC
d) factor concentrate
e) albumin

8. which blood component is most useful at patients with inherent deficiency of one of
clotting factor synthesis? (choose right)
a) platelet concentrate
b) cryoprecipitate
c) packed RBC
d) specific factor concentrate
e) albumin

52
9. the following solutions are referred to the group of solutions for parenteral nutrition
(choose right)
a) saline solution
b) moderate molecular dextrans (polyglucin)
c) dextrose 40%
d) povidon (hemodes)
e) fat emulsion (10 - 20%)

10. the following solutions are referred to the group of acid-base regulating solutions
(choose right)
a) saline solution
b) moderate molecular dextrans (polyglucin)
c) dextrose 40%
d) povidon (hemodes)
e) lactated Ringer's solution

11. the following solutions are referred to the group blood substitutes (choose right)
a) saline solution
b) moderate molecular dextrans (polyglucin)
c) fluorocarbon
d) povidon (hemodes)
e) aminoacids

12. indications to blood transfusion are the following (choose right)


a) septic endocarditis
b) hypertension
c) severe anemia
d) congestive heart failure
e) severe acute blood loss

Clinical tasks

Task № 1
Clinical scenario: A 70 kg victim of a road traffic accident is admitted to the hospital.
He complains of abdominal pain and fainting. He is anxious and prefers to lie still. The skin is
clammy. The vital signs are the following: Pulse rate is 110, weak; arterial blood pressure is
120/70; respiratory rate is 25, a CVP is 2 cm of water. Examining the GIT system there is a
bruising and abrasions at the area of upper left quadrant. A moderate rebound tenderness and
voluntary muscle guarding are noticed over all anterior abdominal wall. The peristalsis is
diminished. A physician has suspected an intraabdominal hemorrhage due to spleen rupture.
Questions:
1. What percentage of circulating blood has been lost?
2. List expected laboratory changes.
3. Name solutions that can be used to replace the lost blood (at least 5)?
4. What is a volume of administered solutions?

Task № 2
Clinical scenario: A 36 year old 70 kg victim of a road traffic accident was admitted
to the hospital with left side hemothorax due to blunt chest trauma. The chest drain is inserted,
shed blood is drained out. There is no evidence of continuous hemorrhage, the lung is fully
expanded. He is confused. The skin is pale. The vital signs are the following: Pulse rate is
140, weak; arterial blood pressure is 80/20; respiratory rate is 30. A physician has decided to

53
perform blood transfusion. According to medical notes the patient has A (II) Rh-negative
blood type. Due to lack of time, the doctor has started transfusion of A (II) Rh-negative
packed RBC without retyping. Almost immediately the patient has experienced fever, chills,
itching, chest and back pain, dyspnea. Vital signs are the following: PR is 150, ABP is 60/0.
Questions:
1. What percentage of circulating blood has been lost?
2. Was the blood transfusion indicated?
3. What complication has developed after beginning of blood transfusion?
4. What are the reasons of the developed complication?
5. What is treatment of the developed complication?

Task № 3
Clinical scenario: A patient suffering from left side hemothorax is treated in the
hospital. The chest drain is inserted, 500 ml of blood is drained out. There is a continuous
leakage of blood through the drain (approximately 200 ml during 10 minutes). A surgeon has
decided to perform thoracotomy to stop bleeding. Having opened the pleural cavity there is
500 ml of shed blood. The surgeon is going to collect and transfuse the shed blood.
Questions:
1. Name the transfusion procedure that the surgeon is going to perform.
2. What are the advantages of this technique?
3. What are the disadvantages of this technique?
4. What are the contraindications to this method?
5. List other methods of autologous blood transfusion.

Task № 4
Clinical scenario: A 22 year male has been stricken by the knife into the left thigh. He
was found 10 minutes later after an accident. The patient is lethargic. The skin is clammy. The
pulse rate is 150 very weak; arterial blood pressure is 40/0; respiratory rate is 35. There is a
stab wound 1 to 0,3 cm size at the left upper thigh with pulsating bright red blood. A
physician has controlled bleeding by application of a tourniquet. Firstly, he has administered
crystalloid solutions (2 L i.v.). After twenty minutes the arterial blood pressure is 100, pulse
rate is 130.
Questions:
1. What percentage of circulating blood has been lost?
2. Name solutions what are to be administered further.
3. What is a volume of administered solutions?
4. List indications to blood transfusion.

Task № 5
Clinical scenario: A 42 year old patient was injured and suffered by severe external
bleeding from the brachial artery. The patient was lethargic. The skin was clammy. The pulse
rate was 150 very weak; arterial blood pressure was 50/10; respiratory rate was 35. After 20
minutes a doctor controlled bleeding and obtained the blood sample for RBC count, typing
and Rh examination. In ten minutes, the results are ready. Hb is 120 gm/l; RBC is 3,6; Ht is
0.35; the doctor is not going to administer blood transfusion because according to lab values
the transfusion is not indicated.
Questions:
1. What percentage of circulating blood has been lost?
2. Why don‟t the lab values show typical changes to this degree blood loss?
3. Is decision of the doctor right?
4. Should the doctor at this situation rely on laboratory values choosing transfusion
agent?

54
TOPIC 10 HEMOSTATIC DISTURBANCES IN SURGICAL PATIENTS

The following professional competences of a student have to be formed after preparation


of the topic:
 Ability to recognize basic pathologic symptoms and signs of disorders of the
hemostatic system
 Ability to provide first aid to patients with disorders of the hemostatic system

I. Motivation of the goal:


Pathology of the blood coagulation occurs very frequently in surgical patients. The
reasons of the blood coagulation pathology are various: coexisting diseases of the blood and
liver, serious trauma, endogenous toxicosis, various kinds of shock. The developing
thromboembolic episodes or hemorrhagic complications considerably worsen the basic
disease, and become quite often the instant causes of lethal outcomes. Therefore, well-timed
diagnosis and treatment of the hemostatic pathology is an important task.

II. The goal of self-preparation:


To study the reasons, clinical manifestations, principles of diagnosis, and treatment of
hemostatic disorders in surgical patients.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the basic features of the system of hemostasis;
 the laboratory and instrumental methods of examination of hemostasis;
 the diseases which can cause the changes in the hemostatic system;
 prophylaxis and principles of treatment of the thromboembolic syndrome;
 prophylaxis and principles of treatment of the hemorrhagic syndrome.
Be able to:
 carry out a subjective examination of patients with pathology of the hemostasis (to
reveal the complaints, to collect anamnesis) ;
 find out clinical symptoms of a thromboembolic syndrome;
 find out clinical symptoms of a hemorrhagic syndrome;
 estimate the parameters of pro- and antihemostatic systems in an individual
patient;
 carry out theelastic bandaging of legs before operation for the prophylaxis of deep
vein thrombosis.
Practice and demonstrate:
 Skills ofthe diagnosis and first aid algorithm actions to patients of different age
groups with hemorrhagic and thromboembolic syndromes.
IV. The initial level of knowledge:
For successful mastering of the given topic,it is necessary to repeat the physiology of
pro- and antihemostatic systems in humans.

V. The plan of studying the topic.


1. Clotting factors and the mechanism of thrombogenesis.
2. Factors of the anticoagulation system and the mechanisms of fibrinolysis.
3. Methods of examination of coagulation and anticoagulation systems.
4. Diseases which can cause changes in the hemostatic system.
5. The influence of a surgical operation on the hemostasis.
6. The medicines influencing the hemostatic system.
7. Prophylaxis and principles of treatment of the thromboembolic syndrome.

55
8. Prophylaxis and principles of treatment of the hemorrhagic syndrome.
9. The syndrome of disseminated intravascular coagulation (DIC-syndrome): the
reasons, principles of diagnosis, treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials
2. Scientific American Surgery 1997, Chapter 1 : 7 (Bleeding) pp. 1-11;
Supplemental materials:
1. "Textbook of surgery. The biological basis of modern surgical practice" Sabiston.,
USA., 1991. Pp. 85-103.
2. "General surgery" the manual., V.K. Gostishev, 2003, Pp. 53-54
3. "Surgery" Bruce E. Jarrell., 1991. Pp. 18-26.

VII. Questions for the self-control.


1. The Virhov‟s triad of spontaneous thrombogenesis.
2. Normal parameters of a coagulogram.
3. Which diseases reduce the natural hemostasis? Why?
4. Which diseases increase the natural hemostasis? Why?
5. Which stages of operation reduce hemostasis?
6. Which stages of operation increase hemostasis?
7. Which medicines activate the hemostaticsystem?
8. Which medicines activate the antihemostatic system?
9. How is the prophylaxis of the thromboembolic syndrome carried out?
10. How is the prophylaxis of the hemorrhagic syndrome carried out?

VIII. Tasks for self-preparation:


1. Draw the scheme of the coagulation system.
2. Draw the scheme of the anticoagulation system.
3. Describe the clinical complex of symptoms of a thromboembolic syndrome.
4. Describe the clinical complex of symptoms of a hemorrhagic syndrome.
5. Introduce the normal parameters of the coagulation system.
6. Introduce the normal parameters of the anticoagulation system.
7. Write the medicines which activate the natural hemostasis.
8. Write the medicines which activate the fibrinolytic activity of blood.
9. Describe the reasons and pathology of the syndrome of disseminated intravascular
coagulation (DIC-syndrome).
10. Write the principles of diagnosis of the DIC-syndrome

Tests

1. which factor activation does seem to be most apt to activation of clotting cascade,
fibrinolysis, and triggering inflammatory response in the case of DIC-syndrome? (choose
right)
a) III factor
b) IV factor
c) I factor
d) XII factor
e) VII factor

2. choose valuable laboratory tests for diagnosis of DIC-syndrome (choose right)


a) platelet count

56
b) PT
c) D-dimer level (fibrin split products)
d) PTT
e) all are right

3. how are the following values in the case of DIC-syndrome changed? (choose right)
a) PT is shortened
b) D dimer level is decreased
c) PTT is shortened
d) PTT is prolonged
e) D dimer level is elevated

4. how are the following values in the case of DIC-syndrome changed? (choose right)
a) fibrinogen level is increased
b) fibrinogen level is decreased
c) platelet count is increased
d) platelet count is decreased
e) bleeding time is prolonged

5. treatment of DIC-syndrome includes the following (choose right)


a) treatment of underlying reason
b) replenishment of circulating volume with crystalloid solutions and volume expanders
c) administration of e-aminocaproic acid
d) administration of fresh frozen plasma
e) all aforementioned are used

6. vessel response to injury consists of following processes (choose right)


a) adherence of platelets to each other
b) conversion of prothrombin to thrombin
c) constriction
d) activation of fibrinolysis
e) retraction

7. an aspirin (NSAID) has the following kind of action at the hemostatic process (choose
right)
a) increase bleeding
b) inhibition of XII factor
c) activation of fibrinolysis
d) activation of cicloxygenase
e) inhibition of cicloxygenase

8. duration of aspirin action(equal to platelet life span) is approximately the following


(choose right)
a) 1-2 days
b) 2-4 days
c) 4-6 days
d) 7-10 days
e) 10-15 days

9. bleeding time reflects the following (choose right)


a) adequate number of platelets
b) integrity of the extrinsic coagulation pathway

57
c) normal platelet function
d) integrity of the intrinsic coagulation pathway
e) adequate number of RBC

10. prothrombin time reflects the (choose right)


a) adequate number of WBC
b) integrity of the extrinsic coagulation pathway
c) normal platelet function
d) integrity of the intrinsic coagulation pathway
e) adequate number of RBC

11. the majority of clotting factors are synthesized by the following organ (choose right)
a) spleen
b) brain
c) kidney
d) liver
e) GIT

12. the following pathologic conditions are referred to the vessel wall abnormalities (choose
right)
a) hemophilia B
b) Cushing's syndrome
c) splenomegaly
d) scurvy
e) idiopathic thrombocytopenic purpura

Clinical tasks

Task № 1
Clinical scenario: A 56 year old patient has been admitted to the hospital for elective
surgery. A resection of aortic aneurism is planned. The task of examiner is to reveal and
prevent possible hemorrhagic complications during surgery.
Questions:
1. What and why is a patient asked about during subjective examination?
2. What and why does a doctor pay attention to during objective examination?
3. Is laboratory investigation of coagulation system indicated? Why?
4. What laboratory tests do you Plain to administer?
5. List normal laboratory values of administered lab tests.

Task № 2
Clinical scenario: A 68 year old obese patient has been admitted to the hospital for
elective surgery. A replacement of diseased hip joint with prosthetic one is planned. A
subjective and objective examination have not discovered any coexisting diseases.
Questions:
1. What complication is possible in the postoperative period?
2. Does the complication represent direct thread to patient‟s life?
3. What could be the cause of patient‟s death in the postoperative period if the
complication would have developed?
4. List medicines which are to be administered to prevent the possible complication.
5. List other methods which are used to prevent the possible complication.

58
Task № 3
Clinical scenario: A year old obese patient has been operated. A surgery of ruptured
aortic aneurism has been done. The patient has already lost approximately 40% of circulating
intravascular volume. An infusion therapy with colloids and crystalloids is currently being
done. A transfusion of packed RBC is planned. Abdominal cavity contains 1,5 liter of spilled
blood. The patient is in shock (arterial BP is 60/20 mmHg, urine output is 10 ml during last
two hours, CVP is negative), the lactate level is increased significantly. Bleeding from aorta is
controlled with aortic clamp. Suddenly the diffuse bleeding from operative tissues has started.
Questions:
1. What complication is likely responsible for sudden diffuse bleeding?
2. What are the other possible causes of diffuse intraoperative bleeding?
3. Can a reinfusion be done?
4. What specific to complication laboratory changes do you expect?
5. What is the treatment of developed complication?

Task № 4
Clinical scenario: A 74 year old female was operated due to stomach cancer. The
gastrectomy was performed successfully. On a third postoperative day the patient started to
complait of moderate pain and edema of the right leg, elevation of body temperature till
37,5C0. The right leg is half larger of a left one due to edema which extends from tiptoes till
the groin. The color of the left leg is cyanotic. Palpation of the affected limb reveals
tenderness along the medial aspect of the calf and thigh. Pulsation of peripheral arteries is
normal.
Questions:
1. What complication has developed in the postoperative period?
2. What risk factors are responsible for developed complication in this case?
3. List other risk factors which can be responsible for developed complication in other
situations?
4. What should have been done to prevent developed complication?
5. What medicines are to be given to treat developed complication?
6. What lab values are to be monitored when treating developed complication? How
should they be changed if the medicine is effective?

Task № 5
Clinical scenario: A 54 year okd male has been suffering from mechanical jaundice
for 3 weeks caused by compression of the common bile duct due to the tumor of the
pancreatic head. The open surgery is planned to treat existing pathology.
Questions:
1. Does the bleeding risk exist during planned surgery?
2. What is the mechanism of developed in the patient coagulopathy?
3. What lab tests can find existing coagulopathy?
4. How are they changed in the patient?
5. What medicine is to be administered to prevent the development of coagulopathy?
6. How can you correct existing coagulopathy instantaneously?

59
TOPIC 11 TERMINAL CONDITIONS. PRINCIPLES OF RESUSCITATION. SHOCK
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize terminal and shock states in surgical patients.
 Provide first aid to surgical patients in terminal and shock states.

I. Motivation of the goal:


Terminal and shock conditions occur quite frequently in surgical patients. Their
reasons and clinical manifestations are various. The decisive importance in the treatment of
these conditions is the well-timed resuscitation, and the knowledge of its principles. They are
obligatory for every student of a high medical school.

II. The goal of self-preparation:


To study clinical manifestations, principles of diagnosis and treatment of the terminal
and shock conditions.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 clinical manifestations of the terminal conditions;
 clinical manifestations of the shock conditions;
 clinical attributes of the clinical and biological death;
 indications for carrying out the resuscitation;
 the criteria of efficacy of the resuscitation;
 principles of diagnosis and treatment of the various kinds of shock.
Be able to:
 reveal the terminal conditions, carry out the cardiopulmonary resuscitation;
 fulfill the artificial respiration;
 give the clinical characteristic to different kinds of shock;
 provide the first aid at a traumatic shock;
 provide the first aid at a hypovolemic shock;
 provide the first aid at an acute anaphylaxis.
Practice and demonstrate:
 recognition of a sort of the terminal and shock state and skills of the
cardiopulmonary resuscitation to patients of different age groups.
IV. The initial level of knowledge:
A student should revise the concept of the first medical aid, the parameters of vital
functions (blood pressure, pulse, frequency and volume of respiratory expansions, etc.).

V. The plan for the topic studying.


1. Clinical evaluation of the patient‟s general condition.
2. The kinds of the terminal conditions.
3. Cardiopulmonary resuscitation.
4. Traumatic shock: reasons, attributes, diagnosis and treatment.
5. Hypovolemic shock: reasons, attributes, diagnosis and treatment.
6. Acute anaphylaxis: reasons, attributes, diagnosis and treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. pp. 38-45.

60
3. "Introductory medical-surgical nursing" Jeanne C. Sherer., 1995, Pp. 248-256;
507-518.
4. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp.381-395.
Supplemental materials:
1. "SURGERY. Basic science and clinical evidence". USA., 2000, Pp. 259-277.
2. Scientific American Surgery, 1997. I : 4
3. "Textbook of surgery. The biological basis of modern surgical practice" Sabiston.,
USA., 1991, Pp. 34-57.

VII. Questions for the self-control.


1. What criteria is the general condition of a patient assessed by?
2. The objective methods of evaluation of severity of the patient‟s condition.
3. The kinds of the terminal conditions.
4. The symptoms and diagnosis of the terminal conditions.
5. The criteria of efficacy of the resuscitation.
6. The principles of the cardiopulmonary resuscitation.
7. Indications to stop further cardiopulmonary resuscitation.
8. Kinds of shock.
9. Pathology, clinical manifestations of ashock.
10. Diagnosis of a shock: a shock index.
11. The first medical aid in shock.
12. The reasons of a traumatic shock.
13. The attributes of a traumatic shock.
14. Diagnostics and treatment of a traumatic shock.
15. The reasons and attributes of a hypovolemic shock.
16. Diagnostics and treatment of a hypovolemic shock.
17. The reasons and attributes of an acute anaphylaxis.
18. Diagnostics and treatment of an acute anaphylaxis.
19. Complex therapy of a shock.
20. The criteria of a successful treatment.

VIII. Tasks for self-preparation:


1. Write the symptoms of the terminal conditions.
2. Write the shock index to be calculated.
3. Write the stages and phases of a traumatic shock development.
4. Make a scheme of a hypovolemic shock treatment.
5. Describe the first pre-medical aid in a traumatic shock.
6. Describe the symptomsof an acute anaphylaxis.
7. Make a scheme of the homeostasis impairment in various terminal conditions.
8. Make a scheme of protective and adaptive mechanisms of an organism while
dying.
9. Write the reasons of a cardiac arrest.
10. Describe the complications of a cardiopulmonary resuscitation.

Tests

1. apatient is considered to be in a severe condition in the following circumstances (choose


right)
a) GCS less than 15 points
b) shock index 1,0
c) GCS less than 10 points

61
d) GCS less than 3 points
e) shock index 1,5

2. the following statements are right regarding biological death (choose right)
a) resuscitation lasts for 3-5 minutes
b) this period is limited by 3-5 minutes
c) resuscitation is not performed
d) irreversible changes in the brain have not developed yet
e) irreversible changes in the brain have already occurred

3. find all the measures used to maintain patency of upper airway during CPR (choose
right)
a) evacuation of foreign body from upper airway
b) use of Ambu bag
c) Heimlich maneuver
d) mouth-to-mouth ventilation
e) closed chest massage

4. find all the measures used to maintain breathing during CPR (choose right)
a) evacuation of foreign body from upper airway
b) use of Ambu bag
c) Heimlich maneuver
d) mouth-to-mouth ventilation
e) tracheostomy

5. find all the measures used to maintain circulation during CPR (choose three right)
a) placement of i.v line
b) use of Ambu bag
c) chin-lift maneuver
d) mouth-to-mouth ventilation
e) closed chest massage

6. the ratio of cardiac compression / blowing done by single care provider is as follows
(choose right)
a) 10 to 2
b) 20 to 2
c) 30 to 2
d) 5 to 2
e) 5 to 1

7. the ratio of cardiac compression / blowing done by two care providers is as follows
(choose right)
a) 10 to 2
b) 15 to 1
c) 30 to 2d) 5 to 2
e) 5 to 1

8. the following statements are true regarding treatment of septic shock (choose right)
a) control of infection focus (debridement, drainage etc.)
b) steroids
c) antibiotics
d) infusion therapy
e) diuretics

62
9. find true statements regarding compressive cardiogenic shock (choose right)
a) clear heart sound
b) distention of neck veins
c) rise of arterial blood pressure
d) muffled heart sound
e) rise of central venous blood pressure
10. the following statements are true dealing with management of traumatic shock (choose
right)
a) replenishment of circulating volume
b) treatment is focused on the treatment of cause
c) early reestablishment of circulation to ischemic tissues
d) prompt debridement of devitalized necrotic tissues
e) all are true
11. choose a right site for pericardiocentesis to be performed (choose one right)
a) 0,5cm immediately right to xiphoid tip
b) 0,5cm under the xiphoid tip
c) 1,5cm immediately left to xiphoid tip
d) at the fourth left intercostal space
e) 0,5cm immediately left to xiphoid tip
12. the following characteristic changes in the laboratory values are seen in the analyses of
a patient suffering by hypovolemia caused by fluid sequestration (choose right)
a) RBC decreases
b) WBC increases
c) central venous pressure is increased
d) central venous pressure is decreased
e) Hb increases
f) Hb decreases
Clinical tasks
Task № 1
Clinical scenario: A 12 year old girl has choked by the candy two minutes ago.
Prompt examination has revealed that carotid pulse, heart sounds, and breathing are absent.
The patient is unconscious and cyanotic.
Questions:
1. Name the existing condition.
2. What will happen if treatment is delayed?
3. How can you restore patency of upper airway? How much time do you have?
4. What surgery can restore airway if conservative measures have failed?
5. How can the breathing and circulation be maintained after restoration of airway
patency?
6. How should the effectiveness of CPR be assessed.

Task № 2
Clinical scenario: A surgeon is going to excise a hypertrophic scar of the right
shoulder. After prepping and draping of the area of surgery an injection of local anesthetic
lidocaine has been done. Almost immediately after injection the patient has lost the
consciousness. The skin is clammy. The vital signs are as follows: pulse rate on carotid
arteries is 150, weak; arterial blood pressure is 40; respiratory rate is 35.
Questions:
1. What has happened with the patient?
2. What should have been done before local anesthesia to avoid the complication?

63
3. List other factors leading to the same complication.
4. Explain the pathogenesis of developed complication.
5. What is a treatment of developed complication?

Task № 3
Clinical scenario: A 70 kg woman is admitted to the hospital. She complains of a
cramp-like abdominal pain and repeated vomiting. The mentioned signs have lasted during
one day. Two years ago, she was operated due to appendicitis. Examining the patient the
following signs have been found: the skin is dry and cold, peripheral veins are deflated, the
tongue is dry, heart rate is 140, 80/40 mmHg blood pressure at upright position, urine output
according to the patient was approximately 200 ml during last 24 hours. The CVP is 0 cm of
water. Lactate level is elevated. She is confused. The abdomen is tender, signs of peritoneal
irritation are absent. Basing on the clinical picture and obtained data of instrumental
investigation the doctor has diagnosed a bowel obstruction.
Questions:
1. Is the patient in shock? What is a kind of shock?
2. What pathophysiologic changes are responsible for the developed shock?
3. What specific to the shock laboratory changes are expected?
4. What is the mechanism of lactate level elevation? How can it be determined?
5. What is the immediate management of the patient?
6. How much fluid does she need to cover the existing fluid deficit completely?

Task № 4
Clinical scenario: A 32 year old male was stricken by the knife in the right shoulder.
He was found 10 minutes after an accident. The patient is confused. The skin is clammy. The
pulse rate is 150 very weak; arterial blood pressure is 50; respiratory rate is 35. There is a
lacerated wound 5/1 cm size on the medial surface of the right shoulder with pulsating bright
red blood.
Questions:
1. Is the patient in shock? What is a kind of shock?
2. What is the pathophysiology of the developed shock?
3. When and what specific to the shock laboratory changes are expected?
4. What methods of temporary hemostasis can be accomplished (at least three)?
5. How can the shock be reversed?
6. What method of permanent hemostasis is to be done at the hospital?

Task № 5
Clinical scenario: A 67 year old male is emergently admitted to the hospital. He
complainsof severe pain in the cardiac area. It started 30 minutes ago after physical exertion.
The patient has been suffering from hypertension (160 mmHg) for 10 years and previously
had myocardial infarction two years ago. The patient is confused. The skin is cyanotic and
cold. Pulse rate is irregular approximately 140; arterial blood pressure is 100/60; heart sounds
are muffled, the borders of the heart are increased, respiratory rate is 35, there are multiple
crackles at the lower parts of both lungs. Urine output according to the patient was
approximately 300 ml during last 24 hours. The CVP is 10 cm of water.
Questions:
1. Is the patient in shock? What is a kind of shock?
2. What is the pathophysiology of the developed shock?
3. How can you confirm the etiology of the shock?
4. What are the main principles of medical therapy?
5. What surgical procedures may be useful?

64
TOPIC 12 CRITICAL CONDITIONS IN SURGICAL PATIENТS
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize critical states in surgical patients.
 provide first aid to critical state patients.

I. Motivation of the goal:


The knowledge of critical states is necessary not only for professional work of a
doctor of any specialty, but also for the everyday life, as it allows to reach the well-timed and
targeted aid at accidents in any circumstances.

II. The goal of self-preparation:


To study the clinical manifestations and the principles of medical aid in such
conditions as an acute respiratory failure, an acute cardiovascular failure, an acute renal and
hepatic failure, a multiple organ dysfunction syndrome (MODS).

III. Studying purposes.


After self-contained studying of the topic material a student must
Know:
 the clinical manifestations of an acute respiratory failure;
 the clinical manifestations of an acute cardiac failure;
 the clinical manifestations of an acute renal failure;
 the clinical manifestations of an acute hepatic failure;
 the clinical manifestations of a multiple organ dysfunction syndrome (MODS).
Be able to:
 diagnose an acute respiratory failure, an acute heart failure, an acute renal and
hepatic failure, a multiple organ dysfunction syndrome (MODS);
 diagnose clinical death;
 provide the first pre-medical aid in the respiratory failure;
 provide the first pre-medical aid in the cardiac failure;
 provide the first pre-medical aid in the renal failure;
 provide the first pre-medical aid in the hepatic failure.
To practice and demonstrate:
 algorithm of actions in recognition of a sort of the critical state and skills of the
first aid to surgical profile patients of different age groups.

IV. The initial level of knowledge:


A student should repeat the concept of the first medical aid, parameters of vital
functions (blood pressure, pulse, rate and volume of respiratory expansions, etc.).

V. The plan for the topic studying.


1. Clinical evaluation of the patient‟s general condition.
2. The kinds of pathology of the vital functions in surgical patients.
3. The reasons, mechanisms of development, principles of diagnostics and treatment
of the acute respiratory failure.
4. The reasons, mechanisms of development, principles of diagnosis and treatment of
the acute heart failure.
5. The reasons, mechanisms of development, principles of diagnosis and treatment of
the acute renal failure.
6. The reasons, mechanisms of development, principles of diagnosis and treatment of
the acute hepatic failure.
7. The reasons, mechanisms of development, principles of diagnosis and treatment of
the MODS.

65
VI. The recommended literature:
Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. pp. 36-40, 702-703, 711-718,
910-914.
3. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp.181-196, 123-152, 79-122.
Supplemental materials:
1. Scientific American Surgery 1997, Chapter II - 4, 6, 7, 8.

VII. Questions for the self-control.


1. What criteria is the general condition of a patient estimated by?
2. The objective methods of evaluationof the severity of patient‟s condition.
3. How to determine theacute respiratory failure?
4. The reasons of theacute respiratory failure.
5. The kinds of theacute respiratory failure.
6. Prophylaxis and treatment of theacute respiratory failure.
7. How to determine theacute heart failure?
8. The reasons of theacute heart failure.
9. The kinds of theacute heart failure.
10. Prophylaxis and treatment of theacute heart failure.
11. The reasons of the renal and hepatic failure.
12. Prophylaxis and treatment of the renal and hepatic failure.
13. Prophylaxis and treatment of the syndrome of MODS.

VIII. Tasks for self-preparation:


1. Introduce the classification of the acute respiratory failure.
2. Specify what is the first aid in the acute respiratory failure.
3. Describe the pattern of the acute left-heart failure.
4. Describe the pattern of the acute right-heart failure.
5. Describe the first pre-medical aid in the cardiac failure.
6. Introduce the classification of the acute renal failure.
7. Specify the principles of prophylaxis of the pre-renal form of the renal failure.
8. Describe the etiology of the acute hepatic failure.
9. Describe the clinical manifestations of the acute hepatic failure.
10. Describe a clinical manifestations of the MODS.

Tests

1. the following causes may lead to acute hepatic failure (choose right)
a) liver cirrhosis
b) hepatitis
c) toxic damage of the liver
d) Budd-Chiarri syndrome
e) all are possible

2. the following clinical signs may be present at the end-stage hepatic failure (choose right)
a) jaundice
b) obtundation
c) encephalopathy
d) distended abdomen

66
e) all are possible

3. how are the following values changed in a patient suffering from hepatic failure?
(choose right)
a) shortening of the PT
b) rise of bilirubine level
c) rise of albumin level
d) prolongation of the PT
e) drop of albumin level

4. the following kinds of treatment may be provided to a patient suffering from portal
hypertension and bleeding esophageal varices (choose right)
a) placement of a Blakemore tube is effective
b) surgical treatment with portocaval anastomosis may be done to reduce pressure at the
esophageal veins
c) i.v. administration of vasopressin or somatostatin
d) sclerotherapy of the bleeding esophageal varices
e) all are right

5. the following treatment may be provided to a patient with hepatic failure to reduce CNS
dysfunction (choose right)
a) intestinal sterilization with i.v. administered aminoglycosides or cephalosporines
b) administration of magnesium sulphate or lactulose to accomplish catharsis
c) intestinal sterilization with orally administered aminoglycosides
d) administration of zinc
e) diet should be reach of aromatic amino-acids

6. usually an electrolyte disturbances in patients suffering from hepatic failure are


presented by the following (choose right)
a) hypernatremia
b) hyponatremia
c) hyperkalemia
d) hypokalemia
e) hypercalcemia

7. which kind of an acute renal failure is most common in surgical patients? (choose right)
a) prerenal
b) renal
c) postrenal
d) postural

8. the best method evaluating the volume of excreted urine is the following (choose right)
a) use of ultrasound
b) use of hand-held Doppler
c) use of central venous line
d) use of Foley catheter
e) CT scan

9. the following values are predominantly used to assess kidney function (choose right)
a) PTT
b) urine output
c) serum albumin level
d) serum creatinine level

67
e) serum bilirubine level
10. characteristic laboratory changes in patients with an acute renal failure are the
following (choose right)
a) drop of uric acid
b) reduction of urine output
c) reduced creatinine level
d) increase of urine output
e) increased creatinine level
11. criteria for diagnosis of an acute respiratory failure are the following (choose right)
a) Pa carbon dioxide higher than 65 mm Hg
b) Pa oxygen less than 80 mm Hg
c) respiratory rate higher than 35
d) Pa oxygen less than 70 mm Hg
e) respiratory rate higher than 45
12. the following statements are right regarding treatment of an acute left-heart failure
(choose right)
a) supplemented oxygen
b) steroids
c) antibiotics
d) inotropes
e) diuretics
Clinical tasks
Task № 1
Clinical scenario: A 58 year old patient has been admitted to the hospital. He
complains of vomiting with blood happened 2 hours prior and yellowish color of the skin. The
history of presenting complaints taken, the following information has been obtained. Today in
the morning without any reason the patient started vomiting with dark blood. The patient has
never been examined by a doctor and never admitted to the hospital. The color of the skin is
yellowish, the patient is confused, PR is 130, RR is 30, arterial BP is 100/60. There are dilated
tortuous veins on the anterior abdominal wall. The size of the abdomen is increased, tender at
the upper right quadrant, the liver span is 25cm. A sign of shifting dullness is positive.
Questions:
1. Name the existing condition.
2. What is the likely source of upper GIT bleeding?
3. How can you precisely identify source of bleeding?
4. What tests are to be administered and what changes do you expect from the blood
tests?
5. What medical actions are to be done to control bleeding?
6. How can the portal hypertension be controlled surgically?
7. How can the ascitis be controlled?

Task № 2
Clinical scenario: A 54 year old male has been suffering from jaundice for 4 weeks.
All this period of time he did not seek for medical advice and did not consult a doctor until his
condition has worsened extremely. In the evening a day before admission the patient vomited
twice with blood, in the morning a dark stool was noticed. The patient is confused, the color
of the skin is yellowish, PR is 150, RR is 35, arterial BP is 60/20. The size of the abdomen is
normal, tender at the upper right quadrant, the liver span is 15cm. sign of shifting dullness is
negative. Abdominal ultrasound has discovered choledocholytiasis
Questions:
1. Name the existing condition.

68
2. What is the most likely source of upper GIT bleeding?
3. How can you precisely identify the source of bleeding?
4. What tests are to be administered and what do you expect from the blood tests?
5. What medical actions are to be done to control bleeding?
6. What surgery can resolve mechanical jaundice?

Task № 3
Clinical scenario: A 74 year old male had a dark, tarry stool in the evening a day
before admission to the hospital. In the morning the patient had the same stool. After that he
lost the consciousness. In 6 hours the patient was admitted to the hospital. The patient is
confused, the color of the skin is pale, PR is 150, RR is 35, arterial BP is 50. The tongue is
dry, size of the abdomen is normal, tender at the upper right quadrant. The CVL is inserted,
CVP is negative. The Foley catheter is inserted, the urine is absent. The NG tube is placed,
there are a 200 ml of coffee-like fluid. Fiber-optic esophagogastroduodenoscopy (FEGDS)
has revealed the ulcer of the posterior wall of the duodenum.
Questions:
1. What is the reason of anuria?
2. What form of an acute renal failure is present?
3. What is a treatment of presented renal failure?

Task № 4
Clinical scenario: A 36 year old 70 kg victim of a road traffic accident was admitted
to the hospital with hemoperitoneum. The laparotomy is done to control hemorrhage. Because
of significant blood loss (approximately 40% of CV) a surgeon has decided to perform
homologous blood transfusion. 250 ml of packed RBC were transfused with non-cross-
matching donor‟s blood. During surgery the patient is hypotensive with tendency to bleeding.
The next day after the surgery a daily UO is 400 ml, in second postoperation day the UO is
40ml.
Questions:
1. What complication is developing during the surgery?
2. What organ failure is evident in the postoperative period?
3. What form of organ failure is present?
4. How can you confirm etiology of organ failure?
5. What are the stages of the failure?
6. What is atreatment of the developed complication?

Task № 5
Clinical scenario: A 67 year old male has emergently been admitted to the ICU. He
complains of severe pain in the cardiac area. It started 6 hours prior after physical exertion.
The patient has been suffering from hypertension for 10 years and previously had
myocardial infarction two years before. The patient is confused. The skin is cyanotic and cold.
Pulse rate is irregular, approximately 150; arterial blood pressure is 70/30; heart sounds are
muffled, borders of the heart are increased, respiratory rate is 35, there are multiple crackles
at the lower parts of both lungs. The CVL is inserted, CVP is 14 cm of water. The Foley
catheter is inserted, the urine is absent. Intraarterial line is inserted, the lactate level is
elevated. PaO2 is 70, PaCO2 is 60
Questions:
1. What is a type of acute respiratory failure?
2. Explain the mechanism of acute cardiac failure in the patient?
3. Explain the mechanism of acute respiratory failure in the patient?
4. Why is the urine output absent?
5. How can you confirm the etiology of cardiac and respiratory failure?

69
6. What are the main principles of medical therapy of the patient?

70
TOPIC 13 ENDOGENOUS INTOXICATION SYNDROME. MODS
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize basic pathologic symptoms and signs of endogenous
intoxication.
 Ability to provide first aid to surgical patients suffering from endogenous
intoxication.

I. Motivation of the goal:


The syndrome of endogenous intoxication occurs at 30-35% of patients with various
surgical diseases. The endogenous intoxication has a series of clinical and laboratory
attributes and demands active, targeted and immediate treatment. Thus, the knowledge of the
basic principles of diagnosis and treatment of the syndrome of endogenous intoxication is
very important.

II. The goal of self-preparation:


To study the etiopathogenesis, clinical manifestations, diagnosis and principles of
treatment of the endogenous intoxication syndrome.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the basic reasons of the endogenous intoxication in surgical patients;
 the pathogenesis of the endogenous intoxication syndrome;
 clinical manifestations of the endogenous intoxication;
 laboratory attributes of the toxemia;
 principles of treatment of the endogenous intoxication syndrome.
Be able to:
 reveal subjective and objective attributes of the endogenous intoxication
syndrome;
 estimate the parameters of the endogenous intoxication in a certain patient;
 carry out the infusionhemodilutionin a patient with the endogenous intoxication
(catheterization of a superficial vein, infusion of 3-4 liters of colloid and crystalloid
solutions);
 enforce a diuresis in patients with the endogenous intoxication syndrome;
 carry out the indirect electrochemical oxidation of blood by intravenous injection
of sol.sodium hypochloride.
Practice and demonstrate:
 algorithm of actions in recognition of the endogenous intoxication and skills of the
first aid to surgical profile patients of different age groups with the disorder.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the basic features
of the immune system functioning.

V. The plan for the topic studying.


1. The mechanisms of a natural biological detoxification.
2. The kinds of endogenous intoxicationin surgical patients.
3. The pathogenesis of the endogenous intoxication syndrome.
4. The stages of the endogenous intoxication.
5. Clinical attributes of the endogenous intoxication.
6. Laboratory attributes of the endogenous intoxication.
7. A degree of the endogenous intoxication.

71
8. The principles of the endogenous intoxication complex treatment.
VI. The recommended literature:
1. Lecture materials

VII. Questions for the self-control.


1. What are the mechanisms of neutralization of the toxic products in an organism?
2. What groups of the endogenous toxins do you know?
3. What is the direct damaging action of endotoxins?
4. What is the indirect damaging action of endotoxins?
5. Which clinical features show the alteration of consciousness in a patient with the
endogenous intoxication?
6. Which clinical attributes of the endogenous intoxication do you know?
7. What is the pathology of cardiovascular malfunction in patients with the
endogenous intoxication syndrome?
8. What are the features of developing hepatorenal dysfunction in a patient with
toxemia?
9. What are the basic principles of the detoxification therapy?

VIII. Tasks for self-preparation:


1. Write the formula for calculation of the leukocyte index of intoxication.
2. Write the formula for calculation of the lymphocyte index of intoxication.
3. Describe the laboratory and clinical attributes of the 1st degree endogenous
intoxication.
4. Introduce the characteristics of the 2nd degree endogenous intoxication.
5. Introduce the characteristics of the 3rd degree endogenous intoxication.
6. Write the principles of the indirect electrochemical oxidation of the blood.
7. Specify the composition and the volume of infusion solutions to carry out the
infusion hemodilution.
8. Describe the procedure of carrying out the lymphosorption.
9. Describe the procedure of carrying out the plasmapheresis.
Tests
1. endotoxicosis may be caused by the following pathologic conditions (choose right)
a) peritonitis
b) crash-syndrome
c) severe burns
d) pancreatitis
e) all reasons are possible

2. the following substances are referred to the group of original waste products of a body
metabolism (choose right)
a) leukotriens
b) blood urea
c) myoglobin
d) prostaglandins
e) creatinine

3. the following substances are referred to the group of activated body enzymes (choose
right)
a) leukotriens
b) AST
c) myoglobin
d) prostaglandins

72
e) amylase
4. the following substances are referred to the group of proinflammatory biologically active
substances (choose right)
a) leukotriens
b) blood urea
c) myoglobin
d) prostaglandins
e) amylase

5. the following substances are referred to the group of devitalized tissue products (choose
right)
a) leukotriens
b) blood urea
c) myoglobin
d) prostaglandins
e) amylase

6. the classification of bacterial toxins according to mechanism of action includes the


following (choose right)
a) adenylate cyclase toxins
b) enterotoxins
c) leukotoxins
d) proteolytic toxins
e) neurotoxins

7. the classification of bacterial toxins according to target of action includes the following
(choose right)
a) adenylate cyclase toxins
b) enterotoxins
c) leukotoxins
d) proteolytic toxins
e) neurotoxins

8. the following changes of laboratory values may be present in patients with endogenous
intoxication syndrome (choose right)
a) rise of plasma urea
b) drop of creatinine
c) rise of bilirubine level
d) drop of plasma urea
e) rise of creatinine

9. an UV light produces oxygen from breakdown of water in the blood increasing Hb


saturation. This feature of the UV is applied to the following method of extracorporeal
treatment (choose right)
a) cytapheresis
b) lymph dialysis
c) artificial oxygenizer
d) plasmapheresis
e) plasma exchange

10. the blood formed elements are separated from the plasma by means of membrane
plasma separator or centrifugation. This technique is used in the following method of
extracorporeal treatment (choose right)

73
a) cytapheresis
b) lymph dialysis
c) hemodialysis
d) plasmapheresis
e) plasma exchange

11. removal of low molecular weight compounds from the blood by means of diffusion
through a semipermeable membrane. This technique is used in the following method of
extracorporeal treatment (choose right)
a) cytapheresis
b) hemodialysis
c) artificial oxygenizer
d) plasmapheresis
e) plasma exchange

12. hemofiltration is performed with dialytic component added (diffusion). This technique
is used in the following method of extracorporeal treatment (choose right)
a) cytapheresis (lymphapheresis, erythracytapheresis)
b) lymph dialysis
c) artificial oxygenizer
d) plasmapheresis
e) hemodiafiltration

Clinical tasks

Task № 1
Clinical scenario: A patient complains of constant severe abdominal pain, repeated
vomiting, and fever. The mentioned signs have lasted for two days. During the examination of
the patient the following signs have been found: the skin is dry, heart rate is 120, 110/70
mmHg blood pressure, urine output according to the patient‟s words was approximately 300
ml during last 24 hours. The CVP is 3 cm of water. GIT examination is done. The tongue is
dry, the abdomen is tender, signs of peritoneal irritation are positive. Basing on the clinical
picture and obtained data of instrumental investigation the doctor has diagnosed diffuse
peritonitis. He has administered antibacterial therapy with methicillin i.v. and infusion
therapy. Despite prescribed treatment condition of the patient during the next 24 hours
progressively deteriorates. She is confused. The heart rate is 140, 80/40 mmHg blood
pressure, daily urine output was 100 ml. The CVP is 0 cm of water. The sclera is yellowish.
The liver span is increased.
Questions:
1. What is the etiology of endogenous intoxication in our patient?
2. Why hasn‟t patient‟s condition improved with the medical therapy?
3. List expected to liver dysfunction laboratory changes?
4. List expected kidney dysfunction laboratory changes?
5. What is a treatment of the patient?

Task № 2
Clinical scenario: 4 days before a 56 year old patient was operated due to diffuse
peritonitis. Since the third postoperative day the patient‟s body temperature has been 38,5 C0.
She is confused. Heart rate is 120, 120/80 mmHg blood pressure, daily urine output was 400
ml. The CVP is 4 cm of water. The liver span is increased. A doctor has changed the
antibiotic and continued infusion therapy. Despite antibacterial treatment condition of the
patient does not improve, in three days the patient is still hyperthermic. The sclera is

74
yellowish. The heart rate is 130, 70/30 mmHg blood pressure, daily urine output was 50 ml.
The CVP is negative. Peristalsis is absent, signs of peritoneal irritation are absent. The next
morning the patient has vomiting with coffee-like fluid.
Questions:
1. What may the etiology of endogenous intoxication in the patient be?
2. Why hasn‟t patient‟s condition improved after administration of a new antibacterial
agent?
3. What is the source of GIT bleeding?
4. List expected laboratory changes.

Task № 3
Clinical scenario: 3 days ago a 46 year old patient was admitted to the hospital with
acute destructive pancreatitis. Despite the management the patient‟s condition hasn‟t
improved. The body temperature is decreased, laboratory picture shows signs of liver, kidney,
and hematologic dysfunction. The next day the condition of the patient has deteriorated. The
arterial BP is 90/60, the respiratory rate is 35. Intraarterial line is inserted, the lactate level is
elevated. PaO2 is 70, PaCO2 is 60. Chest radiograph shows patchy infiltrates in both lungs.
Questions:
1. What is the cause and mechanism of respiratory dysfunction in the patient?
2. What is the management of respiratory dysfunction?
3. What are the laboratory signs of hematologic dysfunction?
4. List the laboratory changes expected at liver and kidney dysfunction?

Task № 4
Clinical scenario: A 65 year old patient has a thermal burn of both upper extremities,
back, and the chest. The injured area is leathery and charred. The patient is treated in the burn
center. Despite management the condition of the patient gradually deteriorates. In several
days the signs of liver, kidney, hematologic, and respiratory dysfunction are noticed.
Questions:
1. What evidence of respiratory dysfunction can be expected in the patient?
2. What evidence of kidney dysfunction can be expected in the patient?
3. What evidence of liver dysfunction can be expected in the patient?
4. What evidence of hematologic dysfunction can be expected in the patient?
5. What are the treatment principles of the patient?

Task № 5
Clinical scenario: A 31 year old patient is operated because of a head trauma
complicated by significant brain destruction. After the surgery the patient does not regain
consciousness. Breathing is maintained by mechanical ventilation, arterial blood pressure can
be maintained only by continuous infusion of inotropic agents. During the next three days the
patient is still in coma and artificial ventilation. Laboratory signs: platelet count 60 000, RBC
- 2,3 × 1012; Ley - 3, 3 × 12- Hb – 7 g/dl; albumin – 20 g/l; aPTT and bleeding time are
prolonged, fibrinogen level is decreased, bilirubine and creatinin level are increased. Despite
proper treatment the next day the patient started to bleed from postoperative wound, the blood
has appeared through the previously inserted nasogastric tube. Signs of respiratory failure
become evident.
Questions:
1. What organs dysfunction are present in the patient?
2. What is a possible reason of bleeding through the NG tube?
3. What is a possible reason of bleeding from the postoperative wound?
4. What is a clinical and laboratory manifestation of respiratory dysfunction?
5. What is a prognosis for the patient?

75
TOPIC 14 PAIN AND ANESTHESIA
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize states in surgical patients that require anesthesia.
 Ability to administer analgesics in postoperative surgical patients.

I. Motivation of the goal:


Studying the theoretic background of anesthesia and mastering the definite complex of
practical skills on the given theme is important for doctors of all specialties. It allows to make
a correct option of indications and contraindications to a certain method of anesthesia in
various patients. The knowledge of this theme is particularly important and it helps to
understand the features of patient‟s preparation forthe operation, anesthesia during and after
operation, during endoscopic examinations, providing aid in trauma and thermalinjuries.

II. The goal of self-preparation:


To study the mechanism of the effects of narcotic substances and local anesthetics on
an organism, principles of action of the modern devices for narcosis, to learn how to choose
correctly a method of premedication and anesthesia.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the basic stages of development of anesthesiology;
 mechanisms and reasons of pain development;
 theories and stages of narcosis;
 the properties of the most wide-spread inhalation and non-inhalation narcotic
substances,neuromuscular blockers (myorelaxants);
 advantages and disadvantages of various methods of inhalation and non-inhalation
anesthesia;
 the principles of action of the modern anesthetic devices;
 prophylaxis and treatment of complications related to local anesthsia;
 prophylaxis and treatment of complications related to general anesthsia.
Be able to:
 makea topical skin cryoanesthesia with chlorethyle;
 make a local infiltrative anesthesia of superficial soft tissues;
 make a digital nerve block anesthesia (according to Lukashevich–Oberst);
 performan artificial ventilation of lungs;
 determine the suitability of narcotic substances for narcosis;
 determine the gas volume (oxygen, nitrous oxide, cyclopropane) in a tank;
 determine the depth of narcosis according to clinical symptoms (corneal, pupillary
reflux, etc.);
 assess the development of complications of narcosis according to a clinical picture
(hypoxia, overdose, etc.);
 provide the aid in case of complications of narcosis (vomiting, apnea, hypoxia,
overdose, etc.).
Practice and demonstrate:
 Skills of option algorithm of general and local anesthesia type in surgical patients
of different age groups.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the basic features
of the neurologic system functioning.

76
V. The plan for the topic studying.
1. The basic historical stages of anesthesia development.
2. The mechanisms and the reasons of a pain.
3. Principles of medical treatment of a pain syndrome. Anesthesiologic chart records.
4. Drugs for a local anesthesia, the mechanism of their action, the basic
characteristics.
5. The kinds of local anesthesia and the technique of different kinds of local
anesthesia.
6. The indications, kinds and techniqueof novocaine blocks.
7. The procedure and clinical manifestations of modern general anesthesia, stages of
narcosis.
8. Kinds of narcosis. Devices and methods of inhalation narcosis.
9. Modern inhalation anesthetics, myorelaxants. The combined application of them
for optimal synergism.
10. Complications of narcosis in the early postanesthesia period, prophylaxis and
treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 83-94.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp.-121-
137.
Supplemental materials:
1. "Short practice of surgery" Bailey 1996, Pp. 51-62.

VII. Questions for the self-control.


1. Indications and contraindications for local anesthesia.
2. Methods of local anesthesia.
3. The drugs applied for a local anesthesia.
4. The kinds of novocaine blocks.
5. Theories and stages of anesthesia.
6. Basic modern narcotic drugs fornon-inhalation general anesthesia.
7. Basic modern narcotic drugs forinhalation general anesthesia.
8. Modern anesthetic devices.
9. Methods of anesthesia monitoring.
10. Complications associated with anesthesia.

VIII. Tasks for self-preparation:


1. Draw the scheme of a digital nerve block anesthesia.
2. Draw schematically the technique of a lumbar paranephral novocaine block.
3. List the levels and stages of narcosis.
4. List the drugs in a prescription form, used for premedication.
5. Draw the anesthetic device.
6. Draw and fill in an anesthesiologic chart.
7. List the drugs in a prescribtion form, used for neuroleptanalgesia.
8. List possible complications of narcosiscaused by technique of anesthesia.
9. List possible complications of an endotracheal intubation.
10. List possible cardiovascular complications associated with general anesthesia.

77
Tests

1. find all inhalation general anesthetics (choose right)


a) ketamine
b) enflurane
c) thiopental
d) halothane
e) hexenal

2. find all i.v administered general anesthetics (choose right)


a) ketamine
b) ether
c) thiopental
d) halothane
e) nitrous oxide

3. find all local anesthetics administered for local anesthesia (choose right)
a) ketamine
b) bupivacaine
c) thiopental
d) halothane
e) lidocaine

4. find all the features of surgical stage of general inhalation anesthesia (choose right)
a) unconsciousness
b) normalization of BP, PR
c) agitation
d) muscle relaxation
e) motor excitement

5. preparation before anesthesia should include the following actions (choose right)
a) fastening from food
b) dentures should be removed
c) emptying of the bowel
d) emptying of the bladder
e) all are used

6. find all the types of general anesthesia (choose right)


a) application anesthesia
b) i.v. anesthesia
c) infiltration anesthesia
d) inhalation anesthesia
e) aerosol anesthesia

7. routes of inhalation anesthesia administration are the following (choose right)


a) mask
b) spinal catheter
c) intravenous catheter
d) epidural catheter
e) endotracheal tube

8. the following medicines are used for neuroleptanalgesia (choose right)

78
a) ketamine
b) novocaine
c) fentanil
d) halothane
e) droperidol

9. usual percentage and amount of local anesthetic for local infiltration anesthesia is the
following (choose right)
a) 10 ml
b) 2%
c) 0,25%
d) 5%
e) 80 ml

10. choose all the statements which are right regarding general inhalation anesthesia
administered through endotracheal tube (choose right)
a) excitement stage is absent
b) low risk of aspiration
c) quick anesthesia
d) best control of airway
e) easy to perform

11. the right position of the needle in the subarachnoid space is confirmed by the following
(choose right)
a) unilateral lung wheezing
b) leakage of the blood from the needle
c) loss of consciousness
d) leakage of the cerebrospinal fluid from the needle
e) all are right

12. the following drugs are used to produce spinal anesthesia (choose right)
a) ftorothane
b) lidocaine
c) enflurane
d) epinephrine
e) bupivacaine

Clinical tasks
Task № 1
Clinical scenario: A 62 year old obese patient has been admitted to the hospital for
surgery. A resection of the stomach is planned in order to treat a stomach cancer. The patient
has a history of myocardial infarction (two years ago) and hypertension more than 5 years.
Questions:
1. What type of anesthesia is to be used?
2. What and why does to a doctor have to pay attention to during the subjective
examination?
3. What and why does to a doctor have to pay attention to during objective examination?
4. Is laboratory investigation of coagulation system indicated? Why?
5. What laboratory and instrumental tests do you plan to administer as a part of
preoperative examination?

Task № 2

79
Clinical scenario: A 52 year old patient is suffering from acute DVT of the right
lower extremity. He is treated by injections of LMWH (fraxiparine). At the hospital a patient
has fallen and broken his femoral bone. Emergency surgery is to be done to treat fractured
bone. The patient had dinner 1 hour before. A general anesthesia is planned.
Questions:
1. Does the patient have coagulopathy?
2. How can an action of LMWH be reversed immediately?
3. What lab test is commonly used in patients treated with heparin?
4. How should the stomach be prepared before the surgery?
5. What kind of anesthesia is also commonly used in patients being operated on the
lower extremities?

Task № 3
Clinical scenario: A surgeon is going to perform digital nerve block anesthesia in
order to treat subcutaneous panaritium of an index finger. After prepping and draping an
injection of local anesthetic is done. Almost immediately after injection the patient has lost
the consciousness. The skin is clammy. The vital signs are the following: pulse rate on carotid
arteries is 150, weak; arterial blood pressure is 40/10; respiratory rate is 35, wheezing.
Questions:
1. What has happened to the patient?
2. What other complications of local anesthesia do you know?
3. What is a treatment of developed complication?
4. Explain the procedure of digital nerve block anesthesia
5. List common agents used for local anesthesia (5).

Task № 4
Clinical scenario: A 32 year old patient is suffering from secondary varicose veins of
the right lower extremity. Elective surgery is planned to treat existing pathology. A spinal
anesthesia will be done.
Questions:
1. What is the preparation of a patient for anesthesia?
2. What is a difference between spinal and intrathecal anesthesia?
3. List the advantages of the epidural anesthesia.
4. What complications specific to intrathecal anesthesia are possible?

Task № 5
Clinical scenario: A 23 year old patient is suffering from the ingrown nail of the great
toe. Elective surgery is planned to treat existing pathology. A digital nerve block anesthesia
will be done.
Questions:
1. What is the preparation of a patient for anesthesia?
2. What agents are commonly used for local anesthesia?
3. Explain the technique of digital nerve block anesthesia.
4. What complications are possible?

80
TOPIC 15 WOUNDS AND WOUND HEALING
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize stages of wound healing in surgical patients.
 ability to provide first aid to different wounds depending on a stage of wound
healing in surgical patients.

I. Motivation of the goal:


Wounds are one of the most widespread kinds of surgical pathology. Studying of this
theme will give a student an opportunity to learn the general questions of diagnosis and
treatment of wounds. In the professional work any doctor will inevitably face the treatment of
wounds. The result of a patient treatment depends on the knowledge of the questions
concerning the diagnosis and treatment of wounds, the correct understanding of the phases of
a wound healing, the knowledge of modern aspects of this problem. The knowledge of this
theme will help a student to master such important units of the course of the general surgery
as "Purulent diseases of soft tissues", "Fractures", "Trophic ulcers", "Surgical operation", and
others, studied at the departments havinga surgical profile. Therefore, studying of this theme
is especially important for students of the medical faculty.

II. The goal of self-preparation:


To acquire the classification of wounds, phases of a wound healing, basic principles of
wound treatment, types of wound healing, the purpose of primary surgical debridement (PSD)
of wounds, indications and contraindications to it, the techniques of PSD of a wound; the
concept of a primary, a primary-delayed, a secondary closure, the features of gun-shot
wounds, the basic methods of diagnosis and treatment of wounds based on the correct
understanding of the phases of wound healing.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the definition of a wound;
 the classification of wounds;
 questions of pathology of various kinds of wounds;
 zones of a wound canal;
 complications of wounds;
 indications and contraindications to a PSD and secondary surgical debridement
(SSD) of wounds;
 indications and contraindications to different kinds of a wound closure;
 basic principles of treatment of purulent wounds.
Be able to:
 classify a wound;
 describe a wound;
 determine a type andphase of wound healing;
 dress a wound;
 carry out a PSD and SSD of wounds;
 remove sutures.
Practice and demonstrate:
 The skills of a diagnostic algorithm of the wound type, stages of wound healing
and first aid to surgical patients of different age groups.

IV. The initial level of knowledge:

81
For successful mastering the topic “Wounds” it is necessary to repeat topographic
anatomy, the pathology of inflammation and infectionprocess, pharmacology, desmurgy,
sepsis, and antisepsis.

V. The plan for the topic studying.


1. The classification of wounds.
2. Pathology and phases of a wound healing.
3. Clinical features of various kinds of wounds.
4. Different kinds of wound healing.
5. Principles of the first medical aid in injuries.
6. Primary surgical debridement of wounds, its kinds.
7. Secondary surgical debridement.
8. Closure of a wound.
9. Infection complications of wounds.
10. The general and local signs of wound infection.
11. Modern principles of a purulent wound treatment depending on a phaseof a wound
healing.
12. Prophylaxis of postoperative wound infection.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" the manual., V.K. Gostishev., 2003., Pp. 128-133.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 163-
198.
4. "Short practice of surgery" Bailey and Love's, 1996. Pp. 8-17; 63-92p.
Supplemental materials:
1. "Surgery" B.E. Jarrell 1991, pp. 15-18.
2. SURGERY. Basic science and clinical evidence. USA., 2000. Pp. 221-241.
3. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991. Pp. 164-178.

VII. Questions for the self-control.


1. Give the definition of a wound.
2. Basic clinical signs of a wound.
3. Local symptoms of wounds.
4. General symptoms of wounds.
5. Classification of wounds.
6. The differences between aninfected and contaminated wound.
7. Pathology of primary contamination of wounds.
8. Pathology of a secondary contamination of wounds.
9. What is a penetrating wound and why is it dangerous?
10. Zones of a gun-shot wound.
11. The characteristics of the area of wound canal, primary traumatic necrosis, and
molecular concussion.
12. The first aid at the open soft tissue injuries.
13. Kinds of wound healing.
14. Pathology of wound healing (hypertrophic scar and keloid).
15. Causes of delayed healing
16. Phases of wound healing.
17. Principles of contaminated wound treatment.
18. The definition of a PSD.

82
19. Indications and contraindications to PSD.
20. Types of wound closure.
21. Kinds of a wound suturing according to a time of application.
22. Principles of purulent wound treatment.
23. Tetanus prophylaxis

VIII. Tasks for self-preparation:


1. Write the classification of wounds.
2. Make the diagnostic program in order to determine a wound type.
3. Make schemes of pathology of a PSD and SSD of wounds.
4. Make the description of the local manifestations of different kinds of wounds.
5. Draw the zones of a gun-shot wound.
6. Draw the table of classification of wound healing phases.
7. Draw the scheme of PSD of a wound.
8. Draw the scheme oflayers of granulation tissue.
9. Prescribe the conservative treatment to a patient with a purulent wound.
10. Make the table of the differential diagnosis between penetrating and non-
penetrating wounds of an abdominal cavity.
11. Draw the scheme of a tetanus prophylaxis

Tests

1. the main stages of a healing process include the following (choose right)
a) infiltration
b) inflammation
c) coagulation
d) remodailing
e) proliferation

2. a proliferation stage of a wound healing is characterized by the following (choose right)


a) activation and migration of the fibroblasts to the site of injury
b) deposition of the fibrin matrix
c) increase of vascular permeability
d) activation and migration of the macrophages to the site of injury
e) initiation of coagulation cascade

3. which stages of a healing process are the only characteristic features of healing by
secondary intention? (choose right)
a) fibroplasia
b) granulation
c) contraction
d) epithelization

4. which stages of a healing process are the only characteristic features of healing by
primary intention? (choose right)
a) fibroplasia
b) granulation
c) contraction
d) epithelization

5. which stage of a healing process plays the major role in the shortening of the wound
size? (choose right)

83
a) fibroplasia
b) granulation
c) contraction
d) epithelization
e) inflammation

6. one of the characteristic features of scar tissue is the (choose right)


a) presence of hair follicles
b) all skin appendages are absent
c) presence of the sweat glands
d) all skin appendages are present
e) presence of the sebaceous glands

7. poor wound healing may be caused by the following factors (choose right)
a) use of systemic antibiotics
b) radiation therapy
c) insulinotherapy
d) use of corticosteroids
e) use of hyperbaric oxygenation

8. which conditions are referred to excessive healing? (choose right)


a) hypotrophic scar
b) atrophic scar
c) keloid scar
d) hypertrophic scar

9. treatment options for hypertrophic scars include the following (choose right)
a) application of pressure garment
b) application of topical silicone sheets
c) range-of-motion exercises
d) all statements are right
e) reexcision with primary closure

10. if the postoperative wound has become infected the following treatment must be done
(choose right)
a) postoperative wound is opened
b) sutures are removed
c) irrigation of the wound is performed
d) necrotic tissues are debrided
e) all statements are right

11. the best conditions for wound healing are achieved in the following environment
(choose right)
a) dry
b) moist
c) sterile
d) cool
e) heat

12. the characteristics of tidy wounds are the following (choose right)
a) clean incision
b) more than 12h

84
c) less then 6h old
d) low energy trauma
e) ragged edge

Clinical tasks

Task № 1
Clinical scenario: A 35 years old patient has come to a physician complaining of a
right calf wound. Collecting the history of presenting complaints it was found that two years
ago the patient had closed fracture of the right tibial bone. Even after proper treatment the
edema and dull pain in the right calf still persisted. Approximately one year ago, he noticed
hyperpigmentation and induration of the skin of the right calf. Two months ago the wound of
the right calf opened without any trauma to the area. Despite ambulatory treatment the wound
has not been healed yet. Examination of the right lower extremity is done. There are few
varicose veins at the medial aspect of the right calf. There is a 6/6 cm superficial round-shape
with pale red lining wound without purulent outflow located above a medial malleolus. The
surrounding skin is of brown color, slightly tender and firm on palpation. A pulsation of all
peripheral arteries is normal.
Questions:
1. What is a stage and substage of a wound healing?
2. Characterize this stage of a wound healing.
3. What period of time should the mentioned wound epitelize normally?
4. Why can‟t the wound be healed within two months?
5. What may the causes of long-lasting wounds (ulcers) of low extremities be?
6. What must be included into the treatment beside local wound treatment to achieve
healing?

Task № 2
Clinical scenario: A victim of street assault was admitted to the hospital 1 hour after
an accident. He was injured by a knife in the anterior chest. The patient complains of chest
pain and dyspnea. He is anxious and cyanotic. There is a 5/1 cm wound at the area of right
nipple with bubbling of air in the depth during inspiration and expiration. A crepitation is felt
during palpation of the skin around the wound. An unequal expansion of the chest, absence of
breath sounds, and hyperresonant percussion note at the right part are found. The heart and
arch of the aorta are displaced towards the left.
Questions:
1. What is a stage of wound healing?
2. Characterize this stage of wound healing.
3. Classify the wound according to a) character; b) contamination; c) localization; d)
penetration;
4. Classify the wound according to complications
5. What is your first aid?
6. What is a management of the wound in the hospital?
7. If wound closure is done what method will be used?

Task № 3
Clinical scenario A 33 years old patient was injured by a knife in the chest. Within 30
minutes after the accident he was found and transported to the hospital. He complains of a
chest pain, dyspnea and dizziness. He is anxious and cyanotic. The neck veins are dilated. The
vital signs are the following: Pulse rate is 120; arterial blood pressure is 80/40, very weak;
respiratory rate is 35. Examination of the respiratory system is done. There is a stab wound
2/2 cm size on the right posterior chest wall. An expansion of the chest is normal as well as

85
vocal fremitus, breath sounds, and percussion note over the lungs. There is a dilation of a
heart dullness during percussion and muffled heart sounds on auscultation. GIT exam is
normal.
Questions:
1. Classify the wound according to a) character; b) contamination; c) localization; d)
penetration.
2. Classify the wound according to complications.
3. What is a stage of wound healing? Give its characteristic.
4. What is a management of the wound in the hospital?
5. If wound closure is done what method will be used?

Task № 4
Clinical scenario: Half an hour ago a teenage boy fell on a sharp wooden stick.
Immediately after an accident, he noticed diffuse abdominal pain and malaise. Due to that he
was admitted to the hospital. The boy complains of abdominal pain and fainting. He is
anxious. The skin is clammy. The vital signs are the following: Pulse rate is 110, weak;
arterial blood pressure is 110/70; respiratory rate is 25. Examining the GIT system, there is a
stab wound 3 to 1 cm size in the area of the midabdomen with omentum protruding through it.
A moderate rebound tenderness and voluntary muscle guarding are noticed over all anterior
abdominal wall. The liver span is normal. The peristalsis is diminished. The Mendel sign is
positive.
Questions:
1. Classify the wound according to a) character; b) contamination; c) localization; d)
penetration.
2. Classify the wound according to complications.
3. What laboratory changes are characteristic to this complication?
4. What is a management of the wound in the hospital?
5. Does the patient need exploratory laparotomy?
6. If wound closure is done what method will be used?

Task № 5
Clinical scenario: A teenage girl attempted to commit a suicide by cutting her forearm
veins open with a razor. 20 minutes after an accident she was found. She is confused. The
skin is clammy. The pulse rate is 130, weak; arterial blood pressure is 90; respiratory rate is
30. There is an incised wound 10/3 cm size at the left cubital area with slowly running dark
non-pulsating blood from completely transected cephalic vein. Temporary hemostasis is
accomplished by tight gauze bandaging and the girl is transported to the hospital.
Questions:
1. Classify the wound according to a) character; b) penetration c) contamination; d)
localization.
2. Classify the wound according to complications.
3. What is a management of the wound in the hospital?
4. What method of permanent hemostasis is preferred during wound debridement?
5. If wound closure is done what method will be used?

86
TOPIC 16 GENERAL ASPECTS OF SURGICAL INFECTION. PURULENT
DISEAESES OF THE SKIN, SUBCUTANEOUS TISSUES AND GLANDULAR
ORGANS
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize basic symptoms and signs of purulent diseases of the skin and
subcutaneous tissues.
 Ability to provide first aid to patients with purulent diseases of the skin and
subcutaneous tissues.

I. Motivation of the goal:


Purulent surgical diseases are still a serious problem in medicine. The increased
resistance of microorganisms to antibiotics has shown that the problem of surgical infection is
not absolutely solved and requires further serious researches in this field. Purulent
inflammatory diseases occur in one third of general surgical patients. Therefore, studying the
general questions of surgical infection is extremely necessary for a doctor.

II. The goal of self-preparation:


To study clinical manifestations, laboratory diagnosis, pathology and conditions of
development of a purulent infection in an organism. To acquire the concepts of acute aerobic
and anaerobic surgical infection, the concepts of clostridial and non-clostridial anaerobic
infection, the concept of a mixed infection. To study the features of asepsis in purulent septic
surgery, the modern principles of prophylaxis and treatment of purulent diseases. To acquire
the general principles of treatment of purulent diseases (rational antibiotic therapy,
immunotherapy, enzyme therapy, stimulating and improving therapy). To acquire the general
principles of technique, operations, modern methods of a purulent focus management.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the organizational principles of patients with purulent diseases treatment;
 the features of work of departments and hospitals for treatment of patients with
purulent diseases;
 the types and features of basic pathogens of purulent infection;
 the portals of entry of a purulent infection at exogenous and endogenous
infections;
 factors which contribute to and determine the development of a purulent process;
 clinical manifestations of purulent diseases of soft tissues (furuncle, carbuncle,
hydradenitis, lymphadenitis, abscess, phlegmon of subcutaneous tissue, erysipelas,mastitis),
parotitis;
 the general response of the body to the development of the acute purulent process
insoft tissues;
 the principles of a local treatment;
 the principles of a general treatment.
Be able to:
 determine the localization of an inflammatory process;
 determine the form of disease;
 determine the stage of an inflammatory process;
 define the indications for surgical treatment;
 make a wound dressing after incision of the abscess or phlegmon, to remove or
replace a drain, to process a wound, to place a bandage;
 determine the regimefor patients with acute purulent diseases of soft tissues;

87
 determine the diet;
 determine the recommendations for a rehabilitationof patients.
Practice and demonstrate:
 The skills of a diagnostic and first aid actions algorithm for surgical patients of
different age groups with purulent diseases of the skin and subcutaneous tissues.

IV. The initial level of knowledge:


To repeat the questions in anatomy, microbiology, pathology, desmurgy, asepsis and
antisepsis related to this theme.

V. Plan for studying the topic.


1. Etiology, pathology, clinical manifestations, and diagnosis of the acute surgical
infection.
2. The concept of clostridial and non-clostridial anaerobic infection, mixed infection.
3. Modern principles of prophylaxis and treatment of purulent diseases.
4. Etiology, pathology, clinical manifestations, diagnosis and treatment of furuncle,
carbuncle, hydradenitis, lymphadenitis, abscess, phlegmon of subcutaneous tissue, erysipelas,
mastitis, parotitis and coccygeal sinus (pilonidal sinus).

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. pp. 150-159.
3. "Short practice of surgery" Bailey and Love's, 1996. pp. 63-75.
Supplemental materials:
1. "Principles and Practice of Infectious Diseases" G. Mendell, J. Bennett, R. Dolin.
Volume 1-2, fifth edition, 2000. pp. 2077-2079.

VII. Questions for the self-control.


1. Classification of surgical infection.
2. What microorganisms cause the development of acute surgical diseases?
3. The basic ways of contamination and spread of microorganisms in a human
organism in the development of the acute purulent process.
4. The importance of anatomic and physiologic features of tissues and the general
reactivity of a human organism in the development of the acute purulent infection.
5. The clinical characteristic of the local pyogenic inflammatory processes: furuncle,
carbuncle, hydradenitis, lymphadenitis, abscess, phlegmon of soft tissue, erysipelas, mastitis,
parotitis, coccygeal sinus.
6. The stages of development of a pyogenic inflammatory process.
7. Complications of localpurulent diseases.
8. The importance of asepsis during surgery of purulent conditions.
9. The immune prophylaxis of purulent complications.
10. Principles of conservative treatment, the choice of antibiotics.
11. Principles of surgical treatment.
12. Basic rules of an abscess incision andsubsequent draining.
13. Anesthesia during surgery dealing with acute purulent diseases.
14. Proteolytic enzymes in purulent surgery.

VIII. Tasks for self-preparation:


1. Make the scheme of local and general symptoms of a purulent disease.
2. Specify the principles of treatment of a purulent disease.
3. Introduce the scheme of medical actions in the case of facial furuncle.

88
4. Introduce the scheme of medical actions in the case of carbuncle of the posterior
surface of the neck.
5. Introduce the scheme of medical actions in the case of hydradenitis.
6. Introduce the scheme of medical actions in the case of lymphadenitis.
7. List the medical actions in the case of erysipelas.
8. Introduce the scheme of medical actions in the case of parotitis.
9. Introduce the scheme of medical actions in the case of lactic mastitis depending on
a stage of the inflammatory process.

Tests

1. the following species of microorganisms most frequently lead to pyogenic soft tissue
infection (choose right)
a) staphylococcus aureus
b) cytomegalovirus
c) escherichia coli
d) coronaviruses
e) enterococcus

2. the following predisposing factors for development of purulent infections are identified
(choose right)
a) methabolic disturbances (diabetes mellitus)
b) obesity
c) Cushing syndrome
d) immunodeficiency states
e) all statements are right

3. the classification of the pyogenic infection according to localization includes the


following items (choose right)
a) skin and subcutaneous tissues
b) staphylococcal
c) bones and joints
d) escherichial
e) clostridial

4. the general signs and symptoms of the soft tissue infection are as follows (choose right)
a) fever
b) reddish discoloration
c) malaise
d) tenderness
e) swelling

5. the local signs and symptoms of the soft tissue infection are as follows (choose right)
a) fever
b) reddish discoloration
c) malaise
d) tenderness
e) headache

6. the following stages in the course of the pyogenic infection are identified (choose right)
a) inflammation
b) infiltration

89
c) proliferation
d) suppuration
e) maceration

7. the predisposing factors to acute mastitis are as follows (choose right)


a) milk stagnation
b) poor hygiene
c) poor supplementation with vitamins, microelements
d) immunodeficiency states
e) all statements are right

8. classification of soft tissue infections includes the following items (choose right)
a) carbuncle
b) erysipelas
c) abscess
d) folliculitis
e) phlegmon

9. the clinical course of the erysipelas may have the following forms (choose right)
a) edematous
b) erythematous
c) bullous
d) hemolytic
e) adenomatous

10. the following statements regarding lymphadenitis are right (choose right)
a) use of antibiotics
b) treatment of the primary foci of infection is crucial
c) surgery is always performed
d) only conservative treatment is used
e) choice of treatment is determined by the stage of inflammation

11. in the case of severe infection of the soft tissue the following changes may be present in
the white blood count analysis (choose right)
a) rise of bilirubine
b) rise of WBC
c) rise of band forms
d) rise of creatinine
e) rise of RBC

12. the clinical features of the carbuncle include the following (choose right)
a) dark color of the lesion
b) during course of disease development the yellowish color area is obvious in the center
c) indurated basis
d) size of the lesion (5cm and large)
e) raised, painful, with reddish skin color lesion

Clinical tasks

Task № 1
Clinical scenario: A 56 years old obese patient has come to a physician complaining
of a throbbing pain in the right buttock, rise of body temperature (evening) to 38,5C0, night

90
chills. Collecting the history of presenting complaints it has been found that five days prior
the patient performed himself an i.m. injection of NSAID in the right buttock to relieve
chronic joint pain. Three days ago the mentioned signs had started. Examination of the
gluteal area is done. There is a 10/10 cm area of hyperemiain the right lateral gluteal region. It
is swollen and tender. Fluctuation sign is positive.
Questions:
1. What complication has developed after i.m. injection?
2. What could the possible causes of developed complication be?
3. How is a fluctuation test done?
4. What laboratory and instrumental techniques may help to make a diagnosis?
5. What do you expect to find with a) laboratory and b) instrumental tools?
6. What instrumental invasive diagnostic method can be used. How is it done?
7. What is a treatment of developed complication?

Task № 2
Clinical scenario: A 28 years old male was injured by a lawn-mower. 4 hours after an
accident a deep wound with ragged edges of 20/5 cm size on the posterior surface of the left
lower calf was treated with irrigation, appropriate hemostasis, and debridement. Finally, it
was closed by primary sutures. The patient was recommended ambulatory treatment. In two
days the patient was admitted to the hospital. He complains of a throbbing pain in the area of
traumatic wound, rise of body temperature (evening) till 39,5C0, night chills, loss of appetites,
malaise. Examination of the left lower extremity is done. There is a 20 cm wound at the
posterior surface of the left lower calf closed by sutures. All the calf is of a reddish color, with
marked edema. Palpation is very tender, the skin is hot, fluctuation is positive. The pus comes
out between skin stitches.
Questions:
1. Classify the wound according to a) character; b) contamination; c) localization; d)
complications.
2. What is a stage of wound healing? Give its characteristic.
3. What mistake was done by a doctor treating the wound? How it should have been
done?
4. What a) laboratory and b) instrumental techniques may help to make a diagnosis?
5. What do you expect to find with a) laboratory and b) instrumental tools?
6. What is a treatment of developed complication?

Task № 3
Clinical scenario: A 46 years old diabetes obese patient has come to a physician
complaining of a pustula of the face. It started three days ago and is becoming worse. Body
temperature increased till 38,2C0 in the last evening. Examination of the patient is done. There
is a round shape, 1/1 cm, reddish lesion with yellow spot at the top located above an upper lip.
It is painful and firm in the base.
Questions:
1. What is your diagnosis?
2. What may the presented pathology be complicated by? (potentially fatal).
3. What do you expect to find with laboratory tests?
4. What is a medical treatment of developed complication?
5. What is a surgical treatment of developed complication?

Task № 4
Clinical scenario: A 39 years old male was injured by a dirty shovel into the left calf.
1 hour after an accident his lacerated deep wound 10/5 cm size of the left upper calf was
treated with irrigation, appropriate hemostasis, and debridement. Finally, it was closed by

91
primary sutures. The patient was recommended ambulatory treatment. In two days the patient
came into the policlinic. He complains of a pain in the area of traumatic wound and left groin
region, rise of body temperature (evening) till 39,5C0, night chills, loss of appetites, malaise.
Examination of the left lower extremity was done. There is a 10 cm wound at the posterior
surface of the left upper calfclosed by sutures. The calf is red and swollen. The pus comes out
between skin stitches with foul odor. There are three painful red strips running parallel to the
great saphenous vein. A left groin area is moderately swollen, tender, and infiltrated.
Fluctuation is negative.
Questions:
1. Classify the wound according to a) character; b) contamination; c) localization; d)
complications.
2. What mistake was done by a doctor treating the wound? How it should have been
done?
3. What changes do you expect to find with laboratory tests?
4. What is a medical treatment of developed complication?
5. What is a surgical treatment of developed complication?

Task № 5
Clinical scenario: 57 years old patient was operated due to acute appendicitis. On the
third postoperative day the patient starts to complain of throbbing pain in the area of the
surgical wound, rise of body temperature till 38,20C, chills. The condition of the patient is
normal. Skin color and breathing sounds in lungs are normal. PS is 90, blood pressure is
120/80mmHg, the tongue is moist, the abdomen is soft, tender in the area of postoperative
incision. During the dressing procedure the area of the incision is reddish and swollen.
Questions:
1. What complication has developed after surgery?
2. What could the possible causes of developed complication be?
3. What laboratory and instrumental techniques may help to make a diagnosis?
4. What is the management of developed complication?
5. What methods of antisepsis cab be used in managing the complication?

92
TOPIC 17 PURULENT DISEASES OF HAND AND FOOT
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize basic symptoms and signs of purulent diseases of the hand
and foot.
 Ability to provide first aid to patients with purulent diseases of hand and foot.

I. Motivation of the goal:


The necessity of studying this theme is dictated by a great number of patients with
purulent diseases of the fingers and toes, the long terms of disability caused by the disease,
and sometimes followed by loss of hand and foot function, and even amputation of them.
Knowledge of etiology and pathology of purulent diseases of the hand and foot, correct
diagnosis of different forms of the disease, adequate surgical treatment and rational therapy
allows to improve the results of treatment of this serious pathology.

II. The goal of self-preparation:


To study etiology, pathology, classification, clinical manifestations and diagnosis of
purulent diseases of fingers, the features of the purulent inflammation of a hand, to acquire the
principles of diagnosis and treatment of these diseases. To study etiology, pathology of
diabetic foot, clinical forms, clinical and instrumental diagnosis. To acquire the principles of
complex treatment of the diabetic foot.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 anatomical constitution of fingers and toes;
 portals of entry to pathogens;
 predisposing factors to the development of purulent diseases of the hand and foot
(pathology of blood circulation, vitamin deficiency, diabetes);
 pathoanatomical changes in tissues of fingers and toes in the development of an
inflammatory process;
 clinical classification of purulent diseases of fingers;
 clinical symptoms and treatment of panaritiums (felon):paronychia, cutaneous,
subcutaneous, tendon, articular, and osteal panaritiums, pandactilitis;
 etiology, pathology, classification of a hand phlegmons;
 clinical symptoms and treatment of a hand phlegmons;
 etiology, pathology, classification of the diabetic foot;
 clinical and instrumental diagnosis of the diabetic foot;
 principles of the complex treatment of the diabetic foot;
 etiology, pathology, principles of treatment of the ingrown nail.
Be able to:
 determine correctly the form of purulent disease of fingers and toes;
 determine the plan of the complex treatment;
 determine the indications for the surgical treatment of a purulent disease of fingers
and toes;
 determine the method of anesthesia;
 perform digital nerve block anesthesia;
 apply an immobilizing bandages;
 determine the localization of an abscess;
 determine the place and the direction of incisions at various forms of the
panaritiums, phlegmons;
 dress the wounds correctly;

93
 distinguish the complicated development of the disease, determine lymphangitis,
lymphadenitis;
 determine the prognosisof working ability to be resumed.
Practice and demonstrate:
 The skills of a diagnostic and first aid actions algorithm for surgical patients of
different age groups with purulent diseases of the hand and foot.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat questions of the
anatomic constitution of fingers and toes, the questions of microbiology, pathology, related to
this theme; asepsis and antisepsis, desmurgy.

V. The plan of studying the topic.


1. Anatomical constitution fingers and toes (features).
2. Etiology, pathology, classification of panaritium, clinical manifestations and
diagnosis of panaritiums: paronychia, cutaneous, subcutaneous, tendon, articular, and osteal
panaritiums, pandactilitis;
3. Basic principles of treatment of panaritiums (general and local).
4. Etiology, pathology, classification of phlegmons of a hand.
5. Clinical diagnosis and treatment of hand phlegmons.
6. Etiology, pathology,and clinical forms of the diabetic foot.
7. Clinical and instrumental diagnosis of the diabetic foot.
8. Principles of the complex treatment of the diabetic foot.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. pp. 159-164.
Supplemental materials:
1. "Principles of surgery" Schwartz, Shires, Spencer., 1994. Pp.2001-2006.
2. Scientific American Surgery 1997, Chapter IX : 15.

VII. Questions for the self-control.


1. What is panaritium (the definition)?
2. What is the classification of panaritiums based on?
3. Anatomical and physiological features of the constitution of fingers and toes.
4. What are the indications for the conservative treatment of panaritiums?
5. Indications for a surgery and option of the method of anesthesia at panaritiums.
6. Complications of panaritiums.
7. What phlegmons of a hand do you know?
8. Indications for a surgery and option of the method of anesthesia in ahand
phlegmon.
9. Features of surgical incisions at panaritiums and phlegmons of a hand.
10. Main factors leading to the development of the diabetic foot syndrome.
11. Tasks of diagnostic actions of the diabetic foot.
12. Clinical forms and symptoms of the diabetic foot syndrome,
13. Principles of diagnostic actions of the diabetic foot.
14. Principles of the complex treatment of the diabetic foot (general and local).
15. Etiology, pathology, principles of treatment of the ingrown nail.

VIII. Tasks for self-preparation:


1. Make the classification of panaritiums.

94
2. Draw the scheme of treatment of the cutaneous panaritium and paronychia.
3. Introduce the scheme of medical actions in the case of subcutaneous panaritium.
4. Introduce the scheme of medical actions in the case of tendon panaritium.
5. Introduce the scheme of medical actions in the case of articular and osteal
panaritiums.
6. Write the classification of hand phlegmons.
7. Make the scheme of medical actions at the hand phlegmon.
8. Introduce the scheme of diagnostic actions in the case of the diabetic foot.
9. Introduce the scheme of differential diagnosis of two clinical forms of the diabetic
foot.
10. Specify schematically the medical treatment of thediabetic foot.

Tests

1. a pain at the suppurative stage of the felon usually bears the following character (choose
right)
a) dull
b) mild
c) throbbing
d) cutting
e) burning

2. a pain at the infiltrative stage of the felon usually bears the following character (choose
right)
a) throbbing
b) mild
c) dull
d) cutting
e) burning

3. the subcutaneous felon is characterized be the following features (choose right)


a) active movements are limited
b) affect the dorsal aspect of the palm
c) hot, red, and tender pulp
d) uniform swelling of the finger
e) tenderness at the site of lesion

4. the paronychia is characterized be the following features (choose right)


a) active movements are limited
b) blister bulking above the nonaffected skin
c) the skin fold around the nail is affected
d) midflexion of the finger in all joints
e) local reddish discoloration of the skin

5. usual localization of the furuncles and carbuncles in the hand are as follows (choose
right)
a) midaxial aspect of the hand
b) dorsal aspect of the hand
c) volar aspect of the hand
d) anywhere at the hand

95
6. surgical treatment of the subcutaneous felon is indicated by the following situation
(choose right)
a) high temperature
b) first sleepless night
c) swelling of the finger
d) local tenderness

7. option of the anesthesia during surgery of the paronychia (choose right)


a) applicationanesthesia
b) aerosol anesthesia
c) general anesthesia
d) digital nerve block anesthesia
e) spinal anesthesia

8. the following maneuvers are used in surgery of the subcutaneous felon (choose right)
a) parallel to nailfold
b) complete removal of the nail
c) partial removal of the nail
d) single incision on the volar aspect of the finger
e) contralateral incisions of the finger

9. the following type of arterial system involvement is most common in patients with
diabetic foot (choose right)
a) aorta
b) femoral artery
c) popliteal artery
d) peripheral arteries
e) radial artery

10. the following changes in patients with diabetic foot are caused by polineuropathy
(choose right)
a) weakness of the foot muscles
b) structural deformities of the foot with excessive pressure on the bones
c) loss of pain perception
d) osteoarthropathy following Charcot cubic foot formation
e) all statements are right

11. proper position of the hand after surgical treatment of the felon is the following (choose
right)
a) use of sling bandage
b) lifting of the hand above the heart level
c) immobilization with plaster of Paris
d) positioning of the hand below the heart level

12. classification of the diabetic foot includes the following types (choose right)
a) ischemic
b) cubic
c) autonomic
d) posttraumatic
e) neuropathic

96
Clinical tasks

Task № 1
Clinical scenario: A 47 year old female patient complains of a constant pain in the
right foot. The pain is moderate, made worse by lying down or elevation of the foot.
Previously, she had a similar pain, but provoked only by long-distance walking.
Approximately two weeks ago, shefirst noticed dark discoloration of and 5th toe. She has a
long history of diabetes mellitus. The skin of right lower extremity is pale, dry, and cold, hair
distribution is poor. The foot has obvious deformation with absence of foot volt. There is a
dry necrosis of the 5th toe. The pulse is absent over right a. dorsalis pedis and tibialis posterior
artery. Pain sensitivity is decreased. Left lower extremity has similar deformation but the
pulsation of arteries is normal. An auscultation has not revealed any vascular bruits.

Questions:
1. What is a form of the diabetic foot?
2. What is a reason of dry necrosis of the 5th toe?
3. What instrumental tools are to be used (at least five)?
4. What laboratory tests are to be done?
5. Name the groups of medicines used inthe treatment of the patient?
6. What must be included into the treatment beside local wound treatment to achieve
healing?

Task № 2
Clinical scenario: A 38 year old female patient complains of a rise of body
temperature (evening) till 39,5C0, night chills, loss of appetites, malaise, mild throbbing
sensation and hyperemia of the left foot. She has a long history of diabetes mellitus.
Previously, she noticed weakness, muscle cramps, and paresthesias at both lower extremities.
Skin color and breathing sounds in lungs are normal. PS is 120, blood pressure is
110/80mmHg, the tongue is dry, the abdomen is soft. Feet have obvious deformation with
absence of foot volt. There is hyperemia of the plantar surface of the foot with 5/5 cm deep
dark skin necrosis discharging putrid fluid. Palpation is painless. The skin is dry and warm.
There are two painful, red strips running parallel to the great saphenous vein. A left groin area
is moderately swollen, tender, and infiltrated. Pulsation of arteries is normal. An auscultation
has not revealed any vascular bruits.
Questions:
1. What is a form of diabetic foot? What is it complicated by?
2. Explain pathophysiologic changes happening in the foot of a diabetic patient.
3. What is a cause of groin pain?
4. What instrumental tools are to be used?
5. What laboratory tests are to be used?
6. Name the groups of medicines used inthe treatment of the patient?
7. Classify pathology according to Vagener‟s classification.
8. What are the principles of surgical treatment?

Task № 3
Clinical scenario: A 23 year old patient has come to a physician complaining of a
throbbing pain in the index finger, rise of body temperature till 38,2C0. Three days ago, he
injured the finger by a metal splint. One day ago the signs started and the pain forced the
patient to seek medical advice. Examination of the affected finger is done. The terminal
phalanx of the index finger is red, hot, and very tender.

97
Questions:
1. What is your diagnosis?
2. What is a medical treatment of developed complication?
3. What kind of anesthesia is usually used?
4. What incisions are used to treat presented pathology?
5. List principles of surgical treatment of presented pathology.

Task № 4
Clinical scenario: A 32 years patient has come to a physician complaining of a
throbbing pain in the index finger, rise of body temperature till 38,4C0. Three days ago, he
injured the finger by a wooden splint. One day ago the signs started and the pain forced the
patient to seek medical advice. Examination of the affected finger has been done. Entire index
finger is red, evenly swollen, hot, slightly flexed at all joints, and very tender along middle
part of the palmar surface.
Questions:
1. What is your diagnosis?
2. Is it common that the given pathology to be complicated by U-phlegmon?
3. What is a medical treatment of developed complication?
4. What is a surgical treatment of developed complication?

Task № 5
Clinical scenario: A 19 year old patient has come to a physician complaining of a
dull severe constant pain in the right ring finger, rise of body temperature till 38,8C0, malaise.
One week ago a cat scratched his finger. In two days the finger became swollen and tender.
The patient treated himself with gentamycine. Despite of the treatment the signs progressed
and finally the patient decided to come into a hospital. Examination of the affected finger has
been done. Entire right ring finger is red, swollen, and hot. There are multiple sinuses with
protruding debris and tendons. The sinuses discharge pus and parts of necrotized bone.
Palpation is tender. There are two painful red strips running parallel to cephalic vein. A right
armpit area is moderately swollen, tender, and infiltrated.
Questions:
1. What is your diagnosis?
2. Why was a gentamycine ineffective?
3. What is a cause of armpit pain?
4. What is a medical treatment of developed complication?
5. What is a surgical treatment of developed complication?

98
TOPIC 18 SPECIFIC SURGICAL INFECTION. TUBERCULOSIS OF BONES AND
JOINTS. ACTINOMYCOSIS. ANTHRAX
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of specific surgical infections.
 the skills of medicine and non-medicine therapy option algorithm for surgical
patients suffered from specific surgical infections.

I. Motivation of the goal:


The specific surgical infection includes tuberculosis of bones and joints, tubercular
lymphadenitis, actinomycosis, and anthrax. Surgical forms of tuberculosis reach up to 10% of
all tuberculosis forms. Actinomycosis and anthrax are rare forms of the specific surgical
infection and these forms are suggested for a self-contained studying by students.

II. The goal of self-preparation:


To study the definition of surgical forms of tuberculosis, etiology, pathology,
classification, clinical manifestations, diagnostic principles, and general and local treatment of
various forms of tuberculosis of bones and joints.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 etiology, pathology, pathomorphologic changes in the bones and joints altered by
tuberculosis;
 classification, clinical manifestations of tuberculosis of bones and joints;
 diagnostic principles of various forms of a surgical tuberculosis.
Be able to:
 examine a patient with surgical forms of tuberculosis of bones and joints and
lymphadenitis;
 describe a radiograph with various forms of tuberculosis of bones and joints;
 describe the clinical manifestations of various forms of surgical tuberculosis;
 prescribe general and local treatment of various forms of surgical tuberculosis.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from specific surgical infections.

IV. The initial level of knowledge:


It is necessary to revise the anatomy of bones, joints which were studied during the
anatomy course.

V. The plan for the topic studying.


1. Etiology and pathology of surgical forms of tuberculosis.
2. The classification of surgical forms of tuberculosis.
3. The clinical manifestations of a spine tuberculosis (obsolete term is tuberculous
spondylitis).
4. The clinical manifestations of the hip tuberculosis (obsolete term is tuberculous
coxitis).
5. The clinical manifestations of the knee tuberculosis (obsolete term is tuberculous
gonitis).
6. Diagnostic principles of a surgical tuberculosis.
7. Principles of conservative treatment of surgical tuberculosis.
8. Surgical treatment of surgical tuberculosis.

99
VI. The recommended literature:
Suggested reading:
1. Lecture materials.
2. General surgery the manual, V.K. Gostishev., 2003, pp. 192-195.
Supplemental materials:
1. "Short practice of surgery" Bailey and Love's, 1996. Pp. 77-78, 84-85, 271-275,
799.

VII. Questions for the self-control.


1. What are the attributesof a spondylitic phase of the spine tuberculosis?
2. Name a pathogen which causes bones and joints tuberculosis.
3. What is the classification of bones and joints tuberculosis?
4. What are the characteristics of a prespondylitic phase of the spine tuberculosis?
5. What do the clinical manifestations of a prespondylitic phase of a spine
tuberculosis include?
6. What are the characteristics of a prearthritical phase of a hip tuberculosis?
7. What are the symptoms of an arthritic form of coxitis?
8. What are the clinical manifestations of a postarthritic form of coxitis?
9. What are the symptoms of a prearthritical form of tuberculous gonitis?
10. What are the manifestations of an arthritical form of tuberculous gonitis?
11. What are the characteristics of a postarthritical form of tuberculous gonitis?
12. What are the basic diagnostic principles of bones and joints tuberculosis?
13. What are the basic principles of local treatment of bones and joints tuberculosis?
14. How is a general therapy of bones and joints tuberculosis carried out?
15. What operations are carried out at tuberculous spondylitis?
16. What operations are carried out at tuberculous coxitis?

VIII. Tasks for self-preparation:


1. Draw the localization of tuberculous lesions and the routes of extension of the
pathologic process on the scheme of a tubular bone.
2. Write the rate of alteration of different bones by tuberculosis.
3. Represent schematically the ways of edema extension in different localizations of
a tuberculous spondylitis.
4. Prescribe the treatment to a patient with a tuberculous spondylitis of the lumbar
region, who has developed paralysis of lower extremities and functional pathology of pelvic
organs (incontinence of urine and feces).
5. What orthopedic actions are carried out in patients with tuberculous spondylitis in
the emergency case?
6. What scheduled orthopedic actions are carried out at tuberculous spondylitis?

Tests

1. who was the first to discover mycobacterium tuberculosis? (choose right)


a) Celsus
b) Vesalius
c) Kocher
d) Claude Bernard
e) Robert Koch

2. what kind of spread of mycobacterium tuberculosis from primary focus leads to


development of tuberculosis of bones and joints? (choose right)

100
a) air-born
b) lymphogenous
c) contact
d) hematogenous
e) inoculation

3. what joints are most commonly affected by tuberculosis? (choose right)


a) wrist
b) elbow
c) hip
d) ankle
e) knee

4. what bone is most commonly affected by tuberculosis? (choose right)


a) skull
b) jaw
c) tibia
d) brachium
e) vertebrae

5. what part of the spine is most commonly affected by tuberculosis? (choose right)
a) cervical
b) thoracic
c) lumber
d) sacral
e) coccygeal

6. what part of the body is most commonly affected by Tb? (choose right)
a) tb of the skull
b) tb of the hip
c) tb of the tibia
d) tb of the brachium
e) tb of the vertebrae

7. find all clinical signs caused by diseased joint (choose right)


a) ache in the joint
b) subfebrille night temperature
c) weight loss
d) swelling of the joint
e) fatigability

8. find all clinical signs caused by systemic effect of Tb disease (choose right)
a) weight loss
b) subfebrille night temperature
c) ache in the joint
d) hemoptysis
e) fatigability

9. find all clinical signs caused by primary focus of Tb disease (choose right)
a) ache in the joint
b) subfebrille night temperature
c) weight loss
d) loss of appetite

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e) cough
10. precise diagnosis of the Tb is done with the following examination (choose right)
a) clinical picture
b) laboratory data
c) radiography
d) CT
e) histology

11. to assess sensitivity to antibiotics the culture of the mycobacterium tuberculosis may be
grown during the following period (choose right)
a) 1 day
b) 7 day
c) 2 weeks
d) 4 weeks
e) 6 weeks

12. the following clinical forms of Actinomycosis are known (choose right)
a) sacral
b) faciocervical
c) renal
d) abdominal
e) thoracic

Clinical tasks

Task № 1

Clinical scenario: A 49 year old homeless person complains of rise of body


temperature till 37,7 C0, night chills, malaise, cough with sputum. The signs last more than
three months. During this period the patient was not examined by a doctor and did not seek
medical advice. Due to aggravation of condition manifested by cough with blood, swelling
and pain in the right knee joint the patient is admitted to the hospital. Examination of the
patient has been done. The skin is pale and grayish, heart rate is 110, 120/80 mmHg blood
pressure, respiratory rate is 25. There are multiple crackles, wheezing, and decreased
breathing sounds at the upper lobe of the right lung. The right knee joint is swollen, the skin
over the knee joint is of normal color and temperature. Palpation of the joint and active
movements are painful. Ballottment sign is positive. The performed Montoux test is positive.
Questions:
1. What is your primary diagnosis?
2. What pathologies should the affected knee joint be differentiated with?
3. What laboratory changes are expected?
4. What invasive diagnostic method can be performed to confirm the etiology of knee
disease?
5. What are you going to find with performed invasive method?
6. How is ballottment sign examined?
7. Explain surgical treatment if the knee disease is on postarthritic stage.

Task № 2

Clinical scenario: A 61 year old alcohol addict complains of rise of body temperature
till 37,8 C0, night chills, malaise, cough with sputum. The signs has lasted for more than five
months. During this period of time the patient was not examined by a doctor and did not seek

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medical advice. Last two weeks he notices swelling in the groin and increased pain and
deformation of the thoracic spine. Examination of the patient has been done. The skin is pale
and grayish, heart rate is 110, 130/80 mmHg blood pressure, respiratory rate is 24. There are
multiple crackles, wheezing, and decreased breathing sounds at the upper lobe of the right
lung. The thoracic spine has visible kyphos, movements and palpation of the spine are tender,
the skin over it is of normal color and temperature. Palpation of the spine and active
movements are painful. The swelling in the right groin is firm, slightly tender, the skin over it
is not changed. The performed Montoux test is positive.
Questions:
1. What is your primary diagnosis?
2. Explain a pathogenesis of spine and groin pathology.
3. What investigation methods can be administered to assess spine involvement?
4. What period of time may the cultured bacteria take to grow?
5. Administer antibacterial regimen for a) pulmonary and b) spine pathology.
6. Explain principles of surgical treatment of spine Tb.

Task № 3

Clinical scenario: A 37 year old farmer is admitted to the hospital. He complaints of


itching, dark papulae on the dorsum of the palm, fever till 39,8 C0, malaise, vomiting, pain in
the armpit. The signs started in four days after handling a cow carcass. In two days an initial
itching papule with induration was replaced by a black slough. A brawny, congested area of
induration developed around the infection site with new several similar papulae around the
slough. Examination of the patient has been done. He is confused, the skin is dry, heart rate is
120, 120/80 mmHg blood pressure, respiratory rate is 28. Examination of respiratory,
cardiovascular, and GIT system has not discovered any abnormalities. There is a brawny,
congested area of induration around the dark slough of 5/5 cm size with several dark papulae
around it at the dorsum of the palm. The armpit lymph nodes are enlarged and tender.
Questions:
1. What is your likely primary diagnosis?
2. What should the pathology be differentiated with?
3. What do you expect to find at the papula smear?
4. Present characteristic of responsible bacteria.
5. Administer antibacterial regimen for the patient.

Task № 4

Clinical scenario: A 57 year old patient complaints of infiltrate at the area of lower
jaw. The signs started 3 months ago. Initially the infiltrate was small, in two months it
became larger and softer. Five days before admission the purulent sinus opened at the
infiltrate. Examination of the patient has been done. Condition and body temperature are
normal, the skin is moist, heart rate is 76, 120/80 mmHg blood pressure, respiratory rate is 18.
Examination of respiratory, cardiovascular, and GIT system has not discovered any
abnormalities but carious teeth. There is a bluish firm infiltrate (mass) discharging pus and
whitish tiny particles at the right part of the lower jaw. Performed smear of the discharged
fluid has discovered gram-positive, branching, filamentous organisms.
Questions:
1. What is your likely primary diagnosis?
2. What organism is responsible for mentioned signs?
3. What could be the portal for organisms entry?
4. What other forms of disease do you know?
5. What is a treatment of the patient?

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THE LIST OF PRACTICAL SKILLS QUESTIONS
5TH SEMESTER GENERAL SURGERY

Desmurgy
1. Desault‟s bandage on the left or right shoulder.
2. Velpeau‟s Bandage on the left or right shoulder.
3. Galen‟s bandage (head gear).
4. Hippocrates‟ cap.
5. Bandage on the right or left eye.
6. Figure of eight bandaging of the neck.
7. Four-tail bandaging of the nose and chin.
8. Spiral bandaging of a calf.
9. Figure of eight bandaging of the shoulder.
10. Bandaging of the right or left breast.
11. Converging tortoise bandaging of the right or left elbow joint.
12. Gauntlet bandaging for fingers.
13. Mitten bandaging for a palm or stump.
14. Figure of eight bandaging of the left or right hip joint.
15. Diverging tortoise bandaging of the left or right knee joint.
16. Figure of eight bandaging of a foot.
17. Handkerchief bandage to the right or left hand.
18. Spiral bandaging of a chest.
19. Barton bandage on a chin and lower jaw.
20. Spica bandaging of a right thumb.
21. Binocular bandage.
22. Elastic bandaging of a low or upper extremity.
23. Cravat bandage application.

Hemostasis
1. Compressive bandaging in the middle third of the right forearm medial surface.
2. Compressive bandaging in the lower third of the left shoulder medial surface.
3. Compressive bandaging of the right palm dorsal surface.
4. Compressive bandaging in the lower third of the left thigh medial surface.
5. Compressive bandaging of the right calf posterior surface.
6. Bleeding from the left carotid artery: bleeding control using a tourniquet.
7. Tourniquet placement onto the left shoulder.
8. Bleeding control from the left temporal artery using digital pressure.
9. Tourniquet placement onto the left thigh.
10. Bleeding control from the right common carotid artery using digital pressure.
11. Right gluteal area wound tamponade.
12. Bleeding control from the abdominal aorta using compression.
13. Turned cravat bandage placement onto the left shoulder.
14. Bleeding control from the left subclavian artery using digital pressure.
15. Bleeding control from the right forearm using elbow joint hyperflexion.
16. Bleeding control from the left calf using flexion knee joint hyperflexion.
17. Bleeding control from the right groin using hip joint hyperflexion.
18. Digital compression of the left brachial artery.
19. Digital compression of the right femoral artery.
20. Digital compression of a left hand peripheral vessels.
21. Digital compression of a right foot peripheral vessels.

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Miscellaneous
1. The technique and results of a blood typing (with antisera, celiclones).
2. The technique of an i.v. injection.
3. The technique of an i.m. injection.
4. The technique of a subcutaneous injection.
5. The technique of a female bladder catheterization.
6. The technique of a male bladder catheterization.
7. The technique of the Blackemore tube placement nasogastric.
8. The technique of the nasogastric tube placement.
9. The technique of the orogastric tube placement.
10. The technique of the gastric lavage and gavage.
11. The technique of the colon lavage.
12. The Seldinger‟s technique.
13. Alen‟s test technique.
14. The technique of an i.v. line placement.
15. The technique and results of a blood cross-matching.
16. The technique and results of a biological compatibility testing.
17. Recording of a blood transfusion chart.
18. The preparation of an i.v. line for blood transfusion.
19. Check the blood for suitability.
20. Preparation of dressing materials (gauze squares, gauze wicks, etc.).
21. Surgeon‟s hands preparation – scrubbing with (C-4 solution, chlorhexidine).
22. Gloving oneself.
23. Gowning oneself.
24. Gloving by the scrub nurse.
25. Gowning by the scrub nurse.
26. Removal of contaminated gown and gloves.
27. Prepping of the surgical site.
28. Draping of the surgical site.
29. Arrangement and package of materials for sterilization.
30. The technique of a skin suturing.
31. The technique of a skin stitches removal.
32. Steps of a cardiopulmonary resuscitation.
33. Initial steps and first aid for unconscious patient.
34. Initial steps and first aid for conscious and unconscious patient with airway
obstruction.
35. Initial steps and first aid for the patient with respiratory arrest only.
36. Initial steps and first aid for the patient with respiratory and cardiac arrest.
37. Tidy wound care and dressing.
38. Untidy wound care and dressing.
39. Wound dressing technique.
40. Preparation of a wound care tray.
41. Steps of a wound care.

Interviewing skills
1. Examination of a patient for fluid-electrolyte disorders.
2. Examination of a patient for bleeding.
 Hemoperitoneum.
 Hemothorax.
 Hemopericardium.
 Intracranial hematoma.
 Hemarthrosis.

105
 Pulsating hematoma.
3. Examination of a patient for dehydration and infusion therapy.
4. Calculation volume and option of solution for infusion therapy.
5. Calculation volume and option of solution for transfusion therapy.
6. Examination of a patient for bleeding risk.
7. Examination of a patient for thromboembolic complications.
8. Examination of a patient for hypovolemic shock.
9. Examination of a patient for cardiogenic shock.
10. Examination of a patient for septic shock.
11. Examination of a patient for anaphylactic shock.
12. Examination of a patient for acute cardiac failure.
13. Examination of a patient for acute liver failure.
14. Examination of a patient for acute renal failure.
15. Examination of a patient for acute respiratory failure.
16. Examination of a patient for MODS.
17. Examination of a patient before general anesthesia.
18. Examination of a patient before local anesthesia.
19. Examination of a patient with a wound.
20. Daily patient‟s examination.
21. Examination of a patient for purulent infection.
22. Examination of a local status for acute abdomen.

106
TOPIC 19 PURULENT DISEASES OF CELLULAR SPACES
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of purulent infections of cellular
spaces.
 ability to provide first aid to patients with purulent infections of cellular spaces.

I. Motivation of the goal:


Purulent diseases of the cellular spaces are a serious problem in surgery. The increased
resistance of microorganisms to antibiotics has shown that the surgical infection as a problem
is still far away from being solved and demands serious researches in this field. The
development of purulent diseases is complex and they frequently result in septic states.
Therefore, the knowledge of the clinical manifestations of these diseases will help to
distinguish them quickly and to prescribe the adequate treatment timely.

II. The goal of self-preparation:


To study etiology, pathology, ways of pus extension at the abscess and phlegmon of
the neck, the axillary and subpectoral phlegmons, the subfascial and intermuscular phlegmons
of extremities. To study the etiology and pathology of mediastinitis, paraproctitis,
paranephritis. To acquire the clinical manifestations, the diagnosis and the principles of local
and general treatment of these diseases.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 clinical manifestations, diagnosis and treatment of the abscess and phlegmon of
the neck;
 clinical manifestations, diagnosis and treatment of the axillary and subpectoral
phlegmons;
 clinical manifestations, diagnosis and treatment of the subfascial and intermuscular
phlegmons of extremities;
 clinical manifestations, diagnosis and treatment of the purulent mediastinitis;
 clinical manifestations, diagnosis and treatment of the purulent paraproctitis;
 clinical manifestations, diagnosis and treatment of the purulent paranephritis.
Be able to:
 diagnose correctly a purulent disease of the cellular spaces;
 determine the indications to the surgical treatment;
 choose correctly the method of anesthesia;
 dress a wound, change drains;
 prescribe the complex treatment of a purulent disease of the cellular spaces.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from purulent infections of cellular spaces.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to revise the questions of
anatomy, microbiology, pathology, desmurgy, asepsis and antisepsis related to this theme.

V. The plan for the topic studying.


1. Abscesses and phlegmons of the neck: cellular spaces, ways of contamination,
clinical symptoms, complications, treatment.

107
2. Axillary and subpectoral phlegmons: etiology, pathology, clinical symptoms,
complications, treatment.
3. Subfascial and intermuscular phlegmons of extremities. Features of development.
Clinical manifestations, diagnosis, treatment.
4. Purulent mediastinitis. Diagnosis and treatment. Complications.
5. Purulent paranephritis. Etiology. Clinical manifestations, diagnosis and treatment.
Danger and complications.
6. Purulent paraproctitis. Types. Features of clinical manifestations. Danger and
complications. Diagnosis and treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. General surgery the manual, V.K. Gostishev, 2003.

VII. Questions for the self-control.


1. Anatomy of the cellular spaces of the neck.
2. Routes of pus extension in the neck.
3. List the phlegmons of the neck according to their localization.
4. List the clinical symptoms of the neck phlegmon.
5. Name the dangers and complications which can develop at the phlegmons of the
neck.
6. Name the treatment principles of the neck phlegmons.
7. Name the features of the clinical manifestations of the axillary and subpectoral
phlegmons, subfascial and intermuscular phlegmons of extremities. Dangers and
complications of these diseases.
8. Etiology, pathology, classification of the purulent mediastinitis. Dangers and
complications.
9. The features of the surgical tactics.
10. Acute purulent paranephritis. Features of the clinical manifestations. Diagnostic
methods.
11. Treatment principles of the purulent paranephritis.
12. Acute purulent paraproctitis. Etiology. Classification.
13. Features of the clinical manifestation depending on the kind of paraproctitis.
14. Features of the surgical treatment of paraproctitis.
15. Complex therapy of the purulent diseases of cellular spaces.

VIII. Tasks for self-preparation:


1. Make the scheme of the medical actions ina neck phlegmon. Draw the scheme of
incisions on the neck.
2. Make the scheme of medical actions in the axillary and subpectoral phlegmons,
draw the scheme of incisions in the case of these phlegmons.
3. Make the scheme of medical actions in the case of upper and lower extremities
phlegmons. Draw the scheme of incisions in the case of these phlegmons.
4. Make the scheme of the medical actions in the case of mediastinitis.
5. Make the scheme of the medical actions in the case of paranephritis.
6. Write the classification of the acute paraproctitis.
7. Make the scheme of the medical actions in the case of acute paraproctitis.
8. Specify the dangers and complications of the acute paraproctitis.
9. Draw the scheme of incisions in the case of acute paraproctitis.
10. Note the basic treatment principles of purulent diseases of cellular spaces.

108
Tests

1. the following clinical forms of paraproctitis are known (choose right)


a) pelviorectal
b) subcuticular
c) retromammar
d) ischeorectal
e) all are right

2. an acute suppurative inflammation of the pararectal cellular tissue is (choose right)


a) colitis
b) proctitis
c) mediastinitis
d) paraproctitis
e) gonitis

3. the following may be the causes of paraproctitis (choose right)


a) hemorrhoids
b) anal tumor
c) penetrating wounds
d) anal cracks
e) all are right

4. the local signs of infection are more obvious with the following form of paraproctitis
(choose right)
a) pelviorectal
b) subcutaneous
c) ischeorectal
d) retrorectal
e) all are right

5. the following clinical forms of deep neck phlegmons and abscesses are known (choose
right)
a) retropharyngeal
b) presternal
c) retroesophageal
d) of the previsceral space
e) all are right

6. a suppurative inflammation of the mediastinum connective cellular tissue


is (choose right)
a) mastitis
b) mediastinosis
c) paraproctitis
d) mediastinitis
e) pleural empyema

7. the following may be the causes of the mediastinitis (choose right)


a) penetrating wounds
b) perforation of the esophagus
c) pneumonia
d) empyema
e) all are right

109
8. general signs of infection are more obvious with the following form of paraproctitis
(choose right)
a) pelviorectal
b) subcutaneous
c) ischeorectal
d) submucous
e) all are right

9. classification of the retroperitoneal phlegmon includes the following forms (choose


right)
a) paranephritis
b) colitis
c) paraproctitis
d) paracolitis
e) all are right

10. the retroperitoneal phlegmons may be caused by the following (choose right)
a) acute appendicitis
b) purulent diseases of kidney
c) perforation of descending colon
d) osteomyelitis of pelvic bones
e) all are right

11. the following stage of the phlegmon is the indication to surgery (choose right)
a) inflammation
b) infiltration
c) proliferation
d) suppuration
e) maceration

12. a pain at the suppurative stage of the paraproctitis is the following (choose right)
a) dull
b) mild
c) throbbing
d) cutting
e) burning

Clinical tasks

Task № 1
Clinical scenario: A 45 year old male complains of a throbbing pain in the anal area,
rise of body temperature till 38,6 C0. Signs started three days ago and are progressing.
Examination of the patient has been done. The skin is moist, heart rate is 88, 120/80 mmHg
blood pressure, respiratory rate is 15. There is 5/5 cm area of hyperemia located 3 cm laterally
to anus at 11th o‟clock. Palpation of the area is very painful, it is hot, fluctuation sign is
controversial.
Questions:
1. What is your primary diagnosis?
2. What forms of pathology according to localization do you know?
3. What predisposing factors may lead to it?
4. What laboratory changes do you expect?
5. What is your medical and surgical treatment?

110
Task № 2
Clinical scenario: A 37 year old patient complains of a severe deep throbbing pain in
the perineal area, rise of body temperature till 40,6 C0, malaise, chills, headache, severe pain
during defecation. The patient has a long history of hemorrhoids. The signs started three days
ago and are progressing. According to information provided by the patient he was examined
by a doctor when the signs just had started. The doctor prescribed him aspirin and
recommended to come in three days. Examination of the patient has been done. The patient is
slightly confused, the skin is dry, heart rate is 110, 120/70 mmHg blood pressure, respiratory
rate is 25. The perineal area is examined. There is infiltration of tissues around the anus,
palpation is tender, the skin is slightly hyperemic and hot, fluctuation sign is controversial.
Rectal digital exam detects bulging and severe tenderness of the rectum above the anus.
Questions:
1. What is your primary diagnosis?
2. What predisposing factor is responsible for disease?
3. Why didn‟t the patient improve to medical therapy?
4. What instrumental tools may be useful to detect pus localization?
5. What is your medical and surgical treatment?

Task № 3
Clinical scenario: A patient has been admitted to the hospital. He complains of
constant dull deep abdominal pain located inthe lower right abdominal quadrant, rise of
body temperature till 39,6 C0, malaise, chills, headache, and vomiting. The mentioned
signs have lasted two days. At the beginning two days ago the pain was moderate and
located at the epigastrium. Approximately in six hours it was mostly concentrated in the
right iliac area. Next morning condition of the patient worsened, the patient became
febrile. After examination of the patient the following signs have been found: the skin is
dry, heart rate is 110, 110/70 mmHg blood pressure. GIT examination is done. The tongue
is dry, the abdomen is tender at the right lower abdominal quadrant where an infiltrate is
palpated through the anterior abdominal wall laterally to the rectal abdominal muscle.
Signs of peritoneal irritation are negative. The hip is slightly bent and externally rotated.
Its extension is painful. Fluctuation test is negative.
Questions:
1. What is your diagnosis?
2. What may be the likely reason of developed complication?
3. Why are the signs of peritoneal irritation absent?
4. Why does the patient prefer to bend and rotated the hip?
5. What instrumental tools may be used to confirm diagnosis?
6. What is a treatment of the patient?

Task № 4
Clinical scenario: A 28 year old drug addict complains of a throbbing pain at the right
thigh, rise of body temperature (evening) till 39,5C0, night chills, loss of appetites, malaise.
The signs started gradually 3 days ago after drug injection into the upper thigh. Due to
progress of symptoms the patient has come into the hospital. After examination of the patient
the following signs have been found: the skin is dry, heart rate is 120, 110/70 mmHg blood
pressure. The respiratory rate is 26. Examination of the right thigh is done. There are multiple
dots in the projection of the femoral vein left by previous injections. The thigh is swollen, the
skin is hot and reddish, palpation is very tender, fluctuation is positive. Groin lymph nodes are
enlarged and tender.
Questions:
1. What is your diagnosis?
2. Why did the pathology happen?

111
3. Explain possible routs of the pus spread in the low extremity.
4. What do you expect to find with a) laboratory and b) instrumental tools?
5. What is a treatment of developed complication?

Task № 5
Clinical scenario: a 46 years patient is treated in the hospital. A procedure of bouging
of the esophagus is done in order to dilate the area of esophageal stenosis. The stenosis
was caused be inadvertent ingestion of acetic acid. The patient took it 3 months ago as a
substitute of alcohol. During passage of the bougie the patient noticed sudden moderate
pain deep in the chest. In ten hours the patient notices severe retrosternal pain, he prefers
to seat with neck bent forward. A body temperature is 39,5C0. Chills, loss of appetites,
malaise, and headache are present. Examining the patient the following signs are found:
the skin is dry and cyanotic, neck veins are dilated, heart rate is 120, 100/60 mmHg blood
pressure. The respiratory rate is 30. Plain chest X-ray shows mediastinal gas.
Questions:
1. What complication of bouging procedure happened and what is it complicated by?
2. What other factors may lead to developed complication?
3. What instrumental tools may be used to confirm diagnosis?
4. What do you expect to find with administered instrumental tools?
5. What are the principles of treatment of developed complication?

112
TOPIC 20 PURULENT DISEASES OF BONES AND JOINTS
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of purulent infections of bones and
joints.
 ability to provide first aid to patients with purulent infections of bones and joints.

I. Motivation of the goal:


Osteomyelitis is an infectious disease of bones and joints which occurs in 10% of
patients hospitalized in the departments of suppurative surgery. Purulent arthritis and bursitis
are also wide-spread diseases.
The importance of studying of the theme is caused not only by the widespread of the
disease, but also by the great variety of pathologic mechanisms of its development in children,
adults, which is connected to the various kinds of infection, fractures, gunshot wounds of
bones. Osteomyelitis results in a plenty of complications, many of them are life-threatening.
This determines the necessity of the knowledge of osteomyelitis not only for surgeons,
but also for therapists, pediatricians, traumatologists, radiologists, morphologists, etc.

II. The goal of self-preparation:


To study the definition of the osteomyelitis, classification, etiology, pathology, clinical
manifestations of various forms of the acute and chronic osteomyelitis. Principles of diagnosis
of osteomyelitis based on the complaints, anamnesis, laboratory and instrumental data,
additional methods of examination. To study the principles of general and local treatment of
various forms of the acute osteomyelitis.
To study the definition, classification, etiology and pathology, clinical manifestations,
and principles of treatment of the purulent bursitis and arthritis.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 classification of the osteomyelitis;
 clinical manifestations of different forms of the acute hematogenous osteomyelitis;
 clinical manifestations of the non-hematogenous forms of the osteomyelitis;
 principles of diagnosis and treatment of the osteomyelitis;
 clinical manifestations and principles of treatment of the purulent bursitis;
 clinical manifestations of the purulent arthritis and principles of its treatment.
Be able to:
 examine a patient with osteomyelitis;
 diagnose the osteomyelitis;
 describe a radiograph of a patient with the osteomyelitis;
 prescribe general and local treatmentin various forms of the osteomyelitis;
 diagnose the purulent bursitis and prescribe the treatment;
 diagnose the purulent arthritis and prescribe the treatment.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from purulent infections of bones and joints.

IV. Initial level of knowledge:


It is necessary to repeat the anatomy of bones, joints, synovial bursae, the questions of
inflammationdevelopment.

V. Plan of studying the topic.

113
1. Etiology and pathology of the osteomyelitis.
2. Classification of osteomyelitis.
3. Clinical manifestations of various forms of the acute hematogenous osteomyelitis.
4. Clinical manifestations of theprimary - chronic forms of the osteomyelitis.
5. Clinical manifestations of the non-hematogenous forms of the osteomyelitis.
6. Principles of diagnosis of various forms of the osteomyelitis.
7. Principles of the general and local treatment of the osteomyelitis.
8. Etiology and pathology of the purulent bursitis, clinical manifestations, diagnosis,
and treatment.
9. Etiology and pathology of the purulent arthritis, clinical manifestations, diagnosis,
and treatment.

VI. Recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003.Pp. 164-172.
Supplemental materials:
1. "Short practice of surgery" Bailey and Love's, 1996. Pp. 267-271.

VII. Questions for self-control.


1. What does the definition of the osteomyelitis include?
2. Etiology of the acute hematogenous osteomyelitis.
3. What are the theories of pathology of the acute hematogenous osteomyelitis?
4. What does the clinical classification of the osteomyelitis include?
5. What are the clinical manifestations of the toxic form of the acute hematogenous
osteomyelitis?
6. What are the characteristics of the septic form of the acute hematogenous
osteomyelitis?
7. What are the manifestations of the local form of the acute hematogenous
osteomyelitis?
8. What are the characteristics of theprimary - chronic forms of the osteomyelitis?
9. What are the manifestations of thesecondary - chronic osteomyelitis?
10. What are the clinical manifestations of the non-hematogenous forms of the
osteomyelitis?
11. Principles of diagnosis of the osteomyelitis.
12. What are the principles of the general treatment of the osteomyelitis?
13. What are the principles of the local treatment of the osteomyelitis?
14. Etiology and pathology of the purulent bursitis.
15. What are the clinical manifestations of the purulent bursitis?
16. What is the treatment of the purulent bursitis?
17. Etiology and pathology of the purulent arthritis.
18. How is the diagnosis of the purulent arthritis carried out?
19. What are the clinical manifestations of the purulent bursitis?
20. Principles of treatment of the purulent arthritis.

VIII. Tasks for self-preparation:


1. Represent the pathology of the acute hematogenous osteomyelitis (M.V. Grinev)
on the scheme of a tubular bone.
2. Write the rate of cases of the acute hematogenous osteomyelitis of various bones.
3. When and what radiologic changes do take place in tubular bones (4 attributes)?
4. What are the most typical attributes of the chronic hematogenous osteomyelitis?

114
5. What kinds of radical surgery are carried out at the acute hematogenous
osteomyelitis? Represent the scheme.
6. List the main indications for application of the Ilizarov‟s device (external fixation)
at osteomyelitis.
7. List the principles of local treatment of osteomyelitis.
8. Prescribe the treatment to a patient with the purulent radial bursitis.
9. Prescribe the treatment to a patient with the purulent gonitis

Tests

1. most frequent causative germ of the acute hematogenous osteomyelitis is the following
(choose right)
a. streptococcus
b. retrovirus
c. staphylococcus
d. enterococcus
e. E. colli

2. most frequent causative germ of the acute exogenous osteomyelitis is the following
(choose right)
a. streptococcus
b. retrovirus
c. staphylococcus
d. enterococcus
e. microbial associations

3. the following persons are affected most frequently by acute hematogenous osteomyelitis
(choose right)
a. newborn
b. teenage
c. adult
d. female
e. male

4. classification of an acute hematogenous osteomyelitis depending on a time of process


includes the following (choose right)
a. acute
b. primary acute
c. secondary acute
d. chronic
e. secondary chronic

5. the following types of primary chronic hematogenous osteomyelitis are known (choose
right)
a. Brodie's abscess
b. Moor's abscess
c. Ollier's albuminous osteomyelitis
d. Blackmor's osteomyelitis
e. Garre's sclerosing osteomyelitis

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6. radiological confirmation of the bone destruction during course of an acute
hematogenous osteomyelitis may be reliable from the following period of time (choose
right)
a. immediately after onset of symptoms
b. in 2-3 days after onset of symptoms
c. in 5-7 days after onset of symptoms
d. in 7-10 days after onset of symptoms
e. in two - three weeks after onset of symptoms

7. laboratory investigation of a patient with an acute hematogenous osteomyelitis includes


the following changes (choose right)
a. leukocytosis with left shift of the formula
b. drop of blood glucose level
c. rise of immature forms of neutrophyles
d. rise of blood glucose level
e. leukocytosis with right shift of the formula

8. the following forms of an acute hematogenous osteomyelitis are known (choose right)
a. septicophyemic
b. common
c. local
d. toxic
e. general

9. general and local signs of infection in patients with an acute hematogenous osteomyelitis
are characterized by the following (choose right)
a. hyperemia and swelling of the affected extremity
b. rise of PR
c. drop of PR
d. rise of BR
e. fever, malaise, headache, chills

10. clinical presentation of the chronic osteomyelitis is characterized by the following


(choose right)
a. relapsing course of disease
b. presence of the periosteal abscess
c. presence of the sequestra in the cavity of the destructed bone
d. presence of the false joint
e. presence of the purulent fistula

11. find an invasive diagnostic methods used in chronic osteomyelitis investigation (choose
right)
a. ultrasound
b. emergency bore holes in the bone
c. triplex examination
d. plain X-ray of the bone
e. fistulography

12. etiologic classification of an acute suppurative arthritis includes the following forms
(choose right)
a. acute
b. primary acute

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c. exogenous
d. chronic
e. endogenous

Clinical tasks

Task № 1
Clinical scenario: A 10 years old boy complains of a constant severe throbbing pain
in the right thigh, malaise, loss of appetite, headache, chills, and fever till 39,5C0. The
mentioned signs started two days ago. His mother gave her child an aspirin. Before that event
the boy was otherwise healthy, but had a sore throat. Signs started suddenly without any
explicable cause and condition of the boy worsened progressively. Examining the patient the
following signs are found: the skin is dry, heart rate is 120, 120/70 mmHg blood pressure.
The right thigh is slightly increased in size, the skin is of normal color, deep palpation is
tender, punching of the right heel causes pain in the thigh, fluctuation is absent, local
temperature is normal. Pulsation of arteries is normal, signs of DVT are negative.
Questions:
1. What is your primary diagnosis? Classify the pathology.
2. What may be the likely reason of developed disease?
3. Explain a pathogenesis of developed disease.
4. What laboratory changes do you expect?
5. What do you expect to find with Plain X-ray of the right thigh?
6. What are the principles of medical and surgical treatment of the patient?

Task № 2
Clinical scenario: A 49 years old patient is admitted to the hospital. He complains of
a wound at the anterior part of the left calf continuously discharging the pus. Body
temperature is normal. Taking the history of presenting complaints it was found that two
years ago the patient fractured left tibial bone in the road traffic accident. Open fracture was
complicated by osteomyelitis. Despite of antibacterial treatment the local infection of the bone
relapses almost each half of the year with overt signs of local infection culminated by the
discharge of the pus from the wound. There is a wound 3/5 cm at the anterior part of the left
calf with the pus coming out of it. The surrounding wound skin is sclerosed and infiltrated.
Palpation is moderately painful.
Questions:
1. Classify the diagnosed pathology.
2. What may be the likely reasons of developed disease?
3. Explain a pathogenesis of developed disease.
4. What instrumental tools may be used to confirm diagnosis? List a) noninvasive; and b)
invasive tools with expected results.
5. Explain the main steps of surgical treatment of the patient?

Task № 3
Clinical scenario: 4 days ago a 37 years old male was bitten by a dog in the area of
the knee joint. 10 hours after an accident, his lacerated deep wound was closed by primary
sutures. Now the patient complains of a pain at the area of traumatic wound, rise of body
temperature in the evening till 39,5C0, night chills, loss of appetites, malaise. Examination of
the left lower extremity is done. There is a 3 cm wound at the lateral surface of the left knee
joint closed by sutures. The skin over knee joint is red and swollen. Palpation of the area and
active movements at the knee are very painful. Ballottment sign is positive. A left groin area
is moderately swollen, tender, and infiltrated.
Questions:

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1. Classify the wound according to a) character; b) contamination; c) localization; d)
complications
2. What mistake was done by a doctor treating the wound? How it should have been
done?
3. How is ballottment sign examined?
4. What is the medical treatment of developed complication?
5. What is the surgical treatment of developed complication?

Task № 4
Clinical scenario: two weeks ago a 61 years old patient injured a right knee joint. In
two days after trauma the body temperature increased till 38,3 C0. Movements of the knee
joint were extremely painful. The patient noticed night chills, loss of appetite, and malaise.
The patient started self-treatment with penicillin. Despite of treatment the signs persisted,
condition of the patient progressively deteriorated and only in two weeks he was admitted to
the hospital. General signs of infection are still present. The skin over the right knee joint is
red and swollen. Palpation of the area and active movements at the knee are very painful.
Ballottment sign is positive. Plain knee X-ray shows destruction of the tibial and femoral
diaphyses.
Questions:
1. What is your diagnosis?
2. What pathogenetic stages of developed complication do you know?
3. Give characteristic to all pathogenetic stages of developed complication
4. What is the medical treatment of developed complication?
5. What is the surgical treatment of developed complication?

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TOPIC 21 ANAEROBIC SURGICAL INFECTIONS
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of purulent infections of bones and
joints.
 ability to provide first aid to patients with purulent infections of bones and joints.

I. Motivation of the goal:


Anaerobic gangrene as dangerous and progressing complication of a wound healing.
The experience of its diagnosis and treatment, which was gathered during the years of the
World War II, is rather lost. Tetanus is the most widespread form of an acute specific
anaerobic infection. The tetanus occurs mostly during wartime, especially after shrapnel
wounds. However, this disease also occurs in a peace time in rural areas. Moreover, 80% of
cases result from small domestic traumas. Therefore, it is very important to study this theme.

II. The goal of self-preparation:


To study diagnosis, complex treatment and prophylaxis of anaerobic gangrene.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the place of anaerobes in a normal microflora of a person;
 pathogenetic factors of anaerobes;
 the classification of theanaerobic gangrene;
 diagnosis and clinical manifestations of the anaerobic gangrene;
 the treatment principles of theanaerobic gangrene;
 etiology, pathology, clinical picture, diagnosis, and treatment of thenecrotising
fasciitis;
 pathogenetic factors of C. tetani;
 the classification of tetanus;
 diagnosis and clinical manifestations of the tetanus;
 the treatment principles of the tetanus.
Be able to:
 make anexamination plan of a patient;
 estimate a condition of a wound complicated by anaerobic gangrene;
 estimate the results of laboratory diagnosis;
 carry out the prophylaxis of anaerobic gangrene;
 make a plan of examination of a patient;
 estimate a wound condition in tetanus;
 carry out the diagnosis of tetanus;
 carry out the prophylaxis of tetanus.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from purulent infections of bones and joints.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat anaerobes, their
basic features and habitats.

V. Plan of studying the topic.


1. The place of anaerobes in a normal microflora of a person.
2. Factors of pathogenecity of anaerobes.

119
3. The classification of anaerobic gangrene.
4. Clinical manifestations of anaerobic gangrene.
5. Diagnosis of anaerobic gangrene.
6. Treatment of anaerobic gangrene.
7. Etiology, pathology, and clinical picture of necrotising fasciitis
8. Diagnosis and treatment of necrotising fasciitis
9. Etiology and pathology of tetanus.
10. The classification of tetanus.
11. Clinical manifestation of tetanus.
12. Diagnosis of tetanus.
13. Treatment of tetanus.

VI. Recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 133-136.
3. "Short practice of surgery" Bailey and Love's, 1996. Pp. 67-68, 75-77.
Supplemental materials:
1. "Principles and Practice of Infectious Diseases" G. Mendell, J. Bennett, R. Dolin.
Volume 1-2., fifth edition, 2000, pp. 2537-2559.
2. "Surgery" Jarrell, 1991. Pp. 35, 37-38.

VII. Questions for the self-control.


1. What is the difference between aerobes and anaerobes?
2. Where do they dwell?
3. How doesthe contamination happen?
4. Prophylaxis of anaerobic gangrene.
5. The classification of anaerobic gangrene.
6. Clinical manifestations of anaerobic gangrene.
7. Treatment of anaerobic gangrene.
8. The pathogens of anaerobic gangrene.
9. Wound conditions predisposing to anaerobic gangrene.
10. Etiology, pathology, and clinical picture of necrotising fasciitis.
11. Diagnosis and treatment of necrotising fasciitis.
12. The characteristics of a pathogen, its pathogenic properties.
13. The etiology of tetanus.
14. The incubation period of tetanus.
15. The pathology and clinical presentation of tetanus.
16. Initial symptoms of tetanus.
17. Local manifestations of tetanus.
18. Clinical forms of tetanus.
19. Causes of the death of patients with tetanus.
20. Specific and nonspecific therapy.
21. The challenges in tetanus treatment.
22. The actions devoted to control the muscle spasms and pathology of respiration.
23. The tetanus prophylaxis.

VIII. Tasks for self-preparation:


1. Describe the basic pathologicproperties of С. perfringens.
2. Describe the basic pathologicproperties of С. novii.
3. Describe the basic pathologicproperties of С.septicum.
4. Describe the basic pathologicproperties of С. hystoliticum.

120
5. Describe the local symptoms of gas gangrene.
6. Describe the general symptoms of gas gangrene.
7. What instrumental and laboratory methods are used for diagnosis, and what are the
expected results?
8. Specify the principles of a surgical operation in gas gangrene.
9. Make a scheme of conservative treatment in gas gangrene.
10. Make a scheme of conservative treatment at necrotising fasciitis infection.
11. Describe the basic pathological properties of С. tetani.
12. Describe factors of pathogenecity of С. tetani.
13. Write the classification of tetanus according to the portal of entry.
14. Write the classification of tetanus according to the clinical manifestation.
15. Describe the initial symptoms of tetanus.
16. Describe the clinical manifestations of tetanus.
17. What methods of diagnosis are used?
18. Specify the principles of a surgical treatment at tetanus.
19. Make the scheme of tetanus treatment.
20. Write out the drugs used for tetanus treatment.

Tests

1. find all characteristic features of the Clostridium tetani (choose right)


a) anaerobic bacteria
b) round shape
c) terminal spore
d) boxcar appearance
e) drumstick appearance

2. find all characteristic exotoxins produced by Clostridium tetani (choose right)


a) tetanolysin
b) enterotoxin
c) -toxin (lecithinase)
d) -toxin
e) tetanospasmin

3. find all measures headed to support the airway during tetanus treatment (choose right)
a) placement of the nasogastric tube
b) diazepam administration
c) placement of the endotracheal tube
d) benzodiazepam administration
e) tracheostomy

4. find all measures headed to control the muscle spasm during tetanus treatment (choose
right)
a) placement of the nasogastric tube
b) diazepam administration
c) placement of the endotracheal tube
d) benzodiazepam administration
e) vecuronium administration

5. find all measures aimed to passive immunization during tetanus treatment (choose right)
a) benzodiazepam administration
b) HTIG administration

121
c) 0,5-1,0 ml
d) tetanus toxoid administration
e) 500 IU

6. find all measures aimed to active immunization during tetanus treatment (choose right)
a) benzodiazepam administration
b) HTIG administration
c) 0,5-1,0 ml
d) tetanus toxoid administration
e) pancuronium administration

7. find all sorts of tetanus-prone wounds (choose right)


a) wound contaminated with dirt
b) wound contaminated with saliva
c) wound contaminated with feces
d) missile injuries
e) all are right

8. find the right notions regarding administration of tetanus immunization (choose right)
a) HTIG and tetanus toxoid are administered in the separate syringes
b) HTIG and tetanus toxoid are administered in the same site
c) HTIG and tetanus toxoid are administered in the same syringe
d) HTIG and tetanus toxoid are administered in the separate sites
e) depends on physician's preference

9. if a patient has been suffered by excessive burn and previous vaccination status is
uncertain the following agents must be administered (choose right)
a) tetanus toxoid alone
b) HTIG alone
c) both HTIG and tetanus toxoid
d) none is administered

10. find all characteristic features of the Clostridium perfringens (choose right)
a) Gram positive
b) Gram negative
c) terminal spore
d) boxcar appearance
e) drumstick appearance

11. find all characteristic exotoxins produced by Clostridium perfringens (choose right)
a) tetanolysin
b) -toxin
c) -toxin (lecithinase)
d) -toxin
e) tetanospasmin

12. most frequently the clostridial myonecrosis is caused by the following species (choose
right)
a) C. tetany
b) C. septicum
c) C. novyi
d) C. sordellii

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e) C. perfringens
Clinical tasks

Task № 1
Clinical scenario: A 62 years old male was injured by an ax. 12 hours after an
accident a deep crashed wound with ragged edges of 15/5 cm size at the calf was debrided and
closed by primary sutures. The patient was left in the hospital for observation. In the next
morning the patient is anxious, he complains on very severe pain at the wound area. The
temperature is 37,8 C0, the skin is dry, heart rate is 130, 100/60 mmHg blood pressure,
respiratory rate is 28. Examination of the wound area is done. There is a wound at the
posterior surface of the left lower calf closed by sutures. The wound is under tension. A
brownish sweetish fluid comes out of the wound between sutures. Palpation is very painful, a
crepitus is felt. All the calf is of khaki color, with marked edema and hemorrhagic bullae.
Questions:
1. Classify the wound according to a) character; b) contamination; c) localization; d)
complications.
2. What bacteria is likely responsible for developed complication? Give its
characteristics.
3. What do you expect to find with a) laboratory and b) instrumental tools?
4. What do you expect to find during surgical exploration of affected tissues?
5. What is the surgical treatment of developed complication?

Task № 2
Clinical scenario: Two days ago a 71 years old male patient was operated. An
amputation of the left lower extremity of the midthigh level was performed in order to treat a
dry gangrene of the foot caused by atherosclerosis. At next day after surgery the patient
complained of extremely severe pain at the area of postoperative stamp, rise of body
temperature till 38,0 C0, malaise, headache. The patient was confused, the skin was dry, heart
rate was 140, 100/60 mmHg blood pressure, respiratory rate was 30. Examination of the
wound area was done. The postoperative wound was under tension. There was a brownish
mousy smelling fluid coming out of the wound between sutures. Palpation was very painful,
a crepitus was felt. The rest of the thigh was of bronze color, with marked edema and
hemorrhagic bullae. A doctor suspected postoperative wound infection. After necessary
preparation he opened the wound, took a swab from tissues, irrigated the wound with boric
acid, and left the wound for secondary healing. After surgery the doctor administered
gentamycine injections. In 6 hours the patient died due to progressive intoxication and septic
shock.
Questions:
1. What complication developed in the postoperative period?
2. What predisposing factors to developed complication were present at the patient?
3. What could have been found on X-ray (or CT) of the postoperative area?
4. What medical treatment of developed complication should have been administered
after surgery?
5. What do you expect to find during surgical exploration of affected tissues?
6. What mistakes were done by the doctor during surgery and how it should have been
done?

Task № 3
Clinical scenario: A 39 years male was injured by soiled metal stick into the left calf.
Two hours after an accident he was admitted to the hospital. A surgeon performed surgical
debridement and left the wound for secondary healing. Postoperative period was uneventful
till the end of the next week when the patient started to experience dysphagia, severe pain in

123
the neck and back. A doctor examines the patient. He notices that the patient looks smiling
and is in depended position with backward curvature of the body. The temperature is elevated,
the pulse is rapid. Suddenly the patient has become cyanotic and died despite of initiated
CPR.
Questions:
1. Classify the wound according to a) contamination; b) localization; c) complications
2. What bacteria is likely responsible for developed complication? Give its characteristic.
3. What is the diagnosis of developed complication based on?
4. What was the mistake done by the doctor treating the patient initially?
5. How could the developed complication have been prevented?
6. What is the reason of patient‟s death?

Task № 4
Clinical scenario: A patient has been admitted into the burn center. 1 hour ago he
was exposed to flame. The burn involves both lower extremities. After resuscitation of the
patient and management of the burned area a doctor considers tetanus prophylaxis.
Questions:
1. What wounds are referred to tetanus-prone?
2. What is done if information about previous vaccination cannot be obtained?
3. What is done if the patient was properly vaccinated within last five years?
4. What is done if the patient was properly vaccinated within last seven years?
5. What clinical forms and symptoms of the tetanus do you know?
6. What is your treatment if symptoms of the tetanus start?

Task № 5
Clinical scenario: A 67 years old obese male patient complains of a constant severe
pain in the scrotum area, rise of body temperature till 39,0 C0, malaise, headache. Signs
started suddenly two days ago without any reason. The patient has been suffering by diabetes
mellitus for ten years, he takes insulin injections. The skin is dry, heart rate is 120, 120/70
mmHg blood pressure, respiratory rate is 26. Examination of the patient is done. There is a
dark 2/2 cm skin necrosis at the scrotum with offensive smell and discharge, surrounding skin
is slightly reddish. Palpation detects crepitus, the underlying tissues are infiltrated and tender.
Groin lymphatic nodes are tender and enlarged. Infiltration of the underlying subcutaneous
tissue extends from the scrotum towards the anterior abdominal wall.
Questions:
1. What pathology is the patient suffered by?
2. What predisposing to this pathology factors are present at the patient?
3. What bacteria do you expect to find at the gram stain of the wound swab?
4. What is the medical treatment of the pathology?
5. What is the surgical treatment of the pathology?

124
TOPIC 22 PURULENT DISEASES OF SEROUS CAVITIES
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of purulent diseases of serous
cavities.
 ability to provide first aid to patients with purulent diseases of serous cavities.

I. Motivation of the goal:


Purulent pleuritis and purulent peritonitis, as complications of many diseases of
thoracic and abdominal cavity organs, can occur in practice of different experts (surgeons,
therapists, gynecologists, etc.). This theme is very important now while the mortality at a
purulent pleuritis and peritonitis remains high. Purulent peritonitis has a 67% mortality rate
after operations concerning an acute appendicitis, a cholecistitis, a perforated ulcer, etc.,
therefore well-timed detection of these complications, their diagnosis, treatment and
prophylaxis are necessary for all doctors in their future work.

II. The goal of self-preparation:


To study etiology, pathology, classification, clinical manifestations and diagnosis of
peritonitis. To acquire the basic principles of general and local treatment of peritonitis.
To study etiology, pathology, classification, clinical manifestations and diagnosis of
purulent pleuritis, pericarditis. To acquire the basic principles of general and local treatment
of pleuritis, and pericarditis.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the reasons of peritonitis;
 classification of peritonitis according to extend of a process, and the form of a
pathogen;
 clinical manifestations of peritonitis (general and local symptoms);
 indications for an immediate surgery at peritonitis;
 basic principles of the surgical treatment of peritonitis;
 the reasons of pleuritis and pericarditis;
 classification of pleuritis and pericarditis;
 the differences between transudate (effusion), exudate, and frank pus;
 clinical manifestations of pleuritis (general and local symptoms);
 clinical manifestations of pericarditis (general and local symptoms);
 the signs of intoxication at peritonitis, pleuritis, pericarditis;
 indications for a puncture and draining of a pleural cavity, and pericardium;
 basic principles of treatment of pleuritis;
 basic principles of treatment of pericarditis.
Be able to:
 examine a patient with peritonitis (complaints, anamnesis morbi, objective data,
peritoneal symptoms);
 estimate the results of additional diagnostic methods (radiography, ultrasound,
endoscopy, laboratory tests);
 diagnose a peritonitis;
 carry out laparocentesis;
 prescribe the treatment for a patient with peritonitis;
 examine a patient with pleuritis (complaints, anamnesis morbi, objective data,
typical symptoms);

125
 estimate the results of additional diagnostics methods (radiography, ultrasound,
endoscopy, laboratory tests);
 diagnose a pleuritis;
 carry out thoracocentesis, draining of the pleural cavity;
 prescribe the treatment for a patient with pleuritis;
 render the first medical aid to patients with pleuritis, pericarditis, peritonitis;
 make a dressing, wound care, remove a drain at the postoperative period.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from purulent diseases of serous cavities.

IV. Initial level of knowledge:


It is necessary to repeat the questions of anatomy, microbiology, pathology,
pharmacology related to this theme; asepsis, antisepsis; pathology of hemostasis in surgical
patients.

V. Plan of studying the topic.


1. Etiology, pathology, and classification of peritonitis.
2. Clinical manifestations (general and local symptoms) and diagnosis of peritonitis.
3. Basic principles of treatment of peritonitis (general and local).
4. Etiology, pathology, classification of pleuritis.
5. Clinical manifestations (general and local symptoms) and diagnosis of pleuritis.
6. Basic principles of pleuritis (general and local) treatment.
7. Etiology, pathology, and classification of pericarditis.
8. Clinical manifestations (general and local symptoms) and diagnosis of pericarditis.
9. Basic principles of pericarditis (general and local) treatment.

VI. Recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 173-182.
3. "Short practice of surgery" Bailey and Love's, 1996. Pp. 585-586; 620-621; 764-
773.
4. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp.-257-
316/
Supplemental materials:
1. "Principles of surgery" Schwartz, Shires, Spencer., 1994. Pp. 1449-1485.
2. Scientific American Surgery 1997, Chapter IX : 8
3. "Principles and Practice of Infectious Diseases" G. Mendell, J. Bennett, R. Dolin.
Volume 1-2., fifth edition, 2000. Pp. 743-750, 821-849, 930-934.

VII. Questions for the self-control.


1. Name the causes of peritonitis.
2. Classification of peritonitis according to the extend of the process.
3. Classification of peritonitis according to the species of pathogen.
4. What are the indications for an immediate surgery at peritonitis?
5. What are the attributes of intoxication at peritonitis?
6. What are the causes of paresis of intestine (paralytic ileus)?
7. Name the types of pleuritis.
8. What are the primary and secondary pleuritis, an empyema of the pleura?
9. Differences between transudate (effusion), exudate and frank pus.
10. Basic pathological processes in an organism at purulent pleuritis, pericarditis.

126
11. What are the indications for a puncture and draining of the pleural cavity, for a
pericardiocentesis.
12. Basic treatment principles of patients with purulent pleuritis and pericarditis.

VIII. Tasks for self-preparation:


1. Write the detailed classification of peritonitis.
2. Write the classification of pleuritis.
3. Introduce the scheme of diagnostic actions at peritonitis resulted from an acute
appendicitis.
4. Introduce the scheme of treatment of peritonitis caused by acute appendicitis.
5. Introduce the scheme of diagnostic actions at peritonitis caused by a perforated
gastric ulcer.
6. Introduce the scheme of medical actions at the perforated gastric ulcer,
complicated by peritonitis.
7. Name the antibiotics, which are mostly applied for the treatment of pleuritis,
pericarditis, and peritonitis.
8. Introduce the scheme of diagnostic actions at purulent pleuritis.
9. Introduce the scheme of medical actions at purulent pleuritis.
10. Provide the first aid at purulent pericarditis.

Tests

1. classification of the peritonitis according to extend of the pathologic process includes the
following forms (choose right)
a) tertiary
b) diffuse
c) primary
d) localized
e) secondary

2. classification of the peritonitis according to etiology of the pathologic process includes


the following forms (choose right)
a) tertiary
b) diffuse
c) primary
d) localized
e) total

3. the following lab changes are possible at a patient suffered by peritonitis (choose right)
a) urine output increases
b) urine output decreases
c) urine specific gravity increases
d) urine specific gravity decreases
e) WBC increases

4. the following lab changes are possible at a patient suffered by peritonitis (choose right)
a) Hb increases
b) Ht decreases
c) central venous pressure is increased
d) central venous pressure is decreased
e) ESR increases

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5. the following lab changes may be present at a patient suffered by peritonitis (choose
right)
a) drop of AST
b) rise of AST
c) drop of ALT
d) drop of protein level
e) disproteinemia caused by rise of G-globulines

6. choose all appropriate clinical signs of the peritonitis (choose right)


a) dry tongue
b) abdominal tenderness
c) muscle rigidity or guarding
d) distended abdomen
e) all are right

7. find all characteristic features of the peritonitis detected by US and CT (choose right)
a) air-fluid levels
b) free fluid in the peritoneal cavity
c) free air under the diaphragm
d) free air in the Duglas pouch
e) all are detected by that method

8. find all invasive diagnostic methods possible to use in diagnosis of the peritonitis (choose
right)
a) laparoscopy
b) CT
c) diagnostic peritoneal lavage
d) US
e) plain X-ray

9. the following is right regarding of surgical treatment of the peritonitis (choose right)
a) aspiration of the exudate is necessary
b) flashing of the cavity with antiseptic or saline solution
c) best approach is the midline laparotomy
d) drainage of the cavity
e) all are right

10. the following conditions may lead to infection of the pleural space (choose right)
a) pneumonia
b) thoracic surgery
c) thoracic trauma
d) esophageal perforation
e) all are right

11. find the best treatment options for organized empyema (fibrothorax) (choose right).
a) tube drainage
b) needle aspiration (thoracentesis)
c) videothoracoscopy with decortication
d) thoracotomy with decortication
e) all are used

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12. find all characteristic features of the pleural empyema during lab examination (choose
right)
a) positive culture
b) pH less than 7,2
c) LDG activity less than 1000 IU/L
d) glucose less than 40mg/dl
e) pH high than 7,2

Clinical tasks

Task № 1
Clinical scenario: A patient is admitted to the hospital. He complains of a constant
severe abdominal pain, repeated vomiting, and fever. The mentioned signs last two days. At
the beginning two days ago the pain was moderate and located at the epigastrium.
Approximately in six hours it was mostly concentrated in the right iliac area. The patient took
aspirin to relieve pain. At the next morning condition of the patient worsened, the pain
became more intense and involved all the abdomen. Examining the patient the following signs
are found: the skin is dry, heart rate is 120, 110/70 mmHg blood pressure. GIT examination is
done. The tongue is dry, the abdomen is tender, signs of peritoneal irritation are positive.
Questions:
1. What is your diagnosis? Classify it.
2. What may be the likely reason of developed complication?
3. What signs of peritoneal irritation do you know (at least five)?
4. What X-ray signs of developed complication do you know (at least two)?
5. What other useful instrumental tools may be used to confirm diagnosis? List a)
noninvasive; and b) invasive tools.
6. What are the steps of surgical treatment?

Task № 2
Clinical scenario: A patient is admitted to the hospital. He complains of constant
severe abdominal pain, repeated vomiting, and fever. The patient has a long history of
duodenal ulcer (anterior wall). The mentioned signs last two days. At the beginning two days
ago the pain was moderate and located at the epigastrium. Approximately in six hours it was
mostly concentrated in the right iliac area. The patient took aspirin to relieve pain. In the next
morning condition of the patient worsened, the pain became more intense and involved all the
abdomen. Examining the patient the following signs are found: the skin is dry, heart rate is
130, 120/80 mmHg blood pressure. GIT examination is done. The tongue is dry, the abdomen
is tender, signs of peritoneal irritation are positive.
Questions:
1. What is your diagnosis? Classify it.
2. What may be the most likely reason of developing complication?
3. What laboratory changes do you expect?
4. What instrumental tools may be used to confirm diagnosis? List a) noninvasive; and b)
invasive tools with expected results.
5. What is a medical treatment of the patient?
6. Prescribe antibacterial empirical regimen for the patient.

Task № 3
Clinical scenario: A 100 kg patient complains of constant severe abdominal pain,
repeated vomiting, and fever. The mentioned signs last one day. Basing on the clinical
picture and obtained data of instrumental investigation a doctor has diagnosed peritonitis due
to acute destructive cholecystitis. He has administered antibacterial therapy with penicillin

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i.v. and infusion therapy. Despite of prescribed treatment condition of the patient during next
24 hours progressively deteriorates. She is confused. The heart rate is 140, 80/50 mmHg
blood pressure, daily urine output was 100 ml. The CVP is 0 cm of water. The sclera is
yellowish. The liver span is increased.
Questions:
1. Why does patient‟s condition not improve with medical therapy?
2. Classify the peritonitis.
3. What organ dysfunction have you found clinically?
4. What is the medical treatment of the patient?
5. What is the degree of dehydration? Administer the volume and composition of
infusion therapy to reverse hypovolemia.

Task № 4
Clinical scenario: A 47 years old patient is admitted to the hospital. He complains of
constant pain in the right part of the chest, dry cough, dyspnea, rise of body temperature till
39,2 C0, chills, and malaise. The mentioned signs started suddenly four days earlier after
night spend by the patient on the ground. For three days he took broad-spectrum antibiotics
and NSAID. Despite of the antibacterial treatment condition of the patient worsened and he
was sent into the hospital. A skin is pale and cyanotic. The pulse rate is 120; arterial blood
pressure is 120/80; respiratory rate is 30. The chest wall is of normal color. A light tenderness
is present in the right part of the chest during palpation. An unequal expansion of the chest
(right part), bulging of ICS on the affected side, normal vocal fremitus, and dull percussion
note and absence of breath sounds over right chest (II to V ICS at midaxillary and anterior
axillary line) part are found. GIT examination is normal.
Questions:
1. What pathology should be suspected?
2. Why does patient‟s condition not improve with medical therapy?
3. What instrumental tools may be used to confirm diagnosis? List a) noninvasive; and b)
invasive tools with expected results.
4. What laboratory changes do you expect?
5. What are the principles of medical treatment of the patient?
6. What are the principles of surgical treatment of the patient?

Task № 5
Clinical scenario: A 63 years old patient is admitted to the hospital. He complains of
constant heaviness in the right part of the chest, dry cough, and dyspnea. The mentioned signs
last approximately 3 weeks with gradual progression. The patient has a long history of liver
cirrhosis. The skin is cyanotic. Body temperature is normal. The pulse rate is 120; arterial
blood pressure is 130/80; respiratory rate is 28. The chest wall is of normal color. An unequal
expansion of the chest, dull percussion note and absence of breath sounds over right chest are
found. Plain chest X-ray shows fluid in the right chest extending till 3rd rib. The doctor has
performed a diagnostic thoracentesis. Laboratory examination of aspirate shows pH 7,4,
glucose 50mg/dl, LDH 700 IU/liter, negative culture, protein level 2,0mg/dl, and a specific
gravity 1.010. The doctor has established diagnosis of pleural empyema and administered
antibacterial therapy and performed chest drainage.
Questions:
1. What is your diagnosis.
2. Is prescribed treatment right?
3. Present laboratory characteristic of pleural effusion.
4. Present laboratory characteristic of pleural empyema.
5. What is a treatment of a) pleural effusion; b) empyema.
6. How should the patient have been treated?

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TOPIC 23 SURGICAL SEPSIS AND SEPSIS SYNDROME
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of generalized purulent infection.
 ability to choose medical and non-medical therapy option algorithm for surgical
patients suffered from generalized purulent infection.

I. Motivation of the goal:


During the last years the substantial growth of frequency of purulent and septic
diseases, various inflammatory complications after surgical operations and the events of
nosocomial infections took place. The clinical manifestations of the disease are various,
which causes the necessity of having the clear concept of etiology, pathology, and clinical
manifestations of sepsis. Because of the difficulties of clinical diagnostics of sepsis students
should well know the methods of laboratory tests and be able to interpret them. The danger of
the development of sepsis in surgical patients assumes the knowledge of principles of sepsis
prophylaxis.

II. The goal of self-preparation:


To study etiology,pathology, and classification of sepsis, symptoms of the acute and
chronic sepsis, principles of diagnosis and treatment.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 basic principles of prophylaxis of sepsis;
 clinical manifestations of sepsis;
 bases of diagnosis of sepsis;
 indications and ways of surgical treatment.
Be able to:
 characterize sepsis as a serious infectious disease;
 classify sepsis according to the pathogen, the localization of the initial focus,
clinical manifestations and clinical and anatomical attributes, the time of development and the
reaction of the organism of a patient;
 prove the treatment of sepsis with the regard for general and local changes in the
organism;
 characterize the complications of sepsis.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from generalized purulent infection.

IV. The initial level of knowledge: For successful mastering of the given topic it is
necessary to know: the difference between “contamination” and “infectious process”; the
critical level of microbial contamination; phases of development of the wound process
depending on the pathogen; compatibility of antimicrobial drugs, principles of purulent
wound treatment. The concept of theportals of entry to infection, the role of macro- and
microorganism in the development of sepsis.

V. The plan of studying the topic.


1. Definition of the pathologic septic states.
2. Pathology of sepsis.
3. Classification of sepsis.
4. Clinical manifestations of sepsis.

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5. Methods of diagnosis.
6. Methods of the pathogenic treatment of sepsis.
7. Ways of the prophylaxis of sepsis.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. p. 192.
Supplemental materials:
1. "Principles and Practice of Infectious Diseases" G. Mendell, J. Bennett, R. Dolin.
Volume 1-2., fifth edition, 2000., pp. 806-817.
2. "SURGERY. Basic science and clinical evidence". USA., 2000., Pp.267-268.

VII. Questions for self-control.


1. What pathogens do cause sepsis most frequently?
2. Sources of the general purulent infection.
3. Introduce the classification of sepsis depending on the pathogens.
4. The classification of sepsis depending on the duration of the development.
5. What are the possible focuses of sepsis?
6. Stages of sepsis: bacteremia, septicemia, sepsis, sepsis syndrome, septic shock,
SIRS (systemic inflammatory response syndrome), MODS (multiple organ dysfunction
syndrome).
7. What are the causes of metastatic focuses at sepsis and what organs are most
commonly affected by them?
8. Pathology of the purulent infection and the role of the allergy in the development
of the disease.
9. What are the pathologic attributes of sepsis?
10. Definitions of the bacteremia, pyemia, septicemia, and septicopyemia. Features of
the reactivity of an organism at these states.
11. The cause of the appearance of microbes in the blood stream.
12. What are the clinical manifestations of sepsis, metastatic abscesses, septicemia?
13. Clinical manifestations of the septic wound.
14. Methods of the laboratory diagnosis of sepsis.
15. The importance of establishment of the fact of bacteremia.
16. Estimation of the degree of the severity of the state of the patient with sepsis.
17. What are the aims of general and local treatment of sepsis?
18. Principles of the complex treatment.
19. The septic treatment.
20. What are the actions improving the immunobiologic properties of the organism?
21. Treatment of the intoxication.
22. Surgical tactics at the primary and the secondary purulent focuses.
23. Complications of sepsis.
24. Principles of the prophylaxis of sepsis.

VIII. Tasks for self-preparation:


1. Write the factors influencing the development of the purulent infection.
2. Write the classification of sepsis depending on the pathogen.
3. Write the classification of sepsis depending on the clinical and anatomical
development.
4. Write the clinical symptoms of sepsis.
5. What diagnostic methods are necessary for diagnosis, their results.
6. Write the medicines for the treatment of sepsis.

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7. Describe the primary and the secondary purulent focuses.
8. Write the complications which can occur in the patients with sepsis.
9. Make the scheme of the pathology of homeostasis at the septic shock.
10. Make the scheme of the sepsis treatment.

Tests

1. in the case of the sepsis the systemic response of the body is manifested by the following
(choose right)
a) body temperature more than 370C
b) body temperature more than 380C
c) heart rate more than 80;
d) body temperature less than 360C
e) heart rate more than 90;

2. in the case of the sepsis the systemic response of the body is manifested by the following
(choose right)
a) respiratory rate more than 20
b) respiratory rate more than 30
c) PaCO2 less than 32mm Hg
d) PaCO2 more than 32mm Hg
e) heart rate more than 80;

3. in the case of the sepsis the systemic response of the body is manifested by the following
(choose right)
a) WBC more than 12 000 cells/mm3
b) WBC more than 10 000 cells/mm3
c) WBC less than 4000 cells/mm3
d) more than 8 band forms
e) more than 10 band forms

4. the following clinical signs are the evidence of altered organ perfusion (choose right)
a) hypoxemia
b) elevated lactate
c) altered mental status
d) oliguria
e) all are right

5. a sepsis associated with organ dysfunction , hypoperfusion, and hypotension is the


following (choose right)
a) sepsis
b) sepsis syndrome
c) septic shock
d) severe sepsis
e) refractory septic shock

6. a sepsis with hypotension despite adequate fluid resuscitation with evidence of perfusion
abnormalitiesis the following (choose right)
a) sepsis
b) sepsis syndrome
c) septic shock
d) severe sepsis
e) refractory septic shock

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7. a sepsis with evidence of altered organ perfusion is the following (choose right)
a) sepsis
b) sepsis syndrome
c) septic shock
d) severe sepsis
e) refractory septic shock

8. a sepsis with hypotension despite adequate fluid resuscitation with evidence of perfusion
abnormalities longer than 1 hour is the following(choose right)
a) sepsis
b) sepsis syndrome
c) septic shock
d) severe sepsis
e) refractory septic shock

9. what are the possible reasons of sepsis (choose right)


a) postoperative wound infection
b) peritonitis
c) pneumonia
d) indwelling line infection
e) all are right

10. a search for an occult infection in postoperative patients must start with the
examination of (choose right)
a) kidneys
b) peritoneal cavity
c) lungs
d) postoperative wound
e) indwelling lines

11. the following therapy is given to a patient with sepsis (choose right)
a) infusion
b) antibacterial
c) draining of the infection focus
d) detoxication
e) all are right

12. a patient with a sepsis may have the following clinical signs (choose right)
a) fever
b) hypothermia
c) skin lesions
d) chills
e) all are right

Clinical tasks

Task № 1

Clinical scenario: Two days ago a 62 year old male was injured by an ax. In two days
he was admitted to hospital. The patient is confused, he complains of very severe pain at the
wound area. The temperature is 35,2 C0, the skin is dry, heart rate is 140, 100/60 mmHg
blood pressure, respiratory rate is 28. The traumatic wound is under tension. A brownish

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sweetish fluid comes out of the wound. Palpation is very painful, a crepitus is felt. The entire
left leg is of khaki color, with marked edema and hemorrhagic bullae. Daily urine output is
200 ml. WBC is 3 000 cells/mm3, 11 band forms. Wound swab shows gram positive, rod
shape bacteria with boxcar appearance.
Questions:
1. Why can we claim the patient has sepsis syndrome?
2. What is the difference between sepsis and sepsis syndrome?
3. What disease causes sepsis syndrome in the patient?
4. What medical treatment should be administered?
5. What is a surgical treatment of the patient?

Task № 2

Clinical scenario: A 47 year old patient has been admitted to the hospital. He
complains of a constant pain in the right part of the chest, moist cough with sputum, dyspnea,
rise of body temperature till 39,2 C0, chills, and malaise. The mentioned signs started
suddenly four days ago after a night spent by the patient outdoor. The skin is pale and
cyanotic. The pulse rate is 120; arterial blood pressure is 120/80; respiratory rate is 30. The
chest wall is of normal color. There is a light tenderness in the right part of the chest during
palpation. An unequal expansion of the chest (right part), dull percussion note and absence of
breath sounds over the right chest (II to V ICS at midaxillary and anterior axillary line) part
are found. Daily urine output is 700 ml (patient‟s weight is 70kg). WBC is 25 000 cells/mm3,
15 band forms. Plain chest X-ray shows the area of localized fluid collected at area of II to V
i.c.s.
Questions:
1. Why can we claim the patient has sepsis?
2. What pathology is likely responsible for the sepsis?
3. Will the blood culture always be positive if the patient has sepsis?
4. What procedures may be used to obtain bacterial culture?
5. Administer antibacterial regimen for empirical therapy of the patient.
6. What are the principles of surgical treatment of the patient?

Task № 3

Clinical scenario: A 100 kg patient complains of constant severe abdominal pain,


repeated vomiting, rise of body temperature till 39,4 C0, chills, and malaise. The mentioned
signs have lasted three days. She is confused. The skin is dry and cold, heart rate is 140, 70/40
mmHg arterial blood pressure, daily urine output was 150 ml. The CVP is 0 cm of water. The
sclera is yellowish. The liver span is increased. Signs of peritoneal irritation are positive. A
level of lactate, creatinine, and bilirubine is increased, PaO2 is 65. Started infusion therapy
with crystalloids 3000 ml and albumin 1000 during 1 hour has failed to increase arterial blood
pressure.
Questions:
1. Why can we claim the patient has septic shock?
2. What is the difference between severe sepsis and septic shock?
3. Why can we state the patient has a refractory septic shock?
4. What pathology is responsible for septic shock?
5. What is a surgical treatment of the patient?
6. What organ dysfunction have you found?

135
Task № 4

Clinical scenario: A 65 year old patient has thermal burn of both upper extremities,
back, and the chest. The injured area is leathery and charred. The patient is being treated in
the burn center. Three hours after the injury she has the following signs. She is confused.
Body temperature is 38,5 C0, heart rate is 140, 90/50 mmHg arterial blood pressure, urine
output is negligible. The CVP is 1 cm of water. A level of lactate is increased. Started
adequate infusion therapy with crystalloids during 1 hour has failed to increase arterial blood
pressure.
Questions:
1. Can we claim the patient has septic shock?
2. Why have you answered the 1st question in such a way?
3. Explain pathogenesis of presented signs.
4. If will what antibacterial regimen is administered?
5. List all possible reasons of sepsis.
Task № 5

Clinical scenario: 4 days earlier a 56 year old patient was operated due to diffuse
peritonitis. It was caused by gastric ulcer perforation. After the surgery done according to the
common rules the patient was well, but since the third postoperative day his body temperature
had increased till 38,5. The doctor has changed the antibiotic and chosen weighting policy of
treatment. Despite the antibacterial treatment, condition of the patient does not improve, in
three days the patient is still hyperthermic. He is confused, the skin is pale, the sclera is
yellowish. The heart rate is 140, 70/30 mmHg blood pressure, daily urine output was 50 ml.
The CVP is negative. The level of creatinine and bilirubine is increased. WBC is 20 000
cells/mm3, 25 band forms.
Questions:
1. What may be the possible reason of negative changes in a patient‟s condition?
2. What should have been done by the doctor?
3. Where will you search the source of infection firstly?
4. How will you progress in diagnostic search further?

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TOPIC 24 SURGICAL PATIENT EXAMINATION

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of surgical diseases.
 ability to administer sufficient medical and surgical treatment depending on the
established diagnosis.

I. Motivation of the goal:


The treatment is impossible without diagnosis, as well as right treatment is possible
only if the correct diagnosis is established. The last one is done only if the proper patient‟s
examination has been done. Examination of a surgical patient has some principle differences
with those of therapeutic ones. Although in many cases the patient‟s examination has the
basic universal sequence of investigation steps, one must know what are the investigation
features of surgical patients.

II. The goal of self-preparation:


To study the sequence of the patient‟s examination. To get acquainted with methods of
subjective examination. To get acquainted with methods of objective examination. To learn
the examination of body systems. To know how the plan of the laboratory and instrumental
investigation is administered. To get acquainted with recording of the medical records (case
history and so on).

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 methods of subjective examination;
 methods of objective examination;
 examination methods of body systems;
 methods of the laboratory and instrumental investigation;
Be able to:
 do examination of surgical patients with soft tissue injuries;
 perform the subjective examination;
 perform the objective examination;
 perform the examination of body systems;
 administer the plan of the laboratory investigation;
 administer the plan of the instrumental investigation;
 make primary diagnosis;
 record and read medical notes.
To practice and demonstrate:
 The skills of patient‟s condition assessment, evaluation of laboratory and
instrumental investigation data in surgical patients of different age groups.

IV. The initial level of knowledge:


It is necessary to revise the methods of examination of therapeutic patients,
investigation of patients with purulent diseases.

V. The plan of studying the topic.


1. A general scheme of a case history.
2. The psychosocial status.
3. Subjective examination.
4. General inspection.

137
5. System investigation.
6. Local status.
7. Laboratory and instrumental investigation.
8. Final diagnosis.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 95-103.
3. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp. 3-78.
Supplemental materials:
1. "Introductory in medical surgical nursing"

VII. Questions for the self-control.


1. What is the case history?
2. What are the steps of the case history?
3. What is included into psychosocial status?
4. What is included into subjective information?
5. What is included and how to do general inspection?
6. What is included and how to do system investigation?
7. What is included and how to do examination of a local status?
8. How is the plan of the laboratory investigation administered?
9. How is the plan of the instrumental investigation administered?
10. What are the differences of the invasive and noninvasive diagnostic techniques?
11. How is final diagnosis proven?
12. What epycrises do you know?
13. What is a patient‟s diary?
14. What symptoms of acute abdominal surgical diseases do you know?
15. How are signs of the acute appendicitis, cholecystitis, pancreatitis, peritonitis, and
bowel obstruction examined?

VIII. Tasks for self-preparation:


1. Represent schematically the sequence of the case history.
2. List the questions addressed to the patient during the subjective examination.
3. List the set of an instrumental examination.
4. List the set of a laboratory examination.
5. Represent the example of the patient‟s diary.

Tests

1. the following points are included into psychosocial status of a patient (choose right)
a) name
b) car
c) age
d) parents
e) occupation

2. the following points are included into subjective examination of a patient (choose right)
a) chief complaints
b) history of present disease
c) examination of body systems
d) past health history

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e) general inspection
3. the following points are included into objective examination of a patient (choose right)
a) chief complaints
b) history of present disease
c) examination of body systems
d) past health history
e) general inspection

4. what is the first to be examined? (choose right)


a) past health history
b) history of present disease
c) examination of body systems
d) chief complaints
e) general inspection

5. what item is examined in the past health history section of the case history? (choose
right)
a) complaints
b) allergy
c) vital signs
d) tongue
e) rectal examination

6. what is the first to be examined in the GIT system? (choose right)


a) complaints
b) allergy
c) tongue
d) vital signs
e) rectal examination

7. what investigation maneuver is useless examining peripheral vascular system?(choose


right)
a) auscultation
b) percussion
c) palpation
d) inspection

8. what is examined firstly in the GIT system? (choose right)


a) abdomen
b) groin
c) tongue
d) chest
e) rectal examination

9. the plan of the laboratory investigation may include (choose right)


a) glucose level
b) colonoscopy
c) CT
d) urinalysis
e) MRI

10. the plan of the instrumental investigation may include (choose right)

139
a) glucose level
b) colonoscopy
c) CT
d) urinalysis
e) MRI

11. the plan of the invasive instrumental investigation techniques may include (choose
right)
a) glucose level
b) colonoscopy
c) CT
d) urinalysis
e) MRI

12. the plan of the noninvasive instrumental investigation techniques may include (choose
right)
a) glucose level
b) colonoscopy
c) CT
d) urinalysis
e) MRI

Clinical tasks

Task № 1
Clinical scenario: A 25 year old male has been admitted to the reception ward. He
complains of severe chest pain and dyspnea. He has been stricken by the knife into the right
chest. There is a stab wound on the right lateral chest wall in the 5th ICS. The condition of the
patient is severe. The skin is pale. The patient is confused. An unequal expansion, bulging of
ICS, and crepitation are detected at the right side of the chest
Questions:
1. What is your primary diagnosis?
2. What other objective data are necessary for diagnosis?
3. What laboratory and instrumental tools are administered firstly?
4. Where is the patient transported further from the reception ward?
5. What nonoperative techniques is necessary for the patient?

Task № 2
Clinical scenario: A 65 year old woman has come to a physician complaining of a
mass at the neck part, severe throbbing pain, headache, and rise of body temperature till
38,8C0. Signs started 10 days ago and have become worse since then. Examination of the
patient has been done. There is a round shape, 7/7 cm, dark lesion with multiple sinuses
discharging brownish with offensive smell fluid at the posterior neck surface.
Questions:
1. What is your primary diagnosis?
2. What laboratory and instrumental tools and specialist consults are obtained firstly?
3. What surgical treatment is indicated?
4. What kind of anesthesia is preferred?

140
5. What information is reflected in the diaries of the postoperative period?

Task № 3
Clinical scenario: A 40 year old male has had a long history of the gastric ulcer.
Suddenly he noticed general weakness and fainting. Soon he had vomiting of coffee-like
color. The patient is in the reception ward.
Questions:
1. What is your primary diagnosis?
2. What information has to be reflected in the anamnesismorbi?
3. What information has to be reflected in the anamnesis vitae?
4. What examination must be done at the end of the local status assessment?
5. What laboratory and instrumental tools are administered firstly?

Task № 4
Clinical scenario: A 35 year old male person has been admitted into the reception
ward of the emergency hospital. He complains of a pain in the right inguinal area and a
vomiting. Two years ago he had cholecystectomy. The pain initially was in the epigastrium,
in six hours it was in the right iliac area. The condition of the patient is satisfactory. The
palpation of the McBurney's point is painful, here are a musculary guarding, positive rebound
tenderness, and shirt signs
Questions:
1. What is your primary diagnosis?
2. What part of the case history is a dynamic of the pain recorded?
3. What part of the case history is a previous surgery recorded?
4. What invasive diagnostic method helps diagnosis?
5. Who has to sign a consent to surgery in the situation?

Task № 5
Clinical scenario: A 30 year old woman has been admitted into the reception ward of
the emergency hospital. She complains of an intense pain in the right upper abdominal
quadrant and bilous vomiting not relieving the state. The Ortner's, Kalk's, Ker's, Murphy's,
and Razba's signs are positive.
Questions:
1. What is your primary diagnosis?
2. What part of the case history is an information about 1 year prior detected gallstones
recorded?
3. What part of the case history is a previous appendectomy recorded?
4. What part of the case history is a preoperative dynamic recorded?
5. What part of the case history is a premedication recorded?

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TOPIC 25 ARTERIAL DISORDERS

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of arterial disorders.
 ability to provide first aid to patients with arterial disorders.

I. Motivation of the goal:


The pathology of the arterial blood circulation occurs in 2-3 % of Russian population.
There is a great amount of diseases which can result in pathology of the arterial blood
circulation (embolism, thrombosis, atherosclerosis, Burger's disease, etc.) These diseases are
treated by doctors of various specialties (therapists, surgeons, neuropathologists, etc.).
However, the clinical manifestations, the diagnostic principles and treatment of the syndromes
of the acute and the chronic arterial ischemia should be known by a doctor of any specialty.

II. The goal of self-preparation:


To study the causes, the clinical manifestations, the principles of diagnosis and
treatment of the syndromes of the acute and the chronic arterial ischemia.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 principal causes of the arterial blood circulation disorders;
 clinical manifestations of the acute arterial ischemia of extremities;
 clinical manifestations of the chronic arterial ischemia of extremities;
 basic principles of the clinical diagnosis of arterial diseases;
 basic principles of the instrumental diagnosis of arterial diseases;
 principles of the conservative treatment of the arterial blood circulation disorders;
 principles of the surgical treatment of the arterial blood circulation disorders;
Be able to:
 carry out the subjective examination of patients with the artery diseases
(complaints, anamnesis);
 carry out the objective examination of the patients, palpation and auscultation of
the main vessels;
 carry out the functional tests, indicating disorders of the arterial blood circulation:
the plantar ischemia, refilling time, Goldflam‟s, Samuels‟, Rotshov‟s;
 provide the first medical and pre-medical aid at the acute ischemia of the
extremities.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from arterial disorders.

IV. The initial level of knowledge:


For successful mastering of the given topic a student should revise the anatomy of the
arterial vessels of the upper and lower extremities, the histology of the arterial wall.

V. The plan for the topic studying.


1. Surgical anatomy and clinical physiology of the arterial system.
2. Methods of clinical examinations of patients with disorders of the arterial blood
circulation, carrying out the functional tests.
3. Instrumental examination of the arterial blood circulation, advantages and
disadvantages.
4. Acute arterial ischemia: causes, pathology, clinical manifestations, principles of
diagnosis and treatment.

142
5. Chronic arterial ischemia: causes, pathology, clinical manifestations, principles of
diagnosis and treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 196-204.
3. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp.79-121.
4. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition, 2006. Pp. 410-423
5. "Short practice of surgery" Bailey and Love's, 1996. Pp. 124-149.
Supplemental materials:
1. "Introductory in medical surgical nursing". Pp. 331-439.
2. "Surgery" Bruce E. Jarrell, 2nd edition, 1991. Pp. 119-138.

VII. Questions for the self-control.


1. Histology of the arterial wall.
2. Surgical anatomy of arteries of the lower extremity.
3. Surgical anatomy of arteries of the upper extremity.
4. Sites of palpation of the peripheral arteries.
5. Methods of carrying out the functional tests.
6. Principles of carrying out the reovasography, theultrasound investigation (hand-
held Doppler, duplex ultrasound) of the arteries, the aortoarteriography.
7. Degrees of the acute arterial ischemia.
8. Stages of the chronic arterial ischemia.
9. Principles of the first medical and pre-medical aid at the acute arterial ischemia.
10. Principles of the surgical treatment of the thrombosis and the embolism.
11. Principles of the complex conservative treatment of the chronic ischemia.
12. Principles of carrying out the reconstructive surgeries of the aorta and main
arteries.

VIII. Tasks for self-preparation:


1. Draw the typical places of the upper extremities arterial embolism.
2. Draw the typical places of the lower extremities arterial embolism.
3. Describe the plantar ischemia test.
4. Describe the refilling time test.
5. Describe the Goldflam‟s test.
6. Characterize the degrees of acute arterial ischemia.
7. Characterize the stages of chronic arterial ischemia.
8. Draw the scheme of the embolectomy from the bifurcation of the aorta.
9. Write the basic principles of the conservative treatment of the patients with
chronic ischemia.
10. Draw the scheme of aortofemoral bypass grafting.

Tests

1. risk factors for atherosclerosis development are the following (choose right)
a) smoking
b) gender
c) hypertension
d) obesity
e) all are possible

143
2. the possible potential causes of acute arterial obstruction are the following (choose
right)
a) heart aneurysm
b) myocardial infarction
c) Raynaud's phenomenon
d) cardiac arrhythmias
e) obesity
3. the causes of chronic arterial obstruction are the following (choose right)
a) heart aneurysm
b) myocardial infarction
c) Raynaud's phenomenon
d) cardiac arrhythmias
e) Burger's disease
4. choose noninvasive methods used in the examination of arterial vessels (choose right)
a) lymphography
b) ankle / brachial index
c) Duplex scunning
d) arteriography
e) phlebography
5. choose invasive methods used in the examination of arterial vessels (choose right)
a) lymphography
b) ankle / brachial index
c) Duplex imaging
d) arteriography
e) reovasography
6. patients with chronic arterial obstruction may present the following complaints (choose
right)
a) pain in the calf associated with walking
b) coldness and numbness of toes
c) rest pain in the affected limb
d) ulceration of the skin
e) all are possible
7. during inspection of a local status in the patient with chronic arterial obstruction the
following changes are usually found (choose right)
a) pale, cyanotic or reddish discoloration of the skin
b) hair distribution is normal
c) lack of hair distribution
d) presence of muscle hypotrophy
e) muscles of normal condition
8. during auscultation of arteries in the patient with chronic arterial obstruction the
following changes are usually found (choose right)
a) pale, cyanotic or reddish discoloration of the skin
b) bruit above affected artery
c) lack of hair distribution
d) presence of muscle hypotrophy
e) changes of toenails (ragged)
9. which conduits are most frequently used as bypass graft materials? (choose right)
a) cadaver's vein
b) patient's great saphenous vein

144
c) patient's lesser saphenous vein
d) synthetic prosthetic grafts
e) patient's cubital vein
10. action of the aspirin in patients with chronic arterial ischemia consists of the following
(choose right)
a) decrease of blood lipid level
b) reduce conversion of prothrombin to thrombin
c) lyzis of the thrombus
d) reduces platelet aggregation
e) reduces the size of the thrombus
11. the following stage of acute arterial obstruction is characterized by commence of
muscle contracture (choose right)
a) I stage
b) II stage
c) III stage
d) IV stage
12. the following stage of acute arterial obstruction is characterized by commence of
paresis and paralysis of extremity (choose right)
a) I stage
b) II stage
c) III stage
d) IV stage
Clinical tasks
Task № 1
Clinical scenario: A 56 year old male patient complains of a cramp-like pain felt at
both lower extremities (calf) muscles during walking approximately 200 meters and relieved
by standing still. He has been suffering from this pain for 3 years. He is a smoker and
hypertonic. His condition is satisfactory. The skin of the lower extremities is of normal color,
the temperature is slightly decreased. Any trophic changes are absent. There is no pulse over
dorsalis pedis, tibialis posterior, and popliteal arteries of both sides. The pulse over both
femoral arteries is normal. An auscultation has not revealed any vascular bruits.
Questions:
1. Which syndrome is responsible for aforementioned complaints?
2. What risk factors determining current disease are present in the patient?
3. What functional tests are to be performed for examination of the patient?
4. What instrumental tools are to be used for examination of the patient (at least five)?
5. Name the groups of medicines used in the treatment of the patient
Task № 2
Clinical scenario: A 27 year old male patient complains of a constant pain felt at the
right foot. The pain is severe, made worse by lying down or elevation of the foot. The pain is
not relieved by NSAID. Previously, he had a similar pain, but provoked only by long-
distance walking. Approximately two weeks ago he noticed dark discoloration of 2 nd and 3rd
toes. He is a smoker. A condition of the patient is satisfactory. The skin of right lower
extremity is pale and cold, hair distribution is poor. There is a dry necrosis of the 2nd and 3rd
toes. There is no pulse over right dorsalis pedis and tibialis posterior artery. Left lower
extremity is normal. An auscultation has not revealed any vascular bruits.

Questions:
1. What is the most likely reason of mentioned signs?

145
2. What is the degree of ischemia and level of blockage?
3. What instrumental tools are to be used to determine the degree of arterial involvement
(at least five)?
4. Name the groups of medicines used in the treatment of the patient?
5. Which surgery may improve blood circulation in the diseased limb?

Task № 3
Clinical scenario: A 37 year old woman complains of an intense pain in the left arm,
and inability to move fingers of the left palm. She has been suffering fromthese symptoms for
8 hours. The onset of disease was acute without any explicable reason. In childhood she
suffered from rheumatic fever complicated by mitral stenosis. 5 years ago in order to correct
valvular stenosis an artificial mitral valve was implanted. Currently, she doesn‟t take any
medicines. Her condition is of moderate severity. There are normal breathing sounds in the
lungs. Heart auscultation has revealed the typical metallic sound produced by the artificial
valve. The size of the heart is enlarged, a BP is 110/70 mm. Hg, a PR is 120/min. The skin on
left forearm is cold and pale. Any trophic changes are absent. Hair distribution is normal. The
active movements and sensitivity of the left palm are absent. There is no pulse over the left
radial and ulnar arteries. A pulsation of the left brachial artery is enforced.
Questions:
1. Name the syndrome responsible for aforementioned complaints?
2. What basic disease is responsible for aforementioned complaints?
3. What is the degree of ischemia and level of blockage?
4. What first medical aid is to be started?
5. What surgical treatment has to be attempted if medical treatment has failed.

Task № 4
Clinical scenario: A 60 year old male complains of a cramp-like pain felt inthe lower
extremity (calf, thigh, and buttocks) muscles during walking approximately 20 meters and
relieved by rest. He has been suffering for this pain for 3 years. But during the last month the
pain became worse, the walking distance shortened. Due to this change he came to a doctor.
His condition is satisfactory, the body weight is 150kg. The skin of the feet is cyanotic and
cold. Hair is absent. There is no pulse over a. dorsalis pedis, tibialis posterior, popliteal and
femoral arteries at both sides. An auscultation has revealed systolic harsh bruit over
abdominal aorta.
Questions:
1. What disease is the patient suffering from?
2. What is the degree of ischemia and level of blockage?
3. What changes do you expect on duplex scanning, arteriography, and ankle/brachial
index?
4. What king of major revascularizing surgery can be recommended to the patient?

Task № 5
Clinical scenario: A 75 year old male has been admitted to the hospital. He complains
of constant cramp-like pain felt at the right lower extremity (calf muscles), edema and dark
discoloration of the right foot. Body temperature is 38,5 Co. He has been suffering from
arterial atherosclerosis for 20 years. Many times he was treated at hospital. His condition is
severe. PR is 120/min, BP is 100/60mmHg. The skin of the right foot is of black color, there
is an edema of the foot and pus is discharged between toes. There is no pulse over dorsalis
pedis, tibialis posterior, popliteal, and femoral arteries at right side. The left leg is normal.
Questions:
1. What disease is the patient suffering from?
2. What is the level of blockage of arterial circulation?
3. What complication of basic disease is the patient suffering from?
4. What is the management tactic?

146
TOPIC 26 VENOUS AND LYMPHATIC DISORDERS
The following professional competences of a student have to be formed after preparation
of the topic:
 ability to recognize basic symptoms and signs of venous and lymphatic disorders.
 ability to provide first aid to patients with venous and lymphatic disorders.

I. Motivation of the goal:


Thirty five million people suffer from the diseases of the venous and lymphatic
systems. 15 % of them have the advanced forms of the diseases, requiring surgical treatment.
The treatment cost of these diseases is great and reach up to one billion dollars per year in the
Western countries. These patients are treated not only by surgeons, but also by therapists, that
is why after graduating from the medical university a doctor must know main causes, clinical
manifestations, principles of diagnosis and treatment of the syndromes of acute and chronic
venous insufficiency, and lymphedema.

II. The goal of self-preparation:


To study causes, clinical manifestations, principles of diagnosis and treatment of the
acute and the chronic venous insufficiency, lymphedema.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 main causes of the venous and lymphatic blood circulation disorders;
 clinical manifestations of acute venous insufficiency;
 clinical manifestations of chronic venous insufficiency;
 clinical manifestations of acute and chronic lymphatic insufficiency;
 basic principles of the clinical diagnosis of the venous and lymphatic disorders;
 basic principles of the instrumental diagnostics of the venous and lymphatic
disorders;
 principles of the conservative treatment of acute and chronic venous insufficiency,
lymphostasis;
 principles of the surgical treatment of acute and chronic venous insufficiency,
lymphostasis;
Be able to:
 carry out the subjective examination of the patients with the venous and lymphatic
disorders (complaints, anamnesis);
 carry out the objective examination of the patients with the venous and lymphatic
disorders;
 carry out the functional tests, indicating the valve insufficiency of the superficial,
deep, and perforator veins;
 provide the first medical and pre-medical aid at the acute venous insufficiency.
Practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from acute and chronic venous and lymphatic disorders.

IV. The initial level of knowledge:


For successful mastering of the given topic a student should revise the anatomy and
physiology of the venous and lymphatic systems, the histological constitution of the venous
and lymphatic vessels.

V. The plan for the topic studying.


1. Surgical anatomy and clinical physiology of the venous and lymphatic system.

147
2. Methods of clinical examinations of the patients with venous and lymphatic
disorders, carrying out the functional tests.
3. Instrumental investigation of the venous and lymphatic circulation, advantages and
disadvantages.
4. Acute venous insufficiency: causes, pathology, clinical manifestations, principles
of diagnosis and treatment.
5. Chronic venous insufficiency: causes, pathology, clinical manifestations,
principles of diagnosis and treatment.
6. Lymphostasis (lymphedema): causes, pathology, clinical manifestations, principles
of diagnosis and treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. Pp. 179-195.
3. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp. 79-121.
4. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 410-
423.
5. "General surgery" Gostishev, 2003. Pp. 196-198.
Supplemental materials:
1. "Introductory in medical surgical nursing". Pp. 331-439.
2. "Surgery" Bruce E. Jarrell, 2nd edition, 1991. Pp. 139-146.

VII. Questions for the self-control.


1. Histologic constitution of the venous and lymphatic vessels.
2. Surgical anatomy of the venous and lymphatic system of the lower extremities.
3. Factors contributing to venous outflow.
4. Concept of the muscle venous pump of the lower extremities.
5. Methods of carrying out the functional tests, indicating the valvular insufficiency
of the superficial, deep, and perforating veins;
6. Principles of carrying out the plethysmography, the phlebotonometry, the
ultrasound investigation of veins, the phlebography and the lymphography.
7. Clinical picture of the phlegmasia alba dolens
8. Clinical picture of the phlegmasia cerulea dolens
9. Stages of chronic venous insufficiency.
10. Stages of lymphostasis (lymphedema).
11. Principles of the medical treatment of venous and lymphatic insufficiency.
12. Principles of the surgical treatment of venous and lymphatic insufficiency.

VIII. Tasks for self-preparation:


1. Draw the scheme of the surgical anatomy of the lower extremity veins.
2. Describe the principles of carrying out the functional tests, indicating the valvular
insufficiency of the superficial veins;
3. Describe the principles of carrying out the functional tests, indicating the valvular
insufficiency of the deep veins;
4. Describe the principles of carrying out the functional tests, indicating the valvular
insufficiency of the perforating veins;
5. Specify the main symptoms of deep venous thrombosis (DVT).
6. Describe the clinical manifestations of superficial thrombophlebitis.
7. Characterize the degrees of chronic venous insufficiency.
8. Characterize the degrees of chronic lymphostasis.

148
9. Describe the principles of the conservative treatment of patients with the diseases
of the venous and lymphatic systems.

Tests

1. the following provides normal outflow of the venous blood from the lower extremities
(choose right)
a) venous valves
b) arterial pulsation
c) sucking action of the thorax and right heart
d) muscle contraction
e) all are right

2. choose noninvasive methods used in the examination of venous vessels (choose right)
a) lymphography
b) arterial pressure measurement with ankle / brachial difference
c) Duplex imaging
d) arteriography
e) hand held Doppler ultrasound

3. choose invasive methods used in the examination of venous vessels (choose right)
a) phlebography
b) ankle / brachial index
c) Duplex imaging
d) arteriography
e) hand held Doppler ultrasound

4. choose invasive methods used in the examination of lymphatic vessels (choose right)
a) phlebography
b) ankle / brachial index
c) Duplex imaging
d) lymphography
e) hand held Doppler ultrasound

5. the second stage of chronic venous insufficiency is characterized by the following


(choose right)
a) presence of varicose veins
b) presence of active trophic ulcer
c) constant edema of lower extremity
d) hyperpigmentation
e) all are present

6. the following duplex data are characteristic for primary uncomplicated varicose veins
(choose right)
a) absence of blood flow in affected veins
b) incompressibility of affected veins
c) presence of blood reflux
d) pulsating character of blood flow

7. the following measures are used inthe treatment of primary uncomplicated varicose veins
(choose right)
a) elevation of lower extremities

149
b) low molecular weight heparin
c) elastic bandages
d) venotonic medicines
e) sympathectomy

8. assessing local status at patients suffering from superficial thrombophlebitis the


following may be found (choose right)
a) presence of varicose veins
b) presence of active trophic ulcer
c) tenderness on palpation of varicose veins
d) hyperpigmentation
e) all are possible

9. usually the deep venous thrombosis is manifested by the following (choose right)
a) dilated superficial veins
b) presence of active trophic ulcer
c) tenderness on palpation along deep veins
d) hyperpigmentation
e) edema of lower extremity

10. the following measures are used in the treatment of deep venous thrombosis (choose
right)
a) elevation of lower extremities
b) low molecular weight heparin
c) sympathectomy
d) reolytic medicines
e) venectomy

11. the most persistent complaint of patients with lymphatic insufficiency is the following
(choose right)
a) tiredness of lower extremity
b) coldness and numbness of toes
c) edema of lower extremity
d) intermittent claudication
e) night cramps

12. the following surgical treatment may be used in patients with severe lymphedema
(choose right)
a) sympathectomy
b) embolectomy
c) bypass grafting
d) venous lymphatic anastomoses
e) removal of subcutaneous tissue

Clinical tasks

Task № 1
Clinical scenario: A 49 year old male has been admitted to the hospital. He complains
of pain, hyperemia and hardening of the skin on the inner side of right lower extremity. The
signs started suddenly 1 day ago. His condition is satisfactory. Inspecting lower extremities
there are a moderate varicose veins of both calves and thighs. There is a skin hyperemia,
slight edema, induration, and marked tenderness during palpation over varicosities of the right

150
thigh. Any trophic changes are absent. There is a normal pulsation of all peripheral arteries.
Questions:
1. What basic disease is the patient suffering from?
2. What complication of basic disease had developed 1 day ago?
3. What instrumental tool can confirm (exclude) the developed complication?
4. What do you expected to obtain with instrumental tool?
5. If needed what surgery is to be done? What is it done for?

Task № 2
Clinical scenario: A 57 year old patient is admitted to the hospital. He complains of
moderate pain and edema of the left leg, elevation of body temperature till 37,8C0. The signs
started suddenly 3 days ago. His condition is normal. There are no signs of internal organ
diseases. The left leg is twice larger than the right one due to edema extending from tiptoes
till the groin. The color of the left leg is cyanotic. Palpating an affected limb there is a
tenderness along the medial aspect of the calf and thigh. A pulsation of all peripheral arteries
is difficult to find due to edema.
Questions:
1. What disease is the patient likely suffering from?
2. What functional tests can confirm (exclude) the diagnosis?
3. What instrumental tools can confirm (exclude) the disease?
4. What do you expect to obtain with instrumental tools?
5. List groups of medicines with examples of agents used for treatment of the patient.

Task № 3
Clinical scenario: a 28 year old woman complains of varicose veins at the inner
aspect of right lower extremity and evening edema of the right foot that subsides after night
rest. She has been suffering for these signs for 6 years. She first noticed varicose veins after
pregnancy. Also, her mother and sister have the same signs. Her condition is normal. There
are no signs of internal organ pathology. Inspecting right lower extremity there are a moderate
varicose veins extending from medial ankle till upper thigh. Any trophic changes are absent.
There is a normal pulsation of all peripheral arteries.
Questions:
1. What disease is the patient suffering from?
2. What superficial vein is likely affected?
3. What is a degree of CVI?
4. What functional tests should be carried out?
5. What surgical and miniinvasive treatment can be done?

Task №4
Clinical scenario: A 35 year old patient has come to a physician complaining of
moderate constant dull pain and edema of the right foot and calf, presence of the ulcer at the
right calf. Five years ago after closed fracture of the right tibial bone he first noticed the
presence of a constant edema and dull pain in the right calf. Approximately three years ago he
noticed hyperpigmentation and induration of the right calf skin. 1 year ago the ulcer had
formed. Despite numerous ambulatory and hospital treatment the ulcer has not been healed
yet. Condition of the patient is normal. There are no signs of internal organ diseases. The size
of a right foot and calf is increased. There are a few varicose veins at the medial aspect of the
right calf. There is a 5/8 cm trophic ulcer slightly above medial malleolus. The skin
surrounding ulcer is of brown color, slightly tender and firm on palpation. A pulsation of all
peripheral arteries is normal.
Questions:

151
1. What basic syndrome have you found and what is its degree?
2. What complication of fracture did the patient have 5 years ago?
3. What is your current primary diagnosis?
4. What specific to presented pathology laboratory and instrumental tools should be
performed?
5. List principles of patient‟s medical treatment.

Task № 5
Clinical scenario: A 35 year old patient has come to a physician complaining of a
moderate constant edema of the left foot and lower part of the calf. Three years ago he
suffered from bullous form of the erysipelas of the left leg. After that he noticed gradually
progressing edema of the affected limb. Condition of the patient is normal. There are no signs
of internal organ disease. The size of the left foot and calf (till upper part) is increased. An
edema is firm, nonpitting. Any trophic changes are absent as well as varicose veins. A
pulsation of all peripheral arteries is normal.
Questions:
1. What disease is the patient suffering from?
2. List other possible causes of the disease.
3. What invasive diagnostic method can be used?
4. List principles of medical treatment of the patient.

152
TOPIC 27 THERMAL INJURIES
The following professional competences of a student have to be formed after preparation
of the topic:
 Ability to recognize basic symptoms and signs of thermal injuries.
 Ability to provide first aid to patients with thermal injuries.

I. Motivation of the goal:


The importance of this topic is utmost for a doctor since burns, frostbites, an electric
injuries occur frequently enough in the clinical practice and demand special knowledge to
estimate the degree of the lesion, determine the necessary treatment, begin with the first
medical aid, and care the patient through the rehabilitation. Only the correct assessment of
local and general manifestations of injuries allows to develop adequate medical tactics for
each patient. It is known, that the most unfavorable results of these traumas occur in pediatrics
and gerontology. In other words, the importance of this topic is necessary not only for general
surgeons and traumatologists, but also for pediatricians, gerontologists, experts of the plastic
surgery. The given topic has a very close connection with other topics of the general surgery:
anesthesiology, resuscitation, hemotransfusion, infection in surgery, and plastic surgery.

II. The goal of self-preparation:


To study the diagnostic and treatment methods of the thermal injuries.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 classification of burns;
 etiology of burns, frostbite, electric (high voltage) trauma;
 main attributes of the burn disease;
 pathology of the local burns and frostbite;
 principles of the general treatment of the patients with burns and frostbite;
 principles of rendering the first medical aid at electric injuries, burns, and frostbite.
Be able to:
 determine the degree of the burn or the frostbite according to the clinical
manifestations;
 determine the superficial area involved in the burn or frostbite with different
methods;
 provide the first aid at the thermal burn;
 provide the first aid at the electric trauma;
 provide the first aid at the chemical burn.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from thermal injuries.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to revise the histology of the
skin, the influence of the high and low temperature, acids, alkalis, electric current, and
ionizing radiation on tissues.

V. The plan for the topic studying.


1. Definitions of the concepts of “burn”, “frostbite”, “electric trauma”.
2. Etiology of burns, frostbites, and electric injuries.
3. Determining the degree of the burn and the frostbite.
4. Methods determining the superficial area involved to the burn or frostbite.
5. Local changes at the thermal and chemical burns.

153
6. Inhalation injury: etiology, pathophysiology, clinical picture, diagnosis and
treatment.
7. General changes at burns and frostbites.
8. First aid at burns, frostbites, and electric injuries.
9. Principles of the local treatment of these pathologies.
10. Principles of the general treatment.
11. Basic methods of the skin grafting of the injured surface.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 136-144.
3. "Short practice of surgery" Bailey and Love's, 1996. Pp. 141-149.
Supplemental materials:
1. SURGERY. Basic science and clinical evidence. USA., 2000. Pp. 327-341.
2. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991. Pp. 178-210.
3. Scientific American Surgery 1997, Chapter III (Thermal injuries).
4. "Surgery" Bruce E. Jarrell, 2nd edition, 1991. Pp. 367-370.

VII. Questions for the self-control.


1. Define the concepts of “burn”, “frostbite”, “electric trauma”.
2. Etiology of the injuries, the importance of contributing factors.
3. Mechanism of the local and general changes in the organism at burns, frostbites,
electric and chemical injuries.
4. Inhalation injury: etiology, pathophysiology, clinical picture, diagnosis and
treatment.
5. Chemical and alkali burns: pathophysiology, clinical picture, and treatment
6. The importance of determining the lesion area.
7. Stages of the burn disease.
8. Characteristics of the stages of the burn disease.
9. Characteristics of the processes of burn healing depending on the depth of lesions.
10. First aid actions at burns, frostbites, and electric injuries.
11. Features of the initial surgical treatment at thermal injuries.
12. Principles of treatment of burns according to the degree.
13. Complications of burns. Tetanus prophylaxis.
14. Features of the modern surgical treatment including necrectomy, escharotomy,
and skin grafting.
15. Principles of the antibacterial and the immune therapy at burns and frostbites.
16. Prophylaxis of frostbites.
17. The characteristics of the dry and wet gangrene.
18. Features of the electric trauma.
19. Characteristics of the pathological changes at electric injuries.
20. Clinical manifestations of electric injuries.
21. Treatment principles of the electric injuries.
22. Prophylaxis of the electric injuries.

VIII. Tasks for self-preparation:


1. Write the classification of burns.
2. Draw the scheme of determining the area of burns.
3. Make the scheme of the initial surgical treatment at the thermal injuries.
4. Make a table with the characteristics of the general treatment principles of burns
depending on the stage.

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5. Draw the diagnostic scheme of action of acids, alkalis, salts of heavy metals on the
tissues.
6. Write the classification of the frostbites according to the lesion depth.
7. Draw the table with the description of the local manifestations at burns and
frostbites.
8. Draw the scheme of escharotomy and necrectomy.
9. Characterize the stages of the burn disease.
10. Write the scheme of carrying out the burn therapy.

Tests

1. clinical characteristic of the 2nd degree thermal burn is as follows (choose right)
a) absence of sensation
b) blistering of the skin
c) the wounds are leathery
d) injured skin is moist
e) white or charred skin

2. clinical characteristic of the 3rd degree thermal burn is as follows (choose right)
a) hyperemia and slight edema of the epidermis
b) normal sensation of the skin
c) the wounds are leathery
d) injured skin is moist
e) white or charred skin

3. the following is true dealing with acid burn (choose right)


a) is better than alkali burn
b) tend not to be absorbed
c) systemic toxicity is common
d) is worse than alkali burn
e) tend to be absorbed

4. determination of the body surface area involved into the burn can be measured with the
help of the following rule (choose right)
a) the rule of sevens
b) the rule of eighths
c) the rule of nines
d) the rule of tens
e) the rule of twelfths

5. calculate the body surface area involved into the burn if a patient has a burn of one arm
and one leg (choose right)
a) 18%
b) 36%
c) 38%
d) 27%
e) 42%

6. calculate the body surface area involved into the burn if a patient has a burn of both
front and back surfaces of the trunk (choose right)
a) 18%
b) 36%
c) 38%

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d) 27%
e) 42%

7. the following form of shock develops at patients suffering from extensive burn (choose
right)
a) hemorrhagic
b) cardiogenic
c) vasogenic
d) neurogenic
e) hypovolemic

8. during initial resuscitation of a severely burned patient the following measures should
be done (choose right)
a) placement of the peripheral i.v. catheter
b) placement of the rectal tube
c) placement of the nasogastric tube
d) placement of the Blackmor tube
e) placement of the Foley catheter

9. the following group of solutions is preferred on the first postburn day (choose right)
a) colloid solutions
b) sodium-free solutions
c) fat emulsions
d) amino-acids
e) crystalloid solutions

10. replenishment of the intravascular volume on the first postburn day is done according
to Parkland's formula (choose one right)
a) 1ml per kilogram of weight multiply % of burned area
b) 2ml per kilogram of weight multiply % of burned area
c) 3ml per kilogram of weight multiply % of burned area
d) 4ml per kilogram of weight multiply % of burned area
e) 5ml per kilogram of weight multiply % of burned area

11. permanent coverage of the open wound after burn tissue excision may be achieved
using the following (choose right)
a) Alloderm
b) split-thickness autograft
c) pigskin
d) cadaver skin
e) full-thickness autograft

12. second degree frostbite causes the following clinical manifestation (choose right)
a) skin hyperemia
b) capillary blood flow is not restored
c) absence of skin hyperemia
d) sensation remains intact
e) sensation is absent

Clinical tasks
Task № 1
Clinical scenario: A 70 kg patient has been rescued from the firing building. His back
and chest are burned. There is a blistering skin. It is red, moist and painful to touch.

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Questions:
1. What is the depth of the burn?
2. What is the surface area involved into the burn?
3. What first aid must be done at the scene of injury?
4. How much fluid (water) does he need daily?
5. What i.v. solution (s) is administered on the first postburn day?

Task № 2
Clinical scenario: A 100 kg patient has been admitted into the burn center. 1 hour ago he
was exposed to flame. The burn involves both lower and both upper extremities. The
injured area is leathery, charred, dry, and insensate.
Questions:
1. What is the depth of the burn?
2. What is the surface area involved into the burn?
3. What management must be started at the hospital?
4. What fluid and how much (water) does he need the first postburn day?
5. What i.v. solution (s) are added on the second postburn day?

Task № 3
Clinical scenario: A 70 kg patient is suffering from thermal burn. The injured area is
leathery, charred, dry, and insensate. An accident happened in aclosed room. The burn
involves both upper extremities and head.
Questions:
1. What is the depth of the burn?
2. What is the surface area involved into the burn?
3. What kind of injury must be suspected, what is its management at the scene of
injury?
4. How can the extend of suspected injury be examined?
5. What management of suspected injury is started at the hospital?

Task № 4
Clinical scenario: a 100 kg patient has a thermal burn of the back and chest. The
injured area is leathery and charred. In the hospital, despite of proper treatment, the patient is
developing difficulties with breathing. Full expansion of the chest is restricted progressively.
Questions:
1. What is the cause of respiratory problems?
2. What surgery can restore normal breathing process?
3. Can the wound be closed by epitelization?
4. What types of grafting can be done for permanent wound closure?
5. What methods of temporary wound closure can be attempted (name at least four)?

Task № 5
Clinical scenario: An alcohol addict patient spent a night outdoors where he has
frozen both feet. After thawing the injured area is cyanotic, cold, edematous, with formation
of small vesicles. A cutaneous sensation is absent.
Questions:
1. What is the degree of frostbite?
2. What is the treatment at the scene of injury and in the hospital?
3. When can an amputation of severely frostbitten extremity be done?
4. When an amputation is done without delay?
5. What is the scheme of tetanus prophylaxis?

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TOPIC 28 GENERAL TRAUMA

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of mechanical trauma.
 ability to provide first aid to patients with mechanical trauma.

I. Motivation of the goal:


The present time is characterized by the huge growth of technological progress, life of
people is improving, number of vehicles is soaring and, therefore, the number of injuries is
increasing. Traumatic injuries take the third place in the general mortality (12,7%).
Approximately 7 percent of the patients with trauma require hospitalization. Because of the
great diversity and weight of traumatic damages and a plenty of complications, the aid for the
injured should include the first (pre-medical) aid, emergency, and specialized medical care.

II. The goal of self-preparation:


To study the kinds and classification of trauma. To get acquainted with the methods of
medical and social prophylaxis of trauma, to study the immediate and late complications of
trauma. To get acquainted with the methods of diagnosis of traumatic injuries, methods of
organization of pre-hospital and social traumatologic aid. The concept of soft tissue injuries,
bruises, sprains, ruptures, concussion, crush-syndrome. The first medical aid, and treatment.
Dislocations and fractures, classification. The isolated multiple and combined injuries.
Clinical manifestations of fractures. Bases of the radiographic diagnosis. The first medical
aid. The basic principles of treatment: pain relief, reduction (reposition), stabilization
(immobilization), rehabilitation. Complications of traumatic fractures: pain shock, acute
hemorrhage, embolism, development of infection and their prophylaxis.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 classification of the mechanical trauma;
 classification of soft tissue injuries, methods of diagnosis, prophylaxis, and
treatment;
 classification of dislocations, clinical manifestations, diagnosis, and treatment of
dislocations;
 classification of fractures, clinical manifestations, diagnosis, and methods of
treatment.
Be able to:
 examine patients with soft tissue injuries;
 diagnose the kind of the soft tissue injuries, provide the first aid,and prescribe the
treatment;
 examine the dislocation place;
 interpret the radiograph of a patient with dislocation;
 carry out the anesthesia in dislocation;
 carry out the reduction (reposition) of dislocated shoulder with Kocher's method,
Dzanelidze's method, Motais and Hippocrates methods;
 carry out the reductionof dislocated hip by Dzanelidze's method;
 carry out the immobilization of the reduced dislocation of the shoulder;
 carry out the reduction of forearm dislocation, and the mandible;
 examine a patient with fracture, formulate clinical diagnosis;
 provide the first aid in fractures;
 carry out the transport immobilization in shoulder fracture, forearm, hip,and calf;

158
 determine the indications for the conservative and surgical methods of fracture
treatment.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from mechanical trauma.

IV. The initial level of knowledge:


It is necessary to repeat the anatomy of bones and joints (from the course of anatomy),
questions of development of the inflammation and regeneration of the osseous tissue (from
the course of physiology and pathology).

V. The plan of studying the topic.


1. Classification of soft tissue injuries.
2. Clinical manifestations and diagnosis of soft tissue injuries.
3. First aid and treatment of damages of soft tissues.
4. Classification of dislocations.
5. Etiology and pathology of crush-syndrome.
6. Treatment of crush-syndrome.
7. Clinical manifestations of dislocations.
8. Diagnosis of dislocations.
9. Methods of dislocations treatment.
10. Classification of fractures.
11. Complications of fractures.
12. Clinical manifestations of fractures.
13. Diagnosis of fractures.
14. First aid in fractures.
15. Methods of fracture treatment.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 102-128.
3. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp.301-350.
4. "Short practice of surgery" Bailey and Love's, 1996. Pp. 195-217
Supplemental materials:
1. "Introductory in medical surgical nursing". Pp. 968-989.
2. ”Fractures and joint injuries" J.N. Wilson., 1993., Volume 1. Pp. 14-29, 29-45, 12-
147, 258-364;
3. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991. Pp. 258-299.
4. Scientific American Surgery 1997, Chapter I : 2 (Trauma resuscitation) pp. 1-16.
5. "Surgery" Bruce E. Jarrell, 2nd edition, 1991. Pp. 359-363.

VII. Questions for the self-control.


1. What is the classification of the mechanical trauma?
2. Kinds of traumatism.
3. What are the kinds of soft tissue injuries?
4. List the closed soft tissue injuries.
5. Etiology and pathology of crash-syndrome.
6. What is the treatment of crash-syndrome?
7. What is the classification of dislocations?

159
8. What attributes do help to diagnose a dislocation?
9. What are the principles of dislocation treatment?
10. What are the principles of classification in bone extremity fractures?
11. What are the complications of fractures?
12. What are the objective attributes of fractures?
13. What is the diagnosis of the “fracture” based on (list all)?
14. What does the first aid in fracture include?
15. What are the kinds of transport immobilization?
16. What are the kinds of medical immobilization?
17. What are the basic principles of fracture treatment?
18. What methods of fracture treatment are used?
19. What are the kinds of the bone callus?
20. What pathologies of the osseous regeneration do you know?
21. Advantages and disadvantages of various methods of fracture treatment.

VIII. Tasks for self-preparation:


1. Represent schematically the sources of the tubular bone blood supply.
2. Draw and sign the sources of the bone callus in the picture of the longitudinal
section of the shaft of the tubular bone.
3. Describe the indications for the application of the method of skeletal traction in
fractures of the lower extremity.
4. What are the indications for the application of the Ilizarov‟s (external
fixation)device in fracture of the shin bones?
5. What are the indications for the surgical treatment of the lower
extremitybonefractures?
6. What are the criteria for changing of the skeletal traction to another method of
treatment?
7. What is the prophylaxis of the ischemic disturbances after application of the
plaster immobilization on the extremity?
8. Draw the scheme of reduction of the shoulder dislocation with the Kocher's
method.

Tests

1. clinical presentation of soft tissue contusion includes the following (choose right)
a) deformation of affected area
b) pain of different degree
c) pathological movements
d) crepitation is found on palpation
e) local swelling

2. management of soft tissue contusion includes the following (choose right)


a) warming physiotherapy several days after injury
b) ice or chemical cold packs are effective during the first week
c) local use of elastic compression
d) splinting is required
e) ice or chemical cold packs are effective during the first one to two days

3. most commonly the patient with crush-syndrome develops the following organ failure
(choose right)
a) hepatic
b) spleen

160
c) heart
d) kidney
e) respiratory

4. acute renal failure in a patient with crush-syndrome is caused by the following (choose
right)
a) excess of indirect bilirubine
b) lyzis of RBC
c) excess of direct bilirubine
d) creatinine toxicity
e) myoglobin toxicity

5. the following is right regarding ligament sprain (choose right)


a) affected joint is stable
b) local swelling is uncommon
c) only some ligament fibres are torn
d) local bruising is common
e) localized tenderness is absent

6. most frequently the following structures are fractured by the traction injuries (choose
right)
a) femoral bone
b) radius
c) olecranon
d) tibia
e) malleolus

7. clinical presentation of the fracture may include the following (choose right)
a) gross deformation of the affected area
b) pain of different degree
c) abnormal movements
d) crepitation is found on palpation
e) all are right

8. find only characteristic features confirming fracture (choose right)


a) gross deformation of the affected area
b) loss of function
c) abnormal movements
d) local swelling
e) protrusion of bone fragments through the skin

9. the following instrumental examination is to be performed to confirm diagnosis of


fracture (choose right)
a) CT
b) contrast radiography
c) MRI
d) plain radiography
e) Doppler US

10. classification of fractures according to site includes the following (choose right)
a) epiphyseal
b) spiral

161
c) angulation
d) diaphyseal (shaft)
e) transverse

11. classification of fractures according to fracture's line includes the following (choose
right)
a) epiphyseal
b) spiral
c) angulation
d) diaphyseal (shaft)
e) transverse

12. classification of fractures according to displacement of bony fragments includes the


following (choose right)
a) shift
b) comminuted
c) angulation
d) diaphyseal (shaft)
e) oblique

Clinical tasks

Task № 1
Clinical scenario: A 25 years old patient injured his right shoulder in a bicycle
accident 2 hours ago. Examining of the patient was detected the following data: pain,
tenderness, edema and bruising in the area of the right shoulder. The joint area looks like
hollow. The extremity has lost its normal axis. Passive movements in the joint are very
painful. Pulsation of all peripheral arteries is normal.
Questions:
1. What is your diagnosis?
2. What pathologies should the condition be differentiated with?
3. How can you confirm the diagnosis?
4. Does the patient need reduction and which methods can you offer?
5. Does the patient need stabilization and how is it achieved?

Task № 2
Clinical scenario:A 20 years patient is a victim of a road traffic accident. Examining
of the patient was detected the following data: the consciousness is 15 points according to
GCS, vital signs are normal. There are pain, tenderness, edema, and bruising in the area of
right forearm. During palpation of the radial bone a crepitation sound is present. A pulsation
of all peripheral arteries is normal, the sensitivity is not altered.
Questions:
1. What is your diagnosis?
2. How can you confirm the diagnosis?
3. Does the patient need reduction and which method can you offer?
4. What other methods of reduction do you know?
5. Does the patient need stabilization and how is it achieved?
6. What other methods of stabilization do you know?

Task № 3
Clinical scenario: A 15 years soccer injured his right ankle playing football.
Examining of the patient was detected the following data: pain, tenderness, edema and

162
bruising in the area of the right ankle. The size of the ankle is increased due to edema. A
passive and active movements in the joint are painful. There is no pathologic mobility in the
joint during its palpation. A pulsation of all peripheral arteries is normal.
Questions:
1. What is your likely diagnosis?
2. What pathologies should the condition be differentiated with?
3. How can you confirm the diagnosis or rule out other pathology?
4. What is your management?

Task № 4
Clinical scenario: A 47 years patient has been rescued after been trapped under the
collapsed concrete block during 18 hours. Both lower extremities are severely injured.
Examining of the patient was detected the following data: Condition is severe. Consciousness
is 12 points according to GCS, PR is 120, BP is 100/60mmHg. The skin of both legs is of
bluish color till midthigh, skin necroses are present, an edema progressively increases, there is
no pulse over a. dorsalis pedis, tibialis posterior, popliteal arteries on both sides. Sensation of
low limbs is absent.
Questions:
1. What is your diagnosis?
2. What is a cause of progressing edema and signs of acute arterial ischemia?
3. What surgery should be attempted?
4. What organ failure is the mentioned pathology commonly complicated by?
5. What is your medical treatment?

Task № 5
Clinical scenario: A patient is found lying on the ground. He fell down from the roof
of the 10 meter building.
Questions:
1. What is to be done firstly?
2. What is to be done after that?
3. What is a third priority?
4. How is a CNS examination done?
5. A patient has a tension pneumothorax and an open fracture of the femoral bone.
What is to be treated firstly?

163
TOPIC 29 TRAUMA OF THE HEAD, CHEST, AND ABDOMINAL ORGANS

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of head, chest, and abdominal organ
injuries.
 ability to provide first aid to patients with head, chest, and abdominal organ
injuries.

I. Motivation of the goal:


The number of the household, industrial and transport injuries is accompanied with the
high incidence of the skull and brain injuries. The consequences of these injuries appear rather
frequently dangerous to life, thus the knowledge of the clinical symptoms of these injuries
and the principles of the first aid is necessary for a doctor of any specialty. It is statistically
proved, that the relative number of patients with the closed trauma of the abdomen increases
year after year. It is caused by the increasing number of vehicles on citystreets, rising of the
traffic intensity, increase of the volume of building work and the level of industrialization of
business and agriculture. Recognition and treatment of the abdominalorgan injuries are the
crucial problems with the urgent surgery. The life of the injured depends on the correct first
aid at the site of the accident, during transportation, and management tacticchosen by a
doctor.Closed thorax injuries are dominating among chest injuries in the peacetime. The
frequency is 95-98 %. Nowadays is noticed the increasing number of injuries with the serious
complications quite often leading to the lethal outcome. Therefore, the knowledge of the
injuries and principles of the first medical aid are necessary for a doctor of any speciality.

II. The goal of self-preparation:


To study etiology, pathology, and classification of the brain injury. To acquire the
basic dangers of brain injuries which can be life-threatening. To master the principles of first
medical aid at brain injuries. To study the features of patients transportation with brain
injuries. To study classification, etiology and pathology of traumatic injuries of the chest. To
acquire the concept of pneumothorax, and hemothorax. To study the clinical manifestations
and diagnosis of pneumothorax, and hemothorax. To acquire the features of the first medical
aid in closed, tension, open pneumothorax, and hemothorax. To study the treatment principles
of the pneumothorax and hemothorax.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 classification of brain injuries;
 basic dangers of brain injuries, which can be life-threatening;
 basic principles of the first medical aid in brain injuries;
 features of patients transportation with brain injuries;
 principles of diagnosis of brain injuries;
 classification of abdominal trauma;
 clinical, laboratory, and instrumental diagnosis of organ injuries located in the
abdominal cavity and in the retroperitoneal space;
 aims of the first aid in the abdominal trauma;
 principles of treating patients with abdominal trauma;
 diagnosis of the foreign bodies of the gastrointestinal tract;
 aims of the first aid at the foreign bodies of the gastrointestinal tract.
 classification of the chest injuries;
 the concept of pneumothorax, kinds of pneumothorax;
 clinical manifestations and diagnostics of pneumothorax;

164
 features of the first medical aid in closed, tension, and open pneumothorax;
 treatment principles of pneumothorax;
 the concept of hemothorax, kinds of hemothorax;
 clinical manifestations of hemothorax;
 features of the first medical aid in hemothorax.
Be able to:
 estimate the condition of the patient with the brain injury;
 provide the first aid in the brain injury;
 transport correctly patients with brain injuries;
 distinguish the abdominal trauma;
 determine the hollow organ injury;
 determine the parenchymal (solid) organ injury;
 estimate correctly the clinical and laboratory data in abdominal trauma;
 estimate correctly the results of the instrumental examination (laparocentesis,
laparoscopy);
 provide the first aid to patients with abdominal trauma;
 distinguish the pneumothorax;
 provide the first medical aid in closed, tension, and open pneumothorax;
 distinguish the hemothorax;
 render the first medical aid in hemothorax;
 transport patients with a chest injury.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from head, chest, and abdominal organ injuries.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the questions of
anatomy and surgicalnursingrelated to the theme.

V. The plan of studying the topic.


1. Etiology and pathology of the brain injuries.
2. Classification of the brain injuries.
3. Clinical symptoms of the brain injuries.
4. Main dangers in the brain injury.
5. The first aid in the brain injury.
6. Concussion of the brain: diagnostic and treatment principles.
7. Compression of the brain: diagnostic and treatment principles.
8. Contusion of the brain.
9. Intracranial hematoma and brain edema.
10. Classification of abdominal trauma.
11. Hollow abdominal organ injuries.
12. Parenchymal abdominal organ injuries.
13. Retroperitoneal organ injuries.
14. Foreign bodies of the gastrointestinal tract.
15. Thorax injuries.
16. Rib fracture and flail chest:
17. Closed pneumothorax.
18. Open pneumothorax.
19. Tension pneumothorax.
20. Hemothorax.
21. Heart injuries.

VI. The recommended literature:

165
Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp. 173-178;
3. "Short practice of surgery" Bailey and Love's, 1996. Pp. 387-400; 563-571; 387-
400; 563-571; 704-705; 723-724; 764-768; 920-921; 942-943; 987-989;
4. "Introductory in medical surgical nursing". Pp. 511-516; 520-522; 567-571;
5. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin
Robertson. 11th edition.-2005. Pp.381-395, 227-282.
6. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp.-424-
428.
Supplemental materials:
1. SURGERY. Basic science and clinical evidence. USA., 2000. Pp. 247-259;
2. Textbook of surgery. The biological basis of modern surgical practice. Sabiston.,
USA., 1991. Pp. 258-299; 247-259; 258-299; 263-281.
3. Scientific American Surgery 1997, Chapter IV : 2 (trauma to the CNS). Pp. 1-25.
4. ”Fractures and joint injuries" J.N. Wilson., 1993., Volume 1. Pp. 200-210.
5. "Introductory in medical surgical nursing". Pp. 511-516; 520-522; 567-571;

VII. Questions for the self-control.


1. List the closed brain injuries.
2. Name the brain symptoms of the brain injury.
3. Name the focal symptoms of the brain injury.
4. What are the meningeal symptoms of the brain injury?
5. What is the open craniocerebral trauma?
6. What is the combined craniocerebral trauma?
7. The first aid in the brain injury.
8. Features of patienttransportation with brain injuries.
9. Classification of abdominal trauma.
10. Clinical manifestations, diagnosis, first aid, and principles of treatment of the
hollow organ injuries.
11. Clinical manifestations, diagnosis, first aid, and principles of treatment of the
parenchymal organ injuries.
12. Symptoms of the organ injuries located in the abdominal cavity and in the
retroperitoneal space.
13. Principles of injuries treatment of organs located in the abdominal cavity and in
the retroperitoneal space.
14. Foreign bodies of the gastrointestinal tract, first aid, treatment.
15. The causes of severe states in thorax injuries.
16. Rib fracture and flail chest: Clinical manifestations. Diagnosis. First aid.
17. Closed pneumothorax: Clinical manifestations. Diagnosis. First aid.
18. Open pneumothorax: Clinical manifestations. Diagnosis. First aid.
19. Tension pneumothorax: Clinical manifestations. Diagnosis. First aid.
20. Principles of treatment of pneumothorax.
21. Hemothorax: degrees of hemothorax, clinical manifestations, and diagnosis.
22. The importance of the special tests in hemothorax.
23. First aid in hemothorax.
24. Principles of treatment of hemothorax.
25. Heart injuries: clinical manifestations and first aid.

VIII. Tasks for self-preparation:


1. Write the classification of the brain injuries.
2. List the brain injuries in sequence of their clinical significance.

166
3. Specify the principles of the first aid and treatment (schematically) in the brain
injuries.
4. Characterize the degree of the brain contusion.
5. Describe the clinical manifestations of the brain concussion.
6. Describe the clinical manifestations of the epidural hematoma.
7. Describe the clinical manifestations of the subdural hematoma.
8. Describe the principles of surgeryinintracranial hematoma.
9. Write the drugs, which should be prescribed to a patient with the brain concussion.
10. Describe the mechanical changes at the closed brain trauma.
11. Draw the scheme of the consecutive diagnostic actions in abdominal trauma.
12. Introduce the scheme of a general and local treatment in injuries of a hollow organ
of the abdominal cavity.
13. Introduce the scheme of a general and local treatment in injuries of parenchymal
organs (liver, spleen).
14. Introduce the scheme of medical actions at foreign bodies in the gastrointestinal
tract.
15. Describe the technique of the blood reinfusion from the abdominal cavity.
16. Write the changes in the blood test in a hollow organ injury.
17. Write the changes in the blood test in a parenchymal organ injury.
18. Describe the preoperative preparation of the patient with a hollow organ injury.
19. The technique of the abdominal cavity draining in the organ injury.
20. List the groups of drugs which are necessary to prescribe after the surgery.
21. Draw the diagnostic scheme of the thorax trauma.
22. Draw the scheme of the tension pneumothorax.
23. Introduce the scheme of medical actions at open, closed and tension
pneumothorax.
24. Note the features of patient transportation with pneumothorax.
25. Draw schematically the three degrees of hemothorax.
26. Introduce in sequence the scheme of medical actions in hemothorax.
27. Note the features of transportation of patients with hemothorax.
28. Draw the scheme of medical actions in pneumothorax.
29. Specify he medical treatment of the heart injuries.
30. Write the technique of carrying out the Greguar‟s test.

Tests

1. choose right statements regarding a single rib fracture (choose right)


a) diagnosis is confirmed by pleural puncture
b) compressive bandage is not used for stabilization
c) crepitus is always presence
d) diagnosis is confirmed by chest X-ray
e) pain increases at expiration

2. the following statements are right regarding the flail chest (choose right)
a) is caused by unilateral fracture of more than four ribs anteriorly and posteriorly
b) mechanical ventilation support is not required
c) paradoxical movement of the chest
d) intercostal nerve block may be used to relief the pain
e) is caused by unilateral fracture of more than four ribs anteriorly or posteriorly

3. the following statements are right regarding the pneumothorax (choose right)
a) unequal expansion of the chest during respiration
b) resonance sound at percussion of affected side
c) absence of lung sounds during auscultation

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d) underexposed area at the radiograph
e) hyperresonance sound at percussion of affected side
4. the following statements are right regarding hemothorax (choose right)
a) unequal expansion of the chest during respiration
b) resonance sound at percussion of affected side
c) absence of lung sounds during auscultation
d) underexposed area at the radiograph
e) hyperresonance sound at percussion of affected side

5. the following must be taken into account performing neurological assessment (choose
right)
a) severity of bleeding
b) pupillary function
c) presence of peripheral pulsation
d) patency of upper airway
e) level of consciousness

6. accurate information about localization and extend of intracranial hematoma may be


obtained with the following techniques (choose right)
a) scull ultrasound
b) plain scull X-ray
c) CT
d) echoencephalography
e) contrast scull X-ray

7. list all conservative measures effective in reducing the intracranial pressure (choose
right)
a) antibiotics
b) mechanical support with hyperventilation
c) steroids
d) diuretics
e) Trendelenburg position

8. list all surgical measures effective in reducing the intracranial pressure due to expanding
intracranial hematoma (choose right)
a) antibiotics
b) mechanical support with hyperventilation
c) local craniectomy
d) diuretics
e) emergency burr holes

9. the following instrumental investigation methods are useful assessing presence of the
parenchymal organ injury (choose right)
a) abdominal ultrasound
b) colonoscopy
c) MRI
d) RBC
e) gastroscopy

10. a patient with hollow organ rupture usually has the following signs and symptoms
(choose right)
a) peripheral edema
b) dry mucous membranes
c) polyuria

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d) diminished urine output
e) weak and rapid pulse
11. choose the appropriate statements regarding of the membranous urethra rupture
(choose right )
a) pain above symphysis pubis
b) shifting dullness is present
c) abdominal distension
d) abdominal guarding
e) dullness under the umbilicus

12. the following statements are right regarding the extraperitoneal rupture of the bladder
(choose right)
a) rebound tenderness is present
b) excretory urogram is diagnostic
c) signs of peritonitis are common
d) blow to the lower abdomen with a full bladder is usuallycaused
e) fracture of the pelvic bones is the usual cause

Clinical tasks

Task № 1
Clinical scenario: A 36 years old victim of a road traffic accident was admitted to the
hospital. The trauma of the chest was caused by steering wheel. The patient complains of
severe chest pain and dyspnea. He is confused. A skin is pale and cyanotic. The vital signs are
the following: pulse rate is 130, weak; arterial blood pressure is 90/40; respiratory rate is 35.
Examination of the respiratory system is done. There are no any wounds on the chest wall. An
unequal expansion of the left part of the chest, bulging of ICS, normal vocal fremitus and dull
percussion note over left chest part are found. The heart and arch of the aorta are displaced
towards the right. Breath sounds are absent at the left side.
Questions:
1. What is your primary diagnosis?
2. What laboratory changes do you expect? List expected results.
3. How can you confirm diagnosis (at least five methods)?
4. What do you expect to find on the radiograph?
5. What is your further treatment tactic?
6. What are the indications to open surgery?

Task № 2
Clinical scenario: A 23 years victim of a road traffic accident complains of severe
chest pain and dyspnea. He is anxious. A skin is cyanotic. The vital signs are the following:
Pulse rate is 110; arterial blood pressure is 120/80; respiratory rate is 35. Examination of the
respiratory system is done. There is a lacerated wound on the right posterior chest wall
accompanied by whistling sucking sound during inspiration and crepitation on palpation. An
unequal expansion of the right part of the chest, bulging of ICS, decreased vocal fremitus and
hyperresonant percussion note over right chest part are found. The heart and arch of the aorta
are displaced towards left. Breath sounds are absent at the right side.
Questions:
6. What is your primary diagnosis?
7. How can you confirm diagnosis?
8. What do you expect to find on the radiograph?

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9. What treatment is to be done at the scene of injury?
10. What is your further tactic of treatment in the hospital?

Task № 3
Clinical scenario: A 33 years male was assaulted at a street. He was injured by the
knife in the chest. The patient is transported to the hospital. He complains of chest pain,
dyspnea and dizziness. He is anxious. A skin is cyanotic and pale. The neck veins are
dilated. The vital signs are the following: pulse rate is 120; arterial blood pressure is 80/30,
very weak; respiratory rate is 35. Examination of the respiratory system is done. There is a
stab wound 2/2 cm size on the right posterior chest wall. An expansion of the chest is normal
as well as vocal fremitus, breath sounds, and percussion note over the lungs. There is a
dilation of a heart dullness during percussion and muffled heart sounds on auscultation of the
heart.
Questions:
1. What is your primary diagnosis?
2. What causes the severity of patients condition?
3. How can you confirm diagnosis (at least five methods)?
4. What is your further tactic of treatment in the hospital?

Task № 4
Clinical scenario: A half hour ago a 12 years old boy fell down from the tree and
injured his head. In 20 min the boy has been transported to the hospital where he recovered
consciousness. Examination of the patient is done. There is a 7/1 cm incised wound in the
occipital area. The boy does not remember the accident, he complains of headache, nausea,
and fainting. The skin is clammy. The vital signs are the following. The pulse rate is 100;
arterial blood pressure is 120; respiratory rate is 20. Examining the CNS there is a light clonic
nistagm, normal size and reaction of pupils to light, GCS is 15 points, meningeal signs are
absent, reflexes are normal.
Questions:
1. What is your primary diagnosis?
2. What instrumental investigation methods are to be ordered?
3. What is a treatment of scalp wound?
4. What is a treatment of diagnosed brain pathology?
5. What is a management of brain edema?

Task № 5
Clinical scenario: One hour ago a man fell down on the ground from the window of
1stfloor. After 20 min the man came to the hospital. Examination of the patient was done.
There were no any wounds and evidence of the head trauma and anywhere on the body. Vital
signs and objective examination were normal. His answers were correct, as well as peripheral
reflexes. According to the opinion of the physician the patient had not presented any
emergency situation and was placed for further observation into the general ward. In 20 min
the patient was examined. His answers were inappropriate, the eyes were opened only to
painful stimulus, and he was able to localize painful stimulus by the left arm. The right arm
and leg were very weak now. There was a difference in size of pupils, the right was large
2mm than the left one.
Questions:
1. What is your primary diagnosis?
2. What was the score of GCS points a) at admission, b) during last examination?
3. What instrumental investigation method can confirm your primary diagnosis?
4. What is a treatment of diagnosed pathology?

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TOPIC 30 BASIC PRINCIPLES OF SURGICAL ONCOLOGY

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of oncologic diseases.
 ability to provide first aid to patients with oncologic diseases.

I. Motivation of the goal:


A malignant tumor is a serious problem in the modern medical science. In the general
structure of death the rate of oncological pathology takes the second place (after
cardiovascular diseases). Besides the personal tragedy for a sick and the relatives, cancer is a
problem for all mankind. That is why the questions of the duly diagnostics and the correct
treatment of oncological patients are of great value. Early diagnosis of the tumor process and
the treatment started in time determines the favorable outcome of the disease.Tumors are very
important in surgery. Moreover, the knowledge of tumors is especially important because still
the main method of treatment is their surgical removal. Recognition of a tumor is possible
only for the doctor who is well familiarwith the pathology and the clinical manifestations of
tumors.

II. The goal of self-preparation:


To study the general characteristics of tumors, benign and malignant tumors, routes of
metastatic spread of the malignant tumors, clinical classification of tumors. To acquire the
principles of clinical diagnosis of tumors, immunological markers of tumors. To study the
special diagnostic methods, morphological verification of the diagnosis. To acquire the stages
of cancer, principles of surgical treatment of tumors. To study the bases of the complex
therapy of malignant tumors and the principles of organization of the oncological service in
the world.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 concepts of tumor, metastasis, recurrence;
 main tumor theories;
 attributes of benign and malignant tumors;
 features of the oncological patients examination;
 premalignant diseases;
 special methods of the oncological patients examination;
 classification of malignant tumors according to the stages and clinical groups;
 treatment methods of benign and malignant tumors;
 concepts of: ablasty, antiblasty, radical operation, palliative operation,
symptomatic treatment, radiation therapy, chemotherapy, hormonal therapy;
 principles of the oncological service organization in the world.
Be able to:
 distinguish a true tumor from a false one;
 distinguish benign and malignant tumors;
 determine premalignant diseases;
 study the complaints, the anamnesis of disease, carry out the objective
investigation (the state of the lymph nodes, color of the skin, presence of the tumor, its
relation to the surrounding tissues, the surface, the consistence, the tenderness);
 estimate the results of the additional methods of diagnosis (ultrasound
investigation, endoscopy, cytological diagnosis, biopsy, diagnostic operation);
 diagnose a malignant tumor, taking into account the stage and the clinical group;

171
 prescribe correctly the treatment of a benign tumor;
 prescribe correctly the treatment of a malignant tumor;
 make a dressing for an oncological patient;
 carry out the diagnostic puncture (biopsy) of a tumor.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from oncologic diseases.

IV. The initial level of knowledge:


For successful mastering of the given topic it is necessary to repeat the questions of
anatomy, histology, the influence of the X-ray and the G-rays on different tissues of an
organism, the basic properties of chemotherapeutic and hormonal medicines, the questions of
pathology, concerning the given topic.

V. The plan of studying the topic.


1. General characteristics of tumors.
2. Benign and malignant tumors, theories of development.
3. Clinical classification of tumors (stages and clinical groups).
4. Diagnosis of tumors.
5. Special methods of diagnosis of tumors,morphological verification of tumors.
6. Principles of malignant tumors treatment.
7. Principles of organization of the oncological service in the world.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. Pp. 112-119.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp.-219-
393
4. "General surgery" Gostishev, 2003. Pp. 205-210.
Supplemental materials:
1. "Surgery" Bruce E. Jarrell., 1991. Pp. 26-29.
2. Principles of surgery" Schwartz, Shires, Spencer., 1994., Vol 1. Pp. 305-377

VII. Questions for the self-control.


1. Give the definition of a tumor.
2. List and characterize the main tumor theories.
3. Name the attributes of the true tumors.
4. List the attributes of benign tumors.
5. List the attributes of malignant tumors.
6. Give the definition of the concepts of metastasis, recurrence.
7. Characterize the features of complaints, anamnesis morbi (history of present
complaints) and anamnesis vitae (past medical history) of the oncological patient.
8. Name the features of the objective investigation of the oncological patient.
9. List the basic and additional methods of diagnosis, applied for recognition of
tumors.
10. List the premalignant diseases.
11. Introduce the classification of the stages of the tumor process.
12. Name the methods of treatment of benign tumors.
13. Name the methods of treatment of malignant tumors.
14. Give the definition of the concepts of ablasty, antiblasty.
15. Characterize the combined treatment of malignant tumors.

172
16. Give the definition of the concepts of radical and palliative surgery.
17. Characterize the symptomatic(supportive) treatment.
18. Name the main methods of the radiation therapy.
19. List the complications of the radiation therapy.
20. Name the main methods of the chemotherapy and the hormonal therapy.
21. List the benign tumors of the vascular and nervous tissues.
22. Name the malignant tumors of the epithelial tissue and connective tissue.
23. List the tumors of the muscle, vascular and nervous tissues.
24. Name the mixed tumors.
25. List the basic functions of the oncological clinic.

VIII. Tasks for self-preparation:


1. Correlate the names of various tumors and the tissues, which they originate from.
2. Make the scheme of the diagnostic actions in the thyroid gland tumor.
3. Make the scheme of the diagnostic actions in breast cancer.
4. Make the scheme of the diagnostic actions in lung cancer.
5. Make the scheme of the diagnostic actions in stomach cancer.
6. Introduce as a table the classification of tumors according to the stage of the
process.
7. Explain the meaning of the international classification of tumors (TNM).
8. Specify the importance of clinical groups prescribing the treatment.
9. Make the examples: what treatment can be used at the malignant tumor of the
stomach, stage I, stage II, stage III, stage IV.(T1-4; N1-3; M0-1;)
10.Make the examples: what treatment can be used in the breast cancer, stage I, stage
II, stage III, stage IV. (T1-4; N1-3; M0-1;)

Tests

1. find all premalignant states (choose right)


a) atrophic gastritis
b) diverticulitis
c) polyps
d) leycoplakia
e) all are right

2. benign tumors are characterized by the following (choose right )


a) absence of dissemination
b) absence of capsule
c) pleomorphism of cells
d) rapid growth
e) encapsulated

3. malignant tumors are characterized by the following (choose right )


a) absence of dissemination
b) absence of capsule
c) pleomorphism of cells
d) rapid growth
e) encapsulated

4. the following general signs of malignancy manifestation may be present (choose right )
a) malaise

173
b) change of test
c) apathy
d) discomfort
e) all are right

5. the following specific signs are characteristic of the bowel cancer (choose right )
a) sore that does not heal
b) change of elimination habits, consistency and composition
c) cough
d) constipation
e) discharge from the nipple

6. the following specific signs are characteristic of the skin cancer (choose right)
a) sore that does not heal
b) change of elimination habits, consistency and composition
c) cough
d) constipation
e) discharge from the nipple

7. the following specific signs are characteristic of the breast cancer (choose right)
a) sore that does not heal
b) lump
c) cough
d) constipation
e) discharge from the nipple

8. the following specific signs are characteristic of the esophagus cancer (choose right)
a) sore that does not heal
b) epistaxis
c) cough
d) constipation
e) dysphagia

9. the following specific signs are characteristic of the lung cancer (choose right )
a) sore that does not heal
b) epistaxis
c) cough
d) constipation
e) hoarseness

10. the following screening tests are used for early detection of the malignancy (choose
right)
a) MRI of the skull each year after age 50
b) stool for occult blood each year after age 50
c) CT of the body each year after age 50
d) smear of the rectum for occult blood
e) mammography annually after age 40-50

11. find appropriate stage according to TNM classification for a patient with stomach
carcinoma T1 N2 M0 stage (choose right)
a) regional lymph nodes more than 3 cm from tumor but removable surgically
b) distant metastases

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c) tumor through serosa but not into adjacent organs
d) tumor into adjacent organs
e) tumor limited to mucosa or submucosa

12. find appropriate stage according to TNM classification for a patient with stomach
carcinoma T4 N1 M1 stage (choose right)
a) tumor into adjacent organs
b) distant metastases
c) tumor through serosa but not into adjacent organs
d) regional lymph nodes more than 3 cm from tumor but removable surgically
e) affected lymph nodes within 3cm of primary tumor

Clinical tasks

Task № 1
Clinical scenario: A 69 years patient complaints on apathy, rise of body temperature
till 37,6 C0, and difficulties with swallowing of a food. The signs has been lasting for 6
months. Due to exacerbation of symptoms the patient has come into the hospital. The patient
is malnourished, skin color is pale. Lymph nodes are not enlarged. Examination of body
systems does not show any abnormalities.
Questions:
1. What diagnosis have you suspected?
2. What changes do you expect in a full blood count?
3. What methods of investigation can be used to assess localization and extend of the
pathology?
4. What investigations are to be done to differentiate if the patient is M0 or M1 according
to TNM class.
5. What kind of radical surgery can be done?

Task № 2
Clinical scenario: A 59 years old patient is admitted to the hospital. He complains of
epigastric discomfort, multiple vomiting, thirst, loss of body weight approximately 10 kg. The
mentioned signs without any explicable reason started 2 months ago and progressed. After
complex examination using subjective, objective, and instrumental methods the tumor of the
pyloric part of the stomach is found.
Questions:
1. Why does the patient have a thirst and multiple vomiting?
2. What methods of investigation can be used to assess localization and extend of the
pathology?
3. What investigations are to be done to differentiate if the patient is M0 or M1 according
to TNM class.
4. After a complete examination the diagnosis is T3N2M1, III grade. What clinical group
is the patient referred to?
5. What kind of surgery can alleviate the patient‟s sufferings?

Task № 3
Clinical scenario: A 74 years patient complains of constipation, discomfort at the left
lower abdominal quadrant, loss of body weight approximately 20 kg during last 8 months.
Formerly the patient was never examined and did not seek for medical advice. Due to
progression of symptoms the patient has come into the hospital. The patient was
malnourished, skin color was pale. Examination of the GIT revealed 10/10 hard nonmovable
tender mass in the left iliac area. Other body systems were normal.

175
Questions:
1. What diagnosis have you suspected?
2. What changes do you expect in a full blood count?
3. What methods of investigation can be used to assess localization and extend of the
pathology?
4. After a complete examination the diagnosis is T4N2M1. What kind of surgery can be
done?
5. After a complete examination the diagnosis is T3N1M0. What kind of surgery can be
done?

Task № 4
Clinical scenario: A 70 years patient complains of constipation, presence of the blood
in the feces, rise of body temperature till 37,5 C0. The signs last approximately 2 months.
Formerly the patient was never examined and did not seek for medical advice. Due to
progress of symptoms the patient has come into the hospital. The patient was malnourished,
skin color was pale. Examination of the GIT has not revealed any abnormalities. In order to
obtain specimens of the stool for the presence of the blood the doctor performed a digital
examination of the rectum. He has palpated the hard uneven nonmovable tender mass 3 cm
above the anus. Other body systems were normal.
Questions:
1. What methods of investigation can assess localization and extend of the pathology?
2. What investigations are to be done to differentiate if the patient is M0 or M1 according
to TNM class?
3. How can you determine the grade of the tumor?
4. After complete examination the diagnosis is T4N2M1. What kind of surgery can be
done?
5. After complete examination the diagnosis is T3N1M0. What kind of surgery can be
done?

Task № 5
Clinical scenario: A 36 years patient complains of the lump under the skin of the
back. At first the patient noticed the lump more than 3 years ago. Formerly it was of 0.5 cm
size. The swelling gradually increased its size because of that the patient has come to the
doctor. Examination of body systems has not revealed any abnormalities. Examining the lump
area the doctor has found the soft, even, round, movable, nontender mass of 5 cm size in the
area of the left scapula.
Questions:
1. What diagnosis have you suspected?
2. What changes do you expect in a full blood count?
3. What methods of investigation can be used to assess localization and extend of the
pathology?
4. What is the most accurate method to determine the origin of the tumor? What types of
the method do you know?
5. What kind of surgery can be done?

176
TOPIC 31 BASIC PRINCIPLES OF PLASTIC SURGERY AND
TRANSPLANTATION

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to determine indications to organ transplantation and plastic surgery.
 ability to provide first aid to patients after plastic surgery.

I. Motivation of the goal:


Nowadays the plastic surgery is a separate medical speciality. It is caused by the
growing number of plastic operations on skin, nerves, bones, and other tissues and organs.
The cosmetic defects also have the important value. The transplantology is experiencing now
the rough season of the development. From the stage of the clinical experiment the
transplantation of organs has been included in the wide clinical practice. Therefore, the
knowledge of the plastic surgery and the transplantology is obligatory for better medical
education.

II. The goal of self-preparation:


To study the indications and principles of carrying out of the plastics of tissues and
organs.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 principles of carrying out the skin grafting;
 indications and ways of the muscles and tendons plasty;
 indications and ways of carrying out the bone plasty;
 indications and principles of carrying out the nerves and vessels plasty;
 basic methods of preservation of organs and tissues;
 methods of suppression of transplanted organ rejection;
 principles of carrying out the organ transplantation.
Be able to:
 carry out the pre-operative preparation of the operation area before tissue plasty;
 provide the first aid in the traumatic avulsion of the extremity;
 store the torn-off extremity for the subsequent replantation;
 determine the potential organ donors for the subsequent transplantation.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from injuries of the skin, muscles, tendons, bones and vessels.

IV. The initial level of knowledge:


A student should repeat the structure of the skin, muscles, nerves, vessels from the
course of the normal anatomy.

V. The plan of studying the topic.


1. Kinds of the tissue plasty and the classification of the plastic surgery.
2. Indications and principles of carrying out various methods of the skin grafting.
3. Indications and principles of the muscles, tendons and bones plasty.
4. The nerves and vessels plasty.
5. Preservation of organs and tissues.
6. Indications and principles of the internal organs and endocrine glands
transplantation.

177
VI. The recommended literature:
Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. Pp. 93-112.
3. "Surgery" Traves D. Crabtree 2000. Pp. 111-135.
Supplemental materials:
1. "Principles of surgery" Schwartz, Shires, Spencer., 1994. Pp. 2025-2040.
2. "Surgery" Bruce E. Jarrell, 1991. Pp. 391-401, 421-428.
3. "Textbook of surgery. The biological basis of modern surgical practice" Sabiston.,
USA., 1991. Pp. 470-590.

VII. Questions for the self-control.


1. What are the differences between auto-,iso-, homo-, and heteroplasty?
2. What are the differences betweentransplantation, replantation and implantation?
3. What methods of the skin grafting are used in clinic, their advantages and
disadvantages?
4. Classification of skin flaps.
5. What methods of skin flap transplantation are used in clinic, their advantages and
disadvantages?
6. What are the differences in carrying out skin flap and graft plasty?
7. What are the basic principles of nerve plasty?
8. What prostheses are applied for vessel plasty?
9. Option of the donor and recipient for transplantation.
10. What are the methods of organs and tissue preservation?
11. What are the basic reactions of the immune system to transplanted tissue?
12. How can the rejection of transplanted organs and tissues be suppressed?
13. What are the differences between orthotopic and heterotopic transplantation?
14. Which endocrine glands are more frequently transplanted and why?

VIII. Tasks for self-preparation:


1. Draw the basic variants of skin defect closure.
2. Draw the scheme of the “Indian method” of skin grafting.
3. Draw the scheme of the “Italian method” of skin grafting.
4. Draw the scheme of skin grafting with the Filatov‟s flap.
5. Draw the scheme of skin grafting with different types of skin flaps.
6. Draw the basic variants of tendon plasty.
7. Draw the basic variants of arterial plasty.
8. Draw schematically the technique of nerve suture.
9. Write the sequence of carrying out the torn-off extremities replantation.
10. Describe the basic mechanisms of immune system reactions to transplanted organ.
11. Write the medicines, which suppress the rejection of the transplanted organs.

Tests

1. agraft transplanted between genetically nonidentical individuals of the same species is


named (choose right)
a) isograft (syngraft)
b) heterograft
c) autograft
d) allograft (homograft)
e) orthotopic

178
2. a tissue or an organ transferred by grafting into a new position in the body of the same
individual is named (choose right)
a) isograft (syngraft)
b) heterograft
c) autograft
d) allograft (homograft)
e) orthotopic

3. a graft transferred from an animal of one species to one of another species is named
(choose right)
a) isograft (syngraft)
b) heterograft
c) autograft
d) allograft (homograft)
e) orthotopic

4. evidence of brain death are the following (choose right)


a) Glasgow coma scale 6 points
b) isoelectric EEG
c) EEG with B-waves
d) Glasgow coma scale 3 points
e) EEG with A-waves

5. the transplantation of an organ which is performed into the normal or usual organ's
position is named (choose right)
a) isograft (syngraft)
b) heterograft
c) autograft
d) allograft (homograft)
e) orthotopic

6. the following organs are only transplanted orthotopically (choose right)


a) liver
b) pancreas
c) kidney
d) cornea
e) lungs

7. the following organs are commonly transplanted heterotopically (choose right)


a) liver
b) pancreas
c) kidney
d) heart
e) lungs

8. the following medicines possess immunosuppressive action (choose right)


a) azathioprine
b) orthoclone
c) acyclovir
d) heparin
e) cyclosporin

179
9. the following immunosuppressive agents are used during acute graft rejection (choose
right)
a) azathioprine
b) orthoclone
c) acyclovir
d) antilthymocyte globuline
e) cyclosporin

10. possible complications after organ transplantation are the following (choose right)
a) transplanted organ rejection
b) cytomegalovirus infections
c) skin cancer
d) fungi infections
e) all are possible

11. best cosmetic result is achieved with the following type of suture (choose right)
a) simple interrupted sutures
b) vertical mattress sutures
c) horizontal mattress sutures
d) subcuticular sutures
e) continuous over-and-over sutures

12. types of the random flap are the following (choose right)
a) fasciocutaneous flap
b) advancement flap (V-Y plasty)
c) transposition flap
d) groin flap
e) rotation flap

Clinical tasks

Task № 1
Clinical scenario: A 59 years patient has been suffering from chronic posttraumatic
osteomyelitis of the right tibial bone for 5 years. Examining of the patient has detected a
marked skin dystrophy and purulent fistula of 5 cm size on the anterior surface of the calf.
Due to frequent relapses of the disease a surgical treatment is indicated. According to
fistulography and CT the bone defect involves approximately 5 cm of the bone, it contains
sequester and alters 30% of bone circumference.
Questions:
1. How can the bone defect be closed having performed the necrseqestrectomy?
2. What type of tissue flap is preferred to close the skin defect?
3. What method of flap transfer is convenient for the patient?
4. List the advantages and disadvantages of a free flap transfer.

Task № 2
Clinical scenario: A 49 years patient has been suffering from chronic hematogenous
osteomyelitis of the right tibial bone for decades. Examining the patient there is a marked skin
dystrophy and purulent fistula of 7 cm size on the anterior surface of the calf. Due to frequent
relapses of the disease a surgical treatment is indicated. According to fistulography and CT of
the femoral bone the defect involves approximately 10 cm, it contains sequester, and disrupts
80% of bone circumference.

180
Questions:
1. What sort of flap can restore bone integrity after necrseqestrectomy of the tibial bone?
2. What type of tissue flap plasty is preferred to close the skin defect?
3. What method of flap transfer is convenient for the patient?
4. List the advantages and disadvantages of a direct flap (cross-leg flap) transfer.

Task № 3
Clinical scenario: Two days ago a 79 years patient was operated due to secondary
diffuse peritonitis resulted from perforation of the diverticulum of the sigmoid colon. The
postoperative period is complicated by pressure sore of the sacral region. Examining of the
area of the decubitus ulcer has detected a 10/10 round necrosis of the skin. The bottom of the
wound is the sacral bone.
Questions:
1. How can the bed sore be closed after surgical debridement?
2. Why do you prefer this type of plasty?
3. What method of tissue transfer can be done?
4. How can the skin defect be closed at the area where the flap has been taken from?

Task № 4
Clinical scenario: A patient is treated in the burn center. The full-thickness burn
involves left lower and upper extremity. The hypovolemic shock is controlled and the
definitive wound care is to be done.
Questions:
1. How can the burned area be permanently closed?
2. List the advantages and disadvantages of split-thickness skin graft
3. List the advantages and disadvantages of full-thickness skin graft.
4. What areas are preferably closed by full-thickness skin graft.
5. What body areas are used for harvesting of skin graft?

Task № 5
Clinical scenario: A 55 years patient has been suffering from chronic kidney failure
(renal form) for 5 years. He is treated with dialysis three times a week with five hours
sessions. The main disease progresses and kidneyfunction progressively deteriorates. The
patient needs kidney transplantation.
Questions:
1. Who can donate the kidney for the patient?
2. What donor is preferred?
3. What are the requirements for the donor?
4. How can the viability of donated kidney be maintained?
5. Where and what type of positioning of transplanted kidney is preferred?
6. What are the signs of kidney rejection?

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TOPIC 32 BASIC PRINCIPLES OF SURGICAL MALFORMATIONS

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of malformations.
 ability to provide first aid to patients with malformations.
 ability to investigate the foreign and domestic scientific medical data about
malformations.

I. Motivation of the goal:


The malformations are the result of pathology of the prenatal development of the fetus
and occur according to the World Health Organization in 0,3-2 % of births. Frequently these
anomalies result in the pathology of vital organs and systems, handicap and death. Early
diagnosis and treatment is the main way to eliminate malformations.

II. The goal of self-preparation:


To study the main factors, diagnostic principles and treatment of malformations.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 internal and external teratogenic factors;
 classification of malformations;
 clinical manifestations of common malformations;
 diagnosis of malformations;
 principles of malformations treatment.
Be able to:
 carry out the prophylaxis of the abnormal development of the fetus;
 estimate the results of laboratory tests, used in the diagnosis of malformations;
 estimate the results of instrumental examination, used in the diagnosis of the
malformations
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffered from malformations.

V. The plan of studying the topic.


1. Characteristics of the main teratogenic factors.
2. Clinical manifestations, diagnostic principles, and treatment of skull and brain
malformations.
3. Clinical manifestations, principles of diagnosis, and treatment of vertebral column
and the spinal cord malformations.
4. Clinical manifestations, principles of diagnosis, and treatment of face
malformations.
5. Clinical manifestations, principles of diagnosis, and treatment of neck
malformations.
6. Clinical manifestations, principles of diagnosis, and treatment of thorax and the
thoracicorgan malformations.
7. Clinical manifestations, principles of diagnosis, and treatment of heart
malformations.
8. Clinical manifestations, principles of diagnosis, and treatment of GIT
malformations.

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9. Clinical manifestations, principles of diagnosis, and treatment of genitourinary
malformations.
10. Clinical manifestations, principles of diagnosis, and treatment of extremity
malformations.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. Pp. 294-300; 362-364; 388-
389; 422-426; 499-500; 607-613; 673-675; 782-785; 986-987; 999-1000;
Supplemental materials:
3. "Surgery" Bruce E. Jarrell., 1991. Pp. 105-109, 457-471, 471-493, 421-435.
4. "Principles of surgery" Schwartz, Shires, Spencer., 1994. Pp. 1681-1725, 1861-
1900.

VII. Questions for the self-control.


1. What are the differences between meningeocele and myelomeningocele of the
brain?
2. What is the result of the incomplete closure of the vertebral canal?
3. What main malformations of the face can be met in surgical practice?
4. What is the result of the development of the additional cervical ribs?
5. What functional disabilities can develop in the malformations of the thoracic cage?
6. Why are the inborn cysts of the lungs dangerous?
7. What functional disabilities can develop in the coarctation of the aorta?
8. What is the result of the inborn pyloric stenosis?
9. What is the reason of development of Hirschprung‟s disease?
10. What are the most frequent deformations of extremities?
11. Why is the congenital hip dysplasia dangerous?
12. How should you treat the inborn talipes equinovarus?

VIII. Tasks for self-preparation:


1. Write the main reasons of the internal teratogenic factors.
2. Write the main reasons of the external teratogenic factors.
3. Specify the classification of malformations.
4. Draw the scheme of the plasty of the upper lip in cleft lip and cleft palatum.
5. Draw the main types of the thorax deformations.
6. Draw the scheme of the patent ductus arteriosus.
7. Draw the scheme and specify the hemodynamic pathology in the ventricular septal
defect.
8. Draw the scheme of the large intestine in Hirschprung's disease.
9. Draw schematically the congenital hip dislocation.
10. Describe the clinical manifestations of the pyloric stenosis and draw the scheme
of its correction.

Tests

1. reasons of congenital abnormalities are the following (choose right)


a) increased parental age
b) drugs
c) environmental pollution
d) ionizing radiation
e) all are possible

183
2. during clinical assessment the following maneuvermay be done to find congenital hip
dislocation (choose right)
a) hip flexion
b) thigh adduction with extended knees
c) hip extension
d) thigh abduction with flexed knees
e) all are used

3. a complex deformity consisting of plantar flexion of the ankle and inversion of the foot is
called (choose right):
a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) talipes equinovarus
e) torticollis

4. the deformity in which the head is drawn to one side and is usually rotated so that the
chin points to the other side is called (choose right):
a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) talipes equinovarus
e) torticollis

5. a congenital gap in the skull with herniation of brain substance is called (choose right):
a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) talipes equinovarus
e) torticollis

6. a congenital absence of parasympathetic ganglia cells in the wall of the GIT is referred
to (choose right):
a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) talipes equinovarus
e) torticollis

7. a developmental anomaly characterized by a defect on the ventrum of the penis so that


the urethral meatus is more proximal than its normal glandular location, may be associated
with chordee is called (choose right):
a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) talipes equinovarus
e) torticollis

8. the following right notions are referred to meningocele (choose right)


a) incomplete closure of the vertebral column
b) swelling includes the disordered spinal cord
c) protrusion of only meninges

184
d) absence of skin coverage above the spinal cord
e) all are present

9. the following right notions are referred to myelomeningocele (choose right)


a) incomplete closure of the vertebral column
b) swelling includes the disordered spinal cord
c) no obvious swelling
d) absence of skin coverage above the spinal cord
e) protrusion of only meninges

10. clinical presentation of the accessory cervical rib is caused by the following (choose
right)
a) compression of lungs
b) compression of brachial plexus
c) compression of trachea
d) compression of aorta
e) compression of subclavian artery

11. choose the characteristic clinical features of the coarctation of the aorta (choose right)
a) epistaxis
b) easy fatigability
c) diminished pulse in low extremities
d) headache
e) all are present

12. failure of one or both testes to descend is called (choose right):


a) hypospadia
b) encephalocele
c) Hirschsprung disease
d) cryptorhism
e) torticollis

Clinical tasks

Task № 1
Clinical scenario: A 5 weeks old baby is admitted to the hospital. According to data
provided by parents the baby has been suffering from vomiting for five days. Examining the
patient the following signs are found: the weight is 3,5 kg, dry tongue, loss of skin turgor,
increased heart rate, 80/40 mmHg arterial blood pressure. Urine output is decreased.
Examining the GIT there is a palpable oblong mass at the epigastric area, nontender, and
elastic. Signs of peritoneal irritation are absent.
Questions:
1. What pathology have you suspected?
2. How can you confirm the diagnosis?
3. What is a degree of dehydration?
4. What changes do you expect at hematocrit level, urine osmolality, CVP, electrolytes.
5. How much fluid (water) and what i.v. solution does he need to cover the existing
deficit of fluid?
6. What surgery is indicated?

Task № 2
Clinical scenario: A four-years old boy is admitted to the hospital. According to data
provided by parents the boy has been suffering from constipation since birth. He is used to

185
have stool two to three times a week. Examining the patient there is no any obvious evidence
of internal organ diseases. Examining the GIT only an increased size of the abdomen is
noticed. Signs of peritoneal irritation are absent.
Questions:
1. What pathology have you suspected?
2. What is the pathophysiology of the disease?
3. How can you confirm the diagnosis?
4. What surgery is indicated?
5. What factors may cause the pathology?

Task № 3
Clinical scenario: Parents of a 1 year baby have discovered an absence of the right
testicle in the baby‟s scrotum
Questions:
1. What pathology have you suspected?
2. Where can a right testicle be situated?
3. How can you confirm the diagnosis?
4. Why a surgery is indicated?
5. What surgery is indicated?

Task № 4
Clinical scenario: Parents of a 4-years old baby have discovered that their boy often
complains of headache and suffered from frequent nasal bleeding. Examination of the patient
is done. The general condition is normal. An arterial blood pressure of the upper extremities is
twice higher of that of the lower extremities. The skin of the lower extremities is of normal
color, the temperature is slightly decreased. The pulse over a. dorsalis pedis, tibialis posterior,
popliteal, and femoral arteries of both sides is diminished. An auscultation has not revealed
any vascular bruits.
Questions:
1. What pathology is suspected?
2. Explain the underlying pathophysiologic changes responsible for the mentioned above
signs.
3. What investigation methods can help to establish the accurate diagnosis?
4. What do you expect to find with the administered tests?
5. What is a surgical treatment of the pathology?

Task № 5
Clinical scenario:A 14-years old teenage boy complains of tingling sensation,
paraesthesia, weakness after moderate physical exertion, and coldness of the right arm. The
examination of the patient is done. The general condition is normal. There is a palpable lump
in the supraclavicular area. An arterial blood pressure of the upper extremities is normal. The
capillary refilling time is 5 sec in the palm. The pulse over a. radialis and ulnaris is normal but
disappears during elevation of upper extremities. An auscultation has not revealed any
vascular bruits.
Questions:
1. What pathology is suspected?
6. Explain the underlying pathophysiologic changes responsible for the mentioned above
signs.
2. What investigation methods can help to establish accurate diagnosis?
3. What do you expect to find with the administered tests?
4. What is a treatment of the pathology

186
TOPIC 33 BASIC PRINCIPLES OF PARASITIC INFECTION SURGERY

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize the basic symptoms and signs of parasitic diseases.
 ability to provide first aid to patients with parasitic diseases.

I. Motivation of the goal:


About 150 kinds of worms and their embryo can infest human organism. Parasitic
diseases can result in various complications demanding the surgical treatment. Therefore, it is
necessary for the students of the medical high school to know the principles of diagnosis and
treatment of the parasitic surgical diseases.

II. The goal of self-preparation:


To study the basic principles of diagnosis and treatment of the parasitic surgical
diseases.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the basic properties of helminths responsible for surgical diseases;
 ways of human infestation with parasites;
 main clinical manifestations of the parasitic surgical diseases;
 principles of the laboratory and instrumental diagnosis of the parasitic diseases;
 treatment principles of the surgical complications of the parasitic diseases.
Be able to:
 carry out the prophylaxis of the infestation with the parasitic diseases;
 interpret the results of the laboratory tests, applied for the diagnosis of the parasitic
diseases;
 find out the anamnesis of the parasitic diseases, interpret the results of the
instrumental examination.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups suffering from parasitic diseases.

IV. The initial level of knowledge:


It is necessary to repeat the species and the properties of helminths from the course of
biology.

V. The plan of studying the topic.


1. Ways of infestation, clinical manifestations, principles of diagnosis and treatment
of echinococcosis.
2. Surgical complications of ascariasis.
3. Surgical complications of opisthorchiasis.
4. Surgical complications of amoebiasis.
5. Surgical complications of filariasis.
6. Surgical complications of paragonimiasis.
7. Surgical complications of fascioliasis.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.

187
2. "General surgery" Gostishev, 2003. Pp. 211-217.
3. "Short practice of surgery" Bailey and Love's, 1996. Pp. 190-191, 706-710, 748,
798.
Supplemental materials:
4. "Current medical diagnosis and treatment" 1991. Pp. 1089-1094, 1122-1125,
1128-1131, 1133-1134, 1137-1138,
5. SURGERY. Basic science and clinical evidence. USA., 2000. Pp. 425, 591-594,

VII. Questions for the self-control.


1. What are the differences between cystic and alveolar hydatid disease
(echinococcosis and alveococcosis) according to the development of the embryo?
2. What is the similarity in the development of echinococcosis and alveococcosis?
3. What is the laboratory diagnostics of echinococcosis and alveococcosis?
4. What surgical diseases can be caused by ascaris?
5. The most frequent complications of opisthorchiasis.
6. What surgical complications can be caused by amoebiasis?
7. What system of organs does the filariasis affect?
8. What surgical diseases can be caused by paragonimiasis?
9. What are the ways of infestation with fascioliasis?
10. What are the ways of infestation with filariasis and paragonimiasis?

VIII. Tasks for self-preparation:


1. Draw the hydatid cyst with its layers, its capsules, anddaughter cysts.
2. Draw schematically the lesion of the liver with alveococcosis.
3. Write the main laboratory data indicating the infestation with echinococcosis.
4. Draw schematically the basic surgeries used for the treatment of echinococcosis.
5. Draw schematically the changes of the intestine in its occlusion by the ball of
ascaris.
6. Draw the main way of human infestation with opisthorchiasis.
7. Characterize the main surgical diseases caused by amoebiasis.
8. Describe the changes of the lymphatics in filariasis.
9. Name the pathogen of paragonimiasis and specify the way of infestation.
10. Name the pathogen of fascioliasis and specify the main way of infestation.

Tests

1. what parasites are parasites responsible for hydatid disease(choose right)


a) alveococcus
b) filariasis
c) echinococcus
d) opisthorchiasis
e) fascioliasis

2. what parasite isresponsible for elephantiasis(choose right)


a) alveococcosis
b) filariasis
c) echinococcosis
d) opisthorchiasis
e) fascioliasis

3. what organ (tissue) is most commonly affected by F. sanguineus hominis (choose right)
a) gut
b) lungs

188
c) liver
d) pancreas
e) lymphatics

4. what organ (tissue) is most commonly affected by hydatid disease(choose right)


a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

5. what organ (tissue) is most commonly affected by E. histolytica (choose right)


a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

6. what organ (tissue) is most commonly affected by A. lumbricoides (choose right)


a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

7. what organ (tissue) is most commonly affected by Fasciola hepatica (choose right)
a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

8. what organ (tissue) is most commonly affected by O. Felineus (choose right)


a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

9. what organ (tissue) is most commonly affected by Paragonimus westermani (choose


right)
a) gut
b) lungs
c) liver
d) pancreas
e) lymphatics

10. surgical complications of the ascariasis include the following (choose right)
a) bowel obstruction
b) lymphedema
c) mechanical jaundice
d) peritonitis
e) all are right

189
11. surgical complications of the filariasis include the following (choose right)
a) bowel obstruction
b) lymphedema
c) mechanical jaundice
d) peritonitis
e) all are right

12. the following antiparasitic agents are known (choose right)


a) gentamycine
b) methicillin
c) bithinol
d) ofloxacin
e) emetine hydrochloride

Clinical tasks

Task № 1
Clinical scenario: A 45-years old European patient has come to a physician
complaining of moderate constant edema of the right lower extremity extending from tiptoes
to knee joint. The patient was never examined by a doctor previously. According to the
patient‟s opinion, the disease started when he had arrived from Africa, where he was as a
tourist. The condition of the patient is normal. There are no any signs of internal organ
disease. The size of the left foot and calf (to the upper part) is increased. An edema is firm,
nonpitting. Any trophic changes are absent as well as varicose veins. A pulsation of all
peripheral arteries is normal. Groin lymph nodes are enlarged and tender.
Questions:
1. What parasitic disease does the patient suffer from?
2. What investigation can exclude DVT as a reason of edema?
3. What lab tests are to be done to confirm the diagnosis?
4. What do you expect in the administered lab tests?
5. List the principles of treatment of the patient
Task № 2
Clinical scenario: A 42-years old Kuwaiti patient has come to a physician
complaining ofmoderate, dull pain in the right upper abdominal quadrant. The pain lasts
approximately two months. During abdominal palpation the doctor has found light tenderness
in the right upper abdominal quadrant, increased size of the liver, and even round mass of 5
cm in diameter. Having suspected a parasitic disease of the liver the doctor proceeded with a
laboratory and instrumental investigation to confirm diagnosis.
Questions:
1. What parasitic disease is suspected?
2. What types of parasite may cause it. What is a life circle of a parasite?
3. List the administered lab tests with the expected results.
4. List the administered instrumental investigations with the expected results.
5. List the principles of medical treatment of the patient
6. List the principles of surgical treatment of the patient
Task № 3
Clinical scenario: A patient complains of severe pain in the right upper abdominal
quadrant, rise of body temperature till 38,5 C0, malaise. The mentioned signs last
approximately two days. Before that the patient had multiple diarrhea during three days when
he was diagnosed an amebic enteritis. The objective examination is done. A color of the skin

190
is normal. The vital signs are the following: pulse rate is 120; arterial blood pressure is
120/70. Respiratory system: respiratory rate is 30, there is an absence of breathing sounds and
dullness of percussion note in the lower part of right lung. The excursion of the right
hemidiaphragm is limited. The examination of the GIT system is done. Signs of peritoneal
irritation are absent. There is a musculary guarding and tenderness in the right upper
abdominal quadrant. The liver span is increased.
Questions:
1. What complication of amoebiasis developed in the patient?
2. What other surgical complications of amoebiasis do you know?
3. What is a life circle of a parasite?
4. What laboratory and instrumental tests may be used to establish the diagnosis of
developed complication?
5. List the expected results of the administered diagnostic tools.
6. What is a treatment of developed complication?
Task № 4
Clinical scenario: A 100 kgwoman is admitted to the hospital. She complains of
cramp-like abdominal pain, thirst, and repeated vomiting. The mentioned signs last for one
day. Examining the patient the following signs are found: the skin as well as the tongue are
dry, heart rate is 130, 120/80 mmHg blood pressure. The CVP is 1 cm of water. GIT
examination is done. There are no any scars on the abdominal wall. The abdomen is enlarged
due to distention, and tender. The signs of peritoneal irritation are absent. To deflate the
distended stomach the nasogastric tube is inserted. There are numerous ascaris in the effluent.
Questions:
1. What complication of ascariasis developed in the patient?
2. What other surgical complications of ascariasis do you know (5)?
3. What is a life circle of a parasite?
4. What is a radiologic feature of developed complication?
5. What is a surgical treatment of developed complication?
6. What is a degree of dehydration and how much fluid does she need to cover the
existing fluid deficit?

Task № 5
Clinical scenario: A 36 years old patient was admitted to the infection ward due to
multiple diarrhea lasting four days. After stool examination, he was diagnosed an amebic
enteritis. During the last day the patient complains of severe abdominal pain, vomiting, and
rise of body temperature till 38,60C. A color of the skin is normal. The pulse rate is 120,
weak; arterial blood pressure is 120/70; respiratory rate is 25. A CVL is inserted, the CVP is 3
cm of water. Examination of the GIT is done. The tongue is dry. A rebound tenderness and
involuntary muscle guarding are noticed all over anterior abdominal wall. The peristalsis as
well as liver span is absent.
Questions:
1. What complication of amoebiasis developed in the patient?
2. List the laboratory tests with the expected results in the patient with developed
complication?
3. List the instrumental tools with the expected results in the patient with developed
complication?
4. What specific signs can be found in plain abdominal X-ray?
5. What is a treatment of developed complication?

191
TOPIC 34 OUT-PATIENT SURGERY. PREOPERATIVE PERIOD. SURGICAL
OPERATION

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to sort patients depending on the type of surgical disorder that require out-
patient and in-patient care.
 ability to provide out-patient and in-patient preoperative preparation depending on
the type of surgical disorder.

I. Motivation of the goal:


It is well-known that the majority of surgical patients (85-90 %) need only the out-
patient treatment. Duties of surgeons in polyclinics are various. They include quick
orientation in diagnosis of diseases and injuries, rendering the high-level surgical help,
including the urgent one; diagnosis of the diseases demanding hospitalization, directing
patients on the treatment to hospitals, the after-care of the patients who have left a hospital,
consultation at home, preventive work, clinical examination of surgical patients, etc. Thus, the
medical practice of an out-patient surgeon is rather great, and demands the knowledge and
experience, not only in the range of surgery, but also in other subjects. The knowledge of the
clinical manifestations of surgical diseases is also of great importance for doctors of other
specialties, and first of all for a therapist. The successful treatment of a surgical patient in
many respects depends on the preoperative preparation. The detailed studying of the altered
functions of an organism of patients, the correction of these pathologies, creating the reserves
of functions of organs and systems of a patient are the primary aims of the preoperative
period. An operation is the basic method of treatment of surgical patients. Each doctor should
be aware of the basics of the surgical method of treatment of a patient, know what dangers
and complications accompany the operation, know the basic principles of their prevention.

II. The goal of self-preparation:


To get acquainted with the structure of the surgical department of a polyclinic, the
equipment, the organization of work at surgical departments, the maintenance of the surgical
aid at home based on the principle of the preventive work and the clinical examination of the
patients with surgical diseases. To study the absolute and relative indications to an operation,
the contraindications to an operation, the criteria of the surgical risk, and the methods of its
reduction. To acquire the modern principles of anesthesia option and the preparation for it, the
legal bases of carrying out the anesthesia and surgical operations. To master the methods of
preparation of a patient to surgery, especially psychological, medical and physical preparation
of a patient. To study the principles of carrying out the basic kinds of the surgical operations.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 principles of work at the surgical department of the polyclinics;
 the order of admission of elective surgical cases;
 the order of admission of emergency surgical cases;
 the organization of the surgical aid at home;
 the preventive method of examination and treatment of surgical patients.
Estabishement of the urgency of surgery;
 duration of the preoperative period;
 indications to surgery;
 contraindications to surgery;
 dangers of surgery;

192
 preparation of a patient for emergency and urgent surgeries;
 complex of actions devoted to the normalization of the functions of the
cardiovascular and respiratory systems, gastrointestinal tract, liver and kidneys.
 the concept of a surgical operation;
 kinds of a surgical operation (the classification);
 types of operations;
 the position of a patient on the operation table;
 principles of the surgical access option;
 stages of a surgical operation.
Be able to:
 fill in the surgical chart in the polyclinic;
 carry out the wound care and prescribe the further treatment;
 remove stitches;
 determine patients who need an emergency admission;
 determine and prescribe the examination of patients who need an elective
admission;
 estimate the general condition of a patient;
 determine the condition of the nervous, psychological status;
 perform the stomach lavage;
 carry out the catheterization of the bladder;
 administer cleansing enema;
 administer colon lavage;
 carry out prepping the surgery field;
 prescribe the physical training for the prophylaxis of the post-operative physical
complications;
 formulate the basic indications to an operation;
 estimate the risk of a surgical operation;
 formulate the complications which can accompany the operation;
 put a patient onto the operation table;
 prepare the surgical area;
 drape the surgery area with sterile surgical linen.
To practice and demonstrate:
 The skills of a diagnostic and first aid algorithm actions for surgical patients of
different age groups with diseases that require out-patient and in-patient care.

IV. The initial level of knowledge:


To know the materials of the following topics: asepsis, antisepsis, wounds, fractures,
dislocations.

V. The plan of studying the topic.


1. Structure of the surgical service of the polyclinic and the traumatologic unit.
2. The scope of conservative and operative surgical treatment in polyclinics.
3. Basic contingent of the surgical out-patients.
4. Organization and equipment of a surgical consulting room.
5. Out-patient operation theater: the features of asepsis and antisepsis.
6. Order of the surgical out-patient reception.
7. The hospital of one day (day case surgery).
8. Surgical records in polyclinic.
9. Clinical examination of surgical patients.
10. Order of admission of elective and emergency patients.
11. Surgical aspects of the clinical examination of the population.
12. Absolute indications for surgery.

193
13. Relative indications for surgery.
14. Contraindications to surgery.
15. Criteria of the surgical risk, risk reduction;
16. Preparation of patients for surgery. The aims of preparation.
17. Psychological (deontological) preparation for a surgery.
18. Medical and physical preparation for a surgery.
19. The role of the physical preparation in the prophylaxis of the postoperative infectious
complications.
20. Preparation of the oral cavity, the gastrointestinal tract, and the skin.
21. Choice of the anesthesia and preparation to it.
22. Preparation for exigent and urgent operations.
23. Legal bases of carrying out the anesthesia and surgical operations.
24. Concept of a surgical operation.
25. Elective surgeries.
26. Urgent operations.
27. Emergent (exigent) operations.
28. Radical operations.
29. Palliative operations.
30. Operations with the ablation of the pathological focus.
31. Reconstructive operations.
32. Plastic operations.
33. Position of a patient on the operation table.
34. Principles of the surgical access option.
35. Stages of a surgical operation.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "Short practice of surgery" Bailey and Love's, 1996. Pp. 1011-1020.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006. Pp. 10-54,
199-207, 208-218.
Suggested reading:
4. "General surgery" the manual., V.K. Gostishev., 2003. Pp 82-90.
5. "Introductory medical-surgical nursing" Jeanne C. Sherer., 1995. Pp. 227-235
6. "Basic surgical techniques" 2001 Chapter 5. Pp. 114-132

VII. Questions for the self-control.


1. The duties of the surgical departments in polyclinic.
2. Structure of the surgical service of polyclinic.
3. Structure of a traumatic unit.
4. Basic contingent of surgical out-patients.
5. Equipment in a surgical consulting room.
6. Organization of work in the dressing-rooms of polyclinics.
7. Organization of work in the operation theater of polyclinics.
8. Order of the surgical out-patient reception.
9. The hospital of one day (day case surgery).
10. Surgical documentation in polyclinic.
11. Prophylaxis of the industrial, agricultural, street, and sport injuries.
12. Prophylaxis of the acute purulent diseases.
13. Clinical examination of surgical patients.
14. Order of admission of elective surgical patients.
15. Order of admission of emergency surgical patients.

194
16. Definition of the concept "preoperative period".
17. Aims of the preoperative period.
18. When does the preoperative period start?
19. What are the steps of the preoperative period?
20. Basic dangers of a surgery.
21. Indications and contraindications to a surgery.
22. Choice of the operation method.
23. Choice of the anesthesia method.
24. Preparation of the respiratory system for a surgery.
25. Preparation of the gastrointestinal tract for a surgery.
26. Preparation of the cardiovascular andhaemopoetic systems for a surgery.
27. Preparation of the urinary system for a surgery.
28. Preparation of the nervous system for a surgery.
29. Correction of the fluid-electrolyte, and acid-base abnormalities.
30. Correction of theprotein and carbohydrate disbalance.
31. What is the influence of the skin condition on the outcome of a surgery.
32. Preparation of an operation field.
33. Physiotherapy in the preoperative preparation.
34. What is an operation?
35. Indications to an emergency surgery of the abdominal cavity organs.
36. Classification of operations according to urgency.
37. Classification of operations according to their types.
38. Classification of operations according to the volume of a surgery.
39. The conditions necessary to perform operations.
40. Estimation of the surgical risks.
41. What dangerous complications can accompany an operation?
42. Position of a patient on the operation table.
43. Basic stages of a surgical operation.
44. What is the surgical access?
45. Principles of the surgical access option.
46. What is a surgical maneuver?
47. The most frequent complications on an operation table.
48. Miniinvasive surgery.
49. Safety rules during an operation.

VIII. Tasks for self-preparation:


1. Draw the scheme of the structure of the polyclinic surgical service.
2. Write the features of the industrial trauma prophylaxis.
3. Write the surgical documentation which is used in polyclinics.
4. Draw the scheme of the primary surgical debridement of a wound.
5. Write the scopeof the operative surgical treatment in polyclinics.
6. Draw the scheme of the street trauma prophylaxis.
7. Write the surgical documentation which is used for admission of elective and
emergency surgical patients.
8. Draw the scheme of the acute purulent disease prophylaxis.
9. Draw the scheme of incisions of different kinds of panaritium.
10. Write the scopeof the conservative surgical treatment in polyclinics.
11. Make the scheme of indications to a surgery.
12. Draw the scheme of the functional investigation of the respiratory system.
13. Write the normal values of the leukocyte formula.
14. Draw the scheme of the functional investigation of the liver.
15. Draw the scheme of the bladder catheterization.

195
16. Write the sequence of the basic actions of preparing patients for a surgery.
17. Introduce the scheme of assessment of the surgical-anesthesiologic risk before
surgery.
18. Write the normal values of the blood chemistry.
19. Write the scheme of the preoperative preparation of a patient with peritonitis.
20. Specify the criteria of the efficacy of the preoperative preparation of an
emergency surgical patient.
21. Write the classification of surgical operations.
22. Draw the scheme of the patientpositions on the operating table in various
operations.
23. Write the basic rules of antisepsis in carrying out an operation.
24. Write the basic rules of asepsis performing an operation.
25. Draw the scheme of the roomslocatedin a surgical block.
26. Write the basic contraindications to elective operations.
27. Draw the scheme of the surgical team position during an operation on the
abdominal cavity.
28. Describe the basic stages of an operation.
29. Introduce radical and palliative operations in patients with the diseases of the
stomach.
30. Introduce radical and palliative operations in patients with the diseases of the
gallbladder.

Tests

1. classification of the types of a surgery according to urgency includes the following items
(choose right)
a) exigent
b) elective
c) emergency
d) palliative
e) schedule

2. an elective surgery is performed at the following period of time (choose right)


a) immediately, within first minutes
b) within first 2-3 days after admittance
c) during 1-2 hours after admittance
d) in convenient time for a surgeon and a patient

3. an emergency surgery is performed at the following period of time (choose right)


a) immediately, within first minutes
b) within first 2-3 days after admittance
c) during 1-2 hours after admittance
d) in convenient time for a surgeon and a patient

4. an urgent surgery is performed at the following period of time (choose right)


a) immediately, within first minutes
b) within first 2-3 days after admittance
c) during 1-2 hours after admittance
d) in convenient time for a surgeon and a patient

5. if a patient is unconscious and must undergo emergency operation the surgical consent
is signed by (choose right)

196
a) a patient
b) a surgeon
c) relatives
d) an anesthesiologist

6. when the surgical consent is signed? (choose right)


a) after preoperative medication
b) after the performed surgery
c) before preoperative medication
d) during anesthesia

7. hair shaving at the operative site is performed at the following time period (choose right)
a) within 6h before a surgery
b) within 6-12h before a surgery
c) within 12-24h before a surgery
d) within 24-46h before a surgery
e) within a week before a surgery

8. elimination of the urine may be achieved by the following means (choose right)
a) placement of the Miller-Abbott catheter
b) void
c) placement of the Levin tube
d) placement of the Blackmor catheter
e) placement of the Foly catheter

9. usual type of preoperative bowel emptying before an elective surgery on the lower GIT is
the following (choose right)
a) colon lavage
b) cleansing enema
c) placement of the Levin tube
d) retention enema
e) placement of the Foly catheter

10. in the case of an emergency surgery an emptying of the stomach may be attained by the
following (choose right)
a) colon lavage
b) cleansing enema
c) placement of the Levin tube
d) retention enema
e) placement of the Foly catheter

11. usually before an elective surgery the oral intake of food is withheld (choose right)
a) 3 hours before a surgery
b) 12 hours before a surgery
c) withheld oral intake of solid food after the supper hours the night before surgery
d) withheld oral intake of solid food after the supper hours two nights before surgery
e) there is no any restrictions in oral intake of fluids and food

12. the following stages of a surgery are defined (choose right)


a) surgical incision
b) surgical access
c) closure of the wound
d) surgical manoeuvre

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e) surgical excision

Clinical tasks

Task № 1
Clinical scenario: A 65 years old patient is admitted to the hospital for surgery. A
resection of part of the colon is planned in order to treat a cancer of the sigmoid colon. The
patient has a history of myocardial infarction (three years ago), he is a smoker, and suffered
from chronic bronchitis.
Questions:
1. What type of anesthesia is to be used?
2. What and why must a doctor pay attention for during subjective examination?
3. What and why must a doctor pay attention for during objective examination?
4. What laboratory and instrumental tests do you plan to administer as a part of
preoperative examination?
5. Does the patient have the risk of DVT?
6. When and how should the skin be prepared for a surgery?

Task № 2
Clinical scenario: A 68 years old obese patient is admitted to the hospital for elective
surgery. A replacement of diseased knee joint with prosthetic one is planned. The subjective
and objective examination has not discovered any coexisting diseases.
Questions:
1. Does the patient have the risk of DVT?
2. Does DVT represent direct threat to a patient‟s life?
3. What could the cause of the patient‟s death be at the postoperative period if the
complication had developed?
4. List medicines which are to be administered to prevent DVT?
5. List other methods which are used to prevent DVT?

Task № 3
Clinical scenario: A 32 years old patient is admitted to a surgical hospital. He has a
history of myocardial infarction (one year ago), unstable angina pectoris, and suffered from
bronchial asthma. The patient has been diagnosed a wet gangrene of the right lower extremity
secondary to insulin-dependent diabetes mellitus. The patient‟s body temperature is 39,5, he
is confused. The heart rate is 130, 90/40 mmHg blood pressure, daily urine output was 150
ml. The CVP is 1 cm of water. The tongue is dry. The liver span is increased, the sclera is
yellowish. The signs of peritoneal irritation are absent. The patient had dinner 30 min ago.
Questions:
1. Is surgery indicated?
2. What are the indications to a surgery?
3. What surgery and when is to be done?
4. How can the GIT be prepared before a surgery?
5. What kind of anesthesia is indicated. Why is it preferred?
6. What is a surgical and anaesthesiologic risk of the planned surgery?

Task № 4
Clinical scenario: A 78 years old patient is admitted to a surgical hospital. He has a
long history of disrrhythmia, angina pectoris, and insulin-independent diabetes mellitus. The
patient‟s body temperature is 37,5, he is confused. The heart rate is 110, pulse is irregular,
110/70 mmHg blood pressure. The tongue is dry. Signs of acute cholecystitis are positive.

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The signs of peritoneal irritation are absent. The patient‟s diagnosis is an acute cholecystitis
due to gallstones. Medical therapy is ineffective.
Questions:
1. Is a surgery indicated?
2. What are the indications for a surgery?
3. Classify a planned surgery according to urgency.
4. What surgery is to be done? Why is it preferred?
5. What kind of anesthesia is indicated. Why is it preferred?
6. What is a surgical and anesthesiology risk of the planned surgery?

Task № 5
Clinical scenario: A 38 years old patient was diagnosed the gallstones. She is
admitted to a surgical hospital for cholecystectomy. The patient‟s body temperature is normal.
The heart rate is 86, pulse is regular, 120/80 mmHg blood pressure. The tongue is moist. The
signs of acute cholecystitis as well as peritoneal irritation are absent.
Questions:
1. Is surgery indicated?
2. Classify the planned surgery according to urgency.
3. What are the indications for a surgery?
4. What surgery is to be done? Why is it preferred?
5. What kind of anesthesia is indicated. Why is it preferred?
6. What is a surgical and anesthesiology risk of the planned surgery?

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TOPIC 35 POSTOPERATIVE PERIOD. NUTRITION OF SURGICAL PATIENTS

The following professional competences of a student have to be formed after preparation


of the topic:
 ability to recognize basic symptoms and signs of postoperative complications.
 ability to provide first aid to patients with postoperative complications.
 ability to provide nutrition through the enteral and parenteral roots to postoperative
patients.

I. Motivation of the goal:


Any surgical operation and narcosis cause serious changes in the organism. The
postoperative period is characterized by the intense compensatory work of the major organs
and systems. That dictates the essential need for studying the basic features of the
postoperative patient‟s care.

II. The goal of self-preparation:


To study the rules of the postoperative treatment and the principles of prophylaxis,
diagnosis and treatment of the postoperative complications.

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 the stages of the postoperative period;
 pathophysiologic changes evolving in the organism after operations;
 basic principles of patient‟s nursing during the postoperative period;
 complications in the early postoperative period;
 complicationsarising at the second stage of the postoperative period;
 basic methods of prevention of the complications in the postoperative period;
 indications for discharge.
Be able to:
 determine the stages of the postoperative period;
 carry out the preventive actions according to the stage of the postoperative period;
 determine the complications which can occur in the early postoperative period;
 prescribe the treatment, the resuscitation actions according to the complications;
 determine the indications to the possible operative treatment in the early
postoperative period;
 determine the complications in the second part of the postoperative period,
prescribe the adequate treatment depending on the kind of complications;
 determine the time for discharge of a patient.
To practice and demonstrate:
 The skills of management of surgical patients of different age groups in the
postoperative period.

IV. The initial level of knowledge:


For successful mastering the given topic it is necessary to know the normal
composition of the blood, urine, the level of the basic biochemical parameters, the bases of
physiology of the respiration, the cardiac activity, the digestion and the material of the
previous lessons (“The Preoperative period” and “Surgical Operation”).

V. The plan of studying the topic.


1. The organism response to the surgical intervention.

200
2. Distress of the respiration, the cardiac activity, the function of the gastrointestinal
tract and organs of the urinary systems, the thromboembolic complications.
3. Prophylaxis of the above mentioned complications, their diagnosis and treatment.
4. Clinical surveillance of patients.
5. Laboratory and functional diagnostic assessment of the basic systems of the
organism.
6. Regimen, terms, and feeding of a patient after different sorts of surgery.
7. Indications and contraindications to enteral and parenteral nutrition.
8. Calculation of nutritive values and composition of administered fluids.
9. Prophylaxis, diagnosis, and treatment of the wound complications: bleeding,
wound infection, evisceration, seroma, hematoma, and wound dehiscence.
10. Concept of the rehabilitation after the surgical treatment.
11. Dressings, timeof skin suture removal.
12. Physiotherapy and physical exercises.
13. Nutrition through the enteral and parenteral roots for postoperative patients.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.
2. "General surgery" Gostishev, 2003. Pp.76-80; 89-93.
3. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition. 2006. Pp.-55-73,
103-120.
4. "Introductory in medical surgical nursing". Pp. 234-247.
Supplemental materials:
1. "Short practice of surgery" Bailey 1996. Pp. 43-51;
2. "Scientific American Surgery" VI : I;
3. "Surgery" Bruce E. Jarrell., 1991. Pp. 11-15
4. "General surgery" - Traves D. Crabtree. Pp. 51-66.

VII. Questions for the self-control.


1. What is a postoperative period and what are its stages?
2. The basis for dividing a postoperative period into stages.
3. Complications in the early postoperative period.
4. Duration of a postoperative period.
5. How can the early secondary bleeding be determined and what is the treatment of
it?
6. How can the alteration of the gastrointestinal functions be determined and what is
the treatment of it?
7. Treatment of the urinary dysfunctions.
8. How is the postoperative shock diagnosed? Mechanism of its development,
prophylaxis, and treatment.
9. How is the respiratory insufficiency diagnosed? Prophylaxis and treatment.
10. How is the cardiac insufficiency diagnosed? Prophylaxis and treatment.
11. Most frequent complications in the second part of the postoperative term,
prophylaxis and treatment.
12. Which complications are the most dangerous in the second part of the
postoperative term? Prophylaxis, first aid and treatment.
13. Treatment of the secondary late bleeding.
14. Attributes of thepostoperative wound infection. Indications to theremoval of skin
sutures and the incision of the abscess.
15. Treatment of the postoperative wound infection.

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16. What infusion substances are used in the postoperative period according to the
stage?
17. Regimen, terms, and feeding of a patient after different sorts of surgery.
18. Indications and contraindications to enteral and parenteral nutrition.
19. Nutrition through the enteral and parenteral roots for postoperative patients.
20. Calculation of nutritive values and composition of administered fluids.
21. When should patients be discharged?
22. When does a postoperative period end?

VIII. Tasks for self-preparation:


1. Write the phases of a postoperative period.
2. Write the aims of a postoperative period.
3. Draw the scheme of the postoperative shock management.
4. Draw the scheme of prophylaxis and treatment of the respiratory insufficiency in a
postoperative period.
5. Draw the scheme of prophylaxis and treatment of the gastrointestinal dysfunction
(paralytic ileus).
6. Write the most frequent complications in the second part of the postoperative
period.
7. Make the scheme of prophylaxis and treatment of the secondary late bleeding.
8. List the attributes of a postoperative wound infection.
9. Prescribe thetreatment of the postoperative wound infection.
10. Write the infusion substances which are administered in the postoperative period
according to the stage.
11. Calculate the energetic, nutritive, and fluid needs for a patient at the early
postoperative period with total parenteral nutrition.

Tests

1. what is the most frequent type of shock developing in the postoperative period? (choose
right)
a) traumatic
b) cardiogenic
c) hypovolemic
d) hemorrhagic
e) neurogenic

2. the signs of hypoxia are the following (choose right)


a) dilation of pupils
b) dyspnea
c) fall in central venous pressure
d) rise of Hb level
e) cyanosis

3. in unconscious patients the tongue can fall back obstructing the upper airway. The best
treatment measures in this case are the following (choose right)
a) positioning of a patient in side-lying position
b) positioning of a patient in face-lying position
c) positioning of a patient in back-lying position
d) positioning of a patient in Trendelenburg's position
e) insertion of the oropharingeal airway

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4. the most frequent reasons of the vomiting in a postoperative period is (choose right)
a) placement of the gastric tube
b) early feeding of a patient
c) postoperative infection
d) side effects of several drugs
e) use of cephalosporine antibiotics

5. first aid in a vomiting patient is the following (choose right)


a) positioning of a patient in Trendelenburg's position
b) positioning of a patient in face-lying position
c) positioning of a patient in back-lying position
d) positioning of a patient in side-lying position
e) positioning of a patient in Fovler's position

6. control of severe postoperative pain may be attained using the following narcotic agents
(choose right)
a) Demerol (meridipine)
b) aspirin
c) morphine
d) fentanil
e) indometacine

7. which vessels are most prone to be embolized secondary as a result of deep vein thrombi
dislodgment (choose right)
a) common carotic artery
b) subclavian artery
c) pulmonary artery
d) renal artery
e) mesenteric artery

8. signs and symptoms of the fluid volume deficit in a postoperative period are the following
(choose right)
a) dry mucous membranes
b) moist mucous membranes
c) decreased urine output
d) increased urine output
e) increase of urine specific gravity

9. signs and symptoms of the fluid volume excess under the postoperative period are the
following (choose right )
a) peripheral edema
b) weight gain
c) weight loss
d) polyuria
e) oliguria

10. oral intake of fluids after GIT surgery may be resumed at the following conditions
(choose right)
a) after stabilization of BP, PR, and BR
b) full recovery after anesthesia
c) able to swallow
d) recovery of bowel sounds
e) normalization of RBC and blood chemistry values

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11. the best type of body supplementation with fluids within first day after GIT surgery is
the following (choose right)
a) by mouth
b) i.v.
c) i.a.
d) with retention enema
e) by nasogastric tube

12. the following reasons may lead to paralytic ileus (choose right)
a) fluid volume excess
b) abdominal surgery with handling of the intestines
c) myocardial infarction
d) fluid volume deficit
e) diabetes mellitus

Clinical tasks

Task № 1
Clinical scenario: a 100 kg man has had an elective resection of 2/3 of the stomach
due to gastric ulcer under general combined anesthesia. The patient is placed into ICU.
Condition of the patient is of moderate severity. Skin color and breathing sounds in lungs are
normal. PS is 110, blood pressure is 120/80mmHg, the tongue is dry, the abdomen is soft,
slightly tender in the area of postoperative incision. To decompress the GIT a nasogastric tube
is inserted. Over the next 24 hours there is a 1000ml of nasogastric drainage. Serum
electrolytes are normal.
Questions:
1. What diet is prescribed to the patient?
2. What i.v. solution (s) and how much is (are) to be administered during the first
postoperative day?
3. What i.v. solution (s) is (are) to be administered during the second postoperative day if
circumstances are the same?
4. What medicines are to be also administered to the patient?

Task № 2
Clinical scenario: A 62 years old obese patient was operated on three days ago. A
replacement of diseased right hip joint with prosthetic one was done. On a third postoperative
day the patient starts to complain of moderate pain and edema of the right leg, elevation of
body temperature till 37,5C0. The right leg is twice larger than the left one due to edema
which extends from tiptoes till the groin. The color of the left leg is cyanotic. Palpating an
affected limb there is a tenderness along the medial aspect of the calf and thigh. On the next
day the patient started to walk. Almost immediately the patient noticed severe pain in the right
chest, difficulties with breathing, fainting. The patient is cyanotic, breathing is shallow and
rapid, 35 per minute, PS is 130, BP is 90/60 mmHg, abdomen is soft, signs of peritoneal
irritation are absent.
Questions:
1. What complication has developed on the third postoperative day?
2. What complication has developed once the patient started walking?
3. What instrumental investigation methods can confirm the last complication?
4. What medicines are to be given to treat the developed complication?
5. What lab values are to be monitored treating the developed complication? How should
they be changed if the medicine is effective?

204
Task № 3
Clinical scenario: 12 hours ago a 32 years old male patient was operated on due to
acute appendicitis. At the first postoperative morning the patient complains of pain at the
lower abdomen and desire to void. The condition of the patient is normal. Skin color and
breathing sounds in lungs are normal. PS is 110, blood pressure is 120/80mmHg, the tongue is
moist, the abdomen is soft, slightly tender in the area of postoperative incision. There is a soft
round tender mass 20/20 cm at the suprapubic area with a dull percussion note over it.
Questions:
1. What is a mass in the suprapubic area?
2. Why is the mass formed in the patient?
3. What conservative measure may be attempted?
4. What has to be done if conservative measure fails?

Task № 4
Clinical scenario: 37 years old patient was operated on due to incisional hernia. At the
third postoperative day the patient starts to complain of throbbing pain in the area of the
surgical wound, rise of body temperature till 38,20C, chills. The condition of the patient is
normal. Skin color and breathing sounds in lungs are normal. PS is 90, blood pressure is
120/80mmHg, the tongue is moist, the abdomen is soft, tender in the area of postoperative
incision. A diuresis and stool are normal. During the dressing procedure the area of the
incision is reddish and swollen.
Questions:
1. What complication has developed after the surgery?
2. What could the possible causes of the developed complication be?
3. What laboratory and instrumental techniques may aid to diagnosis?
4. What is the management of the developed complication?
5. What medicines are to be given to treat the developed complication?

Task № 5
Clinical scenario: 67 years old male patient was operated on due to acute
cholecystitis. A cholecystectomy was done. On the third postoperative day, the patient starts
to complain of coughing, difficulties with breathing, rise of body temperature till 38,20C,
chills. The condition of the patient is normal. Skin color is slightly cyanotic. RR is 25, PS is
100, blood pressure is 120/80mmHg, the tongue is moist, the abdomen is soft, slightly tender
in the area of postoperative incision. Breathing sounds are decreased at the base of the left
lung where crackles are found. A diuresis and stool are normal. During the dressing procedure
the area of incision has no any signs of inflammation.
Questions:
1. What complication has developed after the surgery?
2. What could the possible causes of the developed complication be?
3. What laboratory and instrumental techniques may aid diagnosis?
4. What is a prophylaxis of the developed complication?
5. What is the management of the developed complication?

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TOPIC 36 FINAL CLASS (EXAMINATION OF PRACTICAL SKILLS)

The following professional competences of a student have to be formed after preparation


of the topic:
 Ability to provide basic medical actions to patients with most common sorts of
surgical diseases in the sufficient volume for a third year education student.

I. Motivation of the goal:


The main purpose to be achieved by a student studying general surgery is to acquire
basic practical skills. Furthermore, nearly 80% of all practical skills of a medical student is
learnedin the course of the general surgery.

II. The goal of self-preparation:


Is to acquire basic practical skills in the course of the general surgery

III. Studying purposes.


After self-contained studying of the topic a student must
Know:
 principles of dressing and bandaging techniques of different body parts;
 principles of transport stabilization;
 principles of hemostasis;
 principles of transfusion therapy;
 principles of cardio-pulmonary resuscitation;
Be able to:
 apply bandages onto different body parts;
 apply splints for transport stabilization;
 stop bleeding using methods of temporary hemostasis;
 provide a first aid in case of internal bleeding;
 perform blood typing and cross-matching;
 fill in an intravenous line;
 read X-ray films;
 drain hollow organs;
To practice and demonstrate:
 The skills of diagnostic and first aid algorithm actions for patients of different age
groups suffered from most common sorts of surgical diseases.
IV. The initial level of knowledge:
For successful mastering the given topic, it is necessary to revise materials of the
previous lessons (desmurgy, bleeding and hemostasis, transfusion therapy, resuscitation,
general trauma).

V. The plan of studying the topic.


 Practical skills in desmurgy.
 Practical skills in transport stabilization.
 Practical skills in hemostasis.
 Practical skills in transfusion therapy.
 Practical skills in parenteral injections.
 Practical skills in draining of hollow organs through natural openings.
 Practical skills in puncture of serous cavities.
 Practical skills in cardio-pulmonary resuscitation.

VI. The recommended literature:


Suggested reading:
1. Lecture materials.

206
2. "General surgery" Gostishev, 2003.
3. "Introductory in medical surgical nursing".
4. "Short practice of surgery" Bailey 1996.
5. "Surgery" Bruce E. Jarrell., 1991.
6. "General surgery" - Traves D. Crabtree.
7. "Clinical examination" Edited by Graham Douglas., Fiona Nicol., Colin Robertson.
11th edition.-2005.
8. "Surgical nursing" Colin Torrance., Eve Serginson.12th edition., 2006.
9. "The Nurse Assistant" - Joan F. Donovan., 1990.
VII. Questions for the self-control.
1. What types of bandaging are used in head trauma?
2. What types of bandaging are used in shoulder trauma?
3. What types of bandaging are used in joint trauma?
4. How is transport stabilization in forearm injuries done?
5. How is transport stabilization in shoulder injuries done?
6. How is transport stabilization in femoral injuries done?
7. How is transport stabilization in calf injuries done?
8. How is transport stabilization in foot injuries done?
9. How is individual compatibility test done?
10. How are blood components assessed for suitability?
11. How is transfusion chart filled in?
12. What are the indications to the packed red blood cells transfusion?
13. What are the indications to fresh frozen plasma transfusion?
14. What are the indications to stomach lavage?
15. What are the indications to enema?
16. What are the indications to bladder catheterization?
17. What are the indications thoracentesis?
18. What are the indications to laparocentesis?
19. What are the indications to joint puncture?
20. What are the indications to cardio-pulmonary resuscitation?

VIII. Tasks for self-preparation:


1. Draw the scheme of putting a Desault's bandage.
2. Draw the scheme of shoulder reduction using Kosher‟s method
3. Draw the example of agglutination typing the blood in case of A blood type.
4. Draw the example of agglutination typing the blood in case of B blood type.
5. Describe the technique of biological compatibility test.
6. What are the steps of stomach lavage?
7. What is the technique of the female bladder catheterization?
8. What is the technique of the intravenous injection?
9. What is the technique of a vein catheterization?
10. What is the technique of shoulder joint puncture?

THE LIST OF QUESTIONS OF PRACTICAL SKILLS

6TH SEMESTER GENERAL SURGERY

Desmurgy
1. Desault‟s bandage on the left or right shoulder.
2. Velpeau‟s Bandage on the left or right shoulder.
3. Galen‟s bandage (head gear).
4. Hippocrates‟ cap.

207
5. Bandage on the right or left eye.
6. Figure of eight bandaging of the neck.
7. Four-tail bandaging of the nose and chin.
8. Spiral bandaging of a calf.
9. Figure of eight bandaging of the shoulder.
10. Bandaging of the right or left breast.
11. Converging tortoise bandaging of the right or left elbow joint.
12. Gauntlet bandaging for fingers.
13. Mitten bandaging for a palm or stump.
14. Figure of eight bandaging of the left or right hip joint.
15. Diverging tortoise bandaging of the left or right knee joint.
16. Figure of eight bandaging of a foot.
17. Handkerchief bandage for the right or left hand.
18. Spiral bandaging of a chest.
19. Barton bandage on a chin and lower jaw.
20. Spica bandaging of a right thumb.
21. Binocular bandage.
22. Elastic bandaging of a low or upper extremity.
23. Cravat bandage application
First aid and transport stabilization
1. Closed fracture of the left radial bone: first aid and transport stabilization.
2. Open fracture of the right ulnar bone: first aid and transport stabilization.
3. Closed fracture of the right clavicle: first aid and transport stabilization.
4. Closed fracture of the left humeral bone: first aid and transport stabilization.
5. Closed fracture of the proximal phalanx of the 2nd right finger: first aid and transport
stabilization.
6. Closed fracture of the right medial malleolus: first aid and transport stabilization.
7. Closed fracture of the right heel bone: first aid and transport stabilization.
8. Open fracture in the middle third of the right ulnar bone: first aid and transport
stabilization.
9. Closed fracture in the low third of the left ulnar bone: first aid and transport
stabilization.
10. Closed fracture in the middle third of the right femoral bone: first aid and transport
stabilization.
11. Closed fracture in the low third of the left femoral bone: first aid and transport
stabilization.
12. Closed fracture of the left kneecap: first aid and transport stabilization.
13. Dislocation of the right shoulder joint: first aid and transport stabilization.
14. Dislocation of the left hip joint: first aid and transport stabilization.
15. Open injuries of the skull and soft tissues: first aid and transport stabilization.
16. Spinal injury: first aid and transport stabilization.
17. Application of vacuum splints.
18. Kramer‟s splint placement technique.
Hemostasis
1. Compressive bandaging in the middle third of the right forearm medial surface.
2. Compressive bandaging in the low third of the left shoulder medial surface.
3. Compressive bandaging of the right palm dorsal surface.
4. Compressive bandaging in the low third of the left thigh medial surface.
5. Compressive bandaging of the right calf posterior surface.
6. Bleeding from the left carotid artery: bleeding control using tourniquet.
7. Tourniquet placement onto the left shoulder.
8. Bleeding control from the left temporal artery using digital pressure.

208
9. Tourniquet placement onto the left thigh.
10. Bleeding control from the right common carotid artery using digital pressure.
11. Right gluteal area wound tamponade.
12. Bleeding control from the abdominal aorta using compression.
13. Turned cravat bandage placement onto the left shoulder.
14. Bleeding control from the left subclavian artery using digital pressure.
15. Bleeding control from the right forearm using elbow joint hyperflexion.
16. Bleeding control from the left calf using flexion knee joint hyperflexion.
17. Bleeding control from the right groin using hip joint hyperflexion.
18. Digital compression of the left brachial artery.
19. Digital compression of the right femoral artery.
20. Digital compression of a left hand peripheral vessels.
21. Digital compression of a right foot peripheral vessels.
Miscellaneous
1. The technique and results of a blood typing (with antisera, celiclones).
2. The technique of an i.v. injection.
3. The technique of an i.m. injection.
4. The technique of a subcutaneous injection.
5. The technique of a female bladder catheterization.
6. The technique of a male bladder catheterization.
7. The technique of the Blackemore tube placement nasogastric.
8. The technique of the nasogastric tube placement.
9. The technique of the orogastric tube placement.
10. The technique of the gastric lavage and gavage.
11. The technique of the colon lavage.
12. The Seldinger‟s technique.
13. Alen‟s test technique.
14. The technique of an i.v. line placement.
15. The technique and results of a blood cross-matching.
16. The technique and results of a biological compatibility testing.
17. Recording of a blood transfusion chart.
18. The preparation of an i.v. line for blood transfusion.
19. Check of the blood for suitability.
20. Preparation of dressing materials (gauze squares, gauze wicks, etc.).
21. Surgeon‟s hands preparation – scrubbing with (C-4 solution, chlorhexidine).
22. Gloving oneself.
23. Gowning oneself.
24. Gloving by the scrub nurse.
25. Gowning by the scrub nurse.
26. Removal of contaminated gown and gloves.
27. Prepping of the surgical site.
28. Draping of the surgical site.
29. Arrangement and package of materials for sterilization.
30. The technique of a skin suturing.
31. The technique of a skin stitches removal.
32. Steps of a cardiopulmonary resuscitation.
33. The initial steps and the first aid for unconscious patient.
34. The initial steps and the first aid for conscious and unconscious patient with airway
obstruction.
35. The initial steps and the first aid for the patient with respiratory arrest only.
36. The initial steps and the first aid for the patient with respiratory and cardiac arrest.
37. Tidy wound care and dressing.

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38. Untidy wound care and dressing.
39. Wound dressing technique.
40. Preparation of a wound care tray.
41. Steps of a wound care.
42. Burns: the first aid.
43. Frostbite: the first aid.
44. High voltage injury: the first aid.
Interviewing skills
1. Sequence of case history recording.
2. Examination of a patient for fluid-electrolyte disorders.
3. Examination of a patient for bleeding.
4. Examination of a patient for dehydration and infusion therapy.
5. Examination of a patient for bleeding risk.
6. Examination of a patient for thromboembolic complications.
7. Examination of a patient for hypovolemic shock.
8. Examination of a patient for cardiogenic shock.
9. Examination of a patient for septic shock.
10. Examination of a patient for anaphylactic shock.
11. Examination of a patient for acute cardiac failure.
12. Examination of a patient for acute liver failure.
13. Examination of a patient for acute renal failure.
14. Examination of a patient for acute respiratory failure.
15. Examination of a patient for MODS.
16. Examination of a patient before general anesthesia.
17. Examination of a patient before local anesthesia.
18. Examination of a patient with a wound.
19. Daily patient‟s examination.
20. Examination of a patient for purulent infection.
21. Examination of a local status for acute abdomen.
22. Examination of a local status for peripheral arterial disease (chronic and acute arterial
ischemia).
23. Examination of a local status for peripheral venous disease (chronic venous
insufficiency, deep vein thrombosis, thrombophlebitis of superficial veins).
24. Examination of a local status for pathology of musculoskeletal system.
25. Examination of a patient with head trauma.
26. Examination of a patient with chest trauma.
27. Examination of a patient with abdominal trauma.
28. Examination of a patient with oncologic disease.

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Test answers
Тема 1 1с; 2d; 3а; 4а; 5с; 6е; 7с; 8b; 9e; 10а; 11с; 12 b
Тема 2 1а, d, e; 2a, b, d; 3e; 4e; 5a; 6d; 7c; 8c; 9c; 10a; 11d; 12e
Тема 3 1c; 2e; 3c; 4e; 5e; 6d; 7e; 8b; 9e; 10e; 11a; 12a, c
Тема 4 1а, d; 2c,e; 3b,d; 4c, e; 5c; 6b, d; 7e; 8d; 9b, e; 10a, c; 11b,e; 12а
Тема 5 1a, c, e; 2e; 3a; 4a; 5b; 6b; 7c, e; 8b; 9c, e; 10a, d; 11e; 12b, d
Тема 6 1b, d, e; 2a, d; 3c, e; 4a, d; 5a, e; 6a, b, e; 7b, d; 8a, c; 9a, d; 10b; 11a, b, d;
12e
Тема 7 1d; 2е; 3b, c, d; 4b, d; 5c, e; 6c; 7d; 8c, e; 9c, d; 10b, d; 11b, d; 12b, c
Тема 8 1a, b, d; 2b; 3b, c, d; 4a, c, e; 5a, e; 6a, d; 7a, c; 8a, b; 9a, e; 10a, c, e; 11b, d;
12b, e
Тема 9 1d; 2c; 3c; 4e; 5a; 6e; 7b; 8d; 9c, e; 10a, e; 11c; 12c, e
Тема 10 1d; 2e; 3d, e; 4b, d, e; 5e; 6c, e; 7a, e; 8d; 9a, c; 10b; 11d; 12b, d
Тема 11 1c, e; 2c, е; 3a, c; 4b, d; 5a, e; 6c; 7с; 8a, c, d; 9b, d, e; 10e; 11e; 12d, e
Тема 12 1e; 2е; 3b, d, e; 4e; 5b, c, d; 6b, d; 7a; 8d; 9b, d; 10b, e; 11c, d; 12a, d, e
Тема 13 1e; 2b, e; 3b, e; 4a, d; 5c; 6a, d; 7b, c, e; 8a, c, e; 9c; 10d; 11b; 12e
Тема 14 1b, d; 2a, c; 3b, e; 4a, b, d; 5e; 6b, d; 7a, e; 8c, e; 9c, e; 10b, d; 11d; 12b, e
Тема 15 1b, d, e; 2a, b; 3b, c; 4a, d; 5c; 6b; 7b, d; 8c, d; 9d; 10e; 11b, c; 12a, c, d
Тема 16 1a, c, e; 2e; 3a, c; 4a, c; 5b, d; 6b, d; 7e; 8c, e; 9b, c; 10a, b, e; 11b, c; 12a, c, d
Тема 17 1c; 2c; 3c, e; 4c, e; 5b; 6b; 7d; 8e; 9d; 10e; 11b; 12a, e
Тема 18 1e; 2d; 3c, e; 4e; 5b; 6e; 7a, d; 8a, b, e; 9e; 10e; 11e; 12b, d, e
Тема 19 1a, d; 2d; 3e; 4b; 5e; 6d; 7e; 8a, c; 9a, d; 10e; 11d; 12c
Тема 20 1c; 2e; 3b, e; 4a, d; 5a, c, e; 6e; 7a, c; 8a, c, d; 9a, e; 10a, c, e; 11e; 12c, e
Тема 21 1a, c, e; 2a, e; 3c, e; 4b, d, e; 5b, e; 6c, d; 7e; 8a, d; 9c; 10a, d; 11b, c, d; 12e
Тема 22 1b, d; 2a, c; 3b, c, e; 4a, d, e; 5b, d, e; 6e; 7b; 8a, c; 9e; 10e; 11c, d; 12a, b, d
Тема 23 1b, d, e; 2a, c; 3a, c, e; 4e; 5d; 6c; 7b; 8e; 9e; 10d; 11e; 12e
Тема 24 1a, c, e; 2a, b, d; 3c, e; 4d; 5b; 6c, e; 7b; 8c; 9a, d; 10b, c, e; 11b; 12c, e
Тема 25 1e; 2a, b, d; 3c, e; 4b, c; 5d; 6e; 7a, c, d; 8b; 9b, d; 10d; 11c; 12b
Тема 26 1e; 2c, e; 3a; 4d; 5a, c, d; 6c; 7a, c, d; 8e; 9a, c, e; 10a, b, d; 11c; 12d, e
Тема 27 1b, d; 2c, e; 3a, b; 4c; 5d; 6b; 7e; 8a, c, e; 9e; 10d; 11b, e; 12a, d
Тема 28 1b, e; 2a, c, e; 3d; 4e; 5a, c, d; 6c, e; 7e; 8a, c, e; 9d; 10a, d; 11b, e; 12a, c
Тема 29 1b, d; 2a, c, d; 3a, c, e; 4a, c, d; 5b, e; 6c; 7b, d; 8c, e; 9a, c; 10b, d, e; 11a, e;
12b, e
Тема 30 1e; 2a, e; 3b, c, d; 4e; 5b, d; 6a; 7b, e; 8e; 9c, e; 10b, e; 11a, e; 12a, b, e
Тема 31 1d; 2c; 3b, c, d; 4b, d; 5e; 6a, d, e; 7b, c; 8a, b, e; 9b, d; 10e; 11d; 12b, c, e
Тема 32 1e; 2d; 3d; 4e; 5b; 6c; 7a; 8a, c; 9a, b; 10b, e; 11a, c, d; 12d
Тема 33 1а, c; 2b; 3e; 4c; 5a; 6a; 7c; 8c; 9b; 10a, c, d; 11b; 12c, e
Тема 34 1b, c; 2d; 3c; 4b; 5c; 6c; 7a; 8b, e; 9b; 10c; 11c; 12b, c, d
Тема 35 1c; 2b, e; 3a, e; 4b; 5d; 6c, d; 7c; 8a, c, e; 9a, b, d; 10d; 11b; 12b, d

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TASK ANSWERS

TOPIC 1 INTRODUCTION INTO SURGERY. HISTORICAL ASPECTS OF SURGERY.

Task № 1
Answers:
1. First medical aid.
2. An analgesic is given followed by wound dressing and transportation splintage of the
injured limb.
3. Into the medical institution with traumatologic unit on duty.
4. Emergency surgical aid.

Task № 2
Answers:
1. The case history.
2. Examination and treatment of scabies and pediculosis (if needed), shaving of the
surgical incision area (groin area).
3. General surgery ward
4. Be feet escorted by a nurse assistant.

Task № 3
Answers:
1. Bleeding from the gastric ulcer.
2. Examination and treatment of scabies and pediculosis are not indicated due to shock
state of the patient.
3. Into the operation theater on a stretcher.
4. Emergency surgery to control the bleeding.

Task № 4
Answers:
1. Stomatologist or faciomaxillar surgeon.
2. X-ray of the low jaw.
3. The ward of the faciomaxillar surgery.
4. Emergeny surgical aid includes stabilization of the fractured low jaw.

Task № 5
Answers:
1. Neurosurgeon.
2. CT or MRI of the brain.
3. Shaving of the surgical incision area (scalp area)
4. Into the operation theater on a stretcher.
5. In the neurosurgical ward.

TOPIC 2 DESMURGY 1

Task № 1
Answers:
1. The wound of the right temporal area.
2. Yes.
3. “Hippocrates‟ cap” or “head gear” are necessary to secure the dressing.
4. Yes.
5. Into traumatologic unit.

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Task № 2
Answers:
1. The closed fracture of the low jaw.
2. Yes.
3. Four-tail bandage of the chin, a Barton bandage on a chin and lower jaw.
4. Yes.
5. Into the faciomaxillar surgical ward.
Task № 3
Answers:
1. The injury of the right eye by the glass pieces.
2. Yes.
3. Right eye bandaging to secure the dressing
4. Yes.
5. Into the ophthalmology ward.
Task № 4
Answers:
1. A closed fracture of the cervical spine.
2. Yes.
3. Neck stabilizer or cotton-and –gauze collar
4. Yes.
5. Into the traumatologic ward.
Task № 5
Answers:
1. Penetrating injury of the right chest complicated by open pneumothorax.
2. The one-way-valve dressing or occlusive one of the chest secured by a spiral chest
bandaging.
3. The applied material onto the wound should be sterile and impermeable. Commonly
that is a specially designed military kit. It includes sterile impermeable material, gauze
squares, atiseptic solution, fixing material – bandage, adhesive tape, and pins
4. A sterile plastic square covers the wound and is secured in a such way that one corner
is left loose to allow the air to escape. Complete occlusive dressing is not desirable in
such situations.

TOPIC 3 DESMURGY 2. TEMPORARY STABILISATION

Task № 1
Answers:
1. A closed fracture of the right clavicle
2. Yes.
3. Right hand Desault's bandage or handkerchief bandage
4. Yes.
5. Into traumatologic unit.

Task № 2
Answers:
1. A closed fracture of the upper third of the left humeral bone.
2. Yes.
3. Crammer‟s splint of the left shoulder.
4. Yes.
5. Into traumatologic unit.

Task № 3

213
Answers:
1. A sprain of the left 1st carpophalangeal joint.
2. A stabilization is necessary using stabilization bandaging.
3. Spica bandaging of the thumb in abduction position.
4. The patient needs a qualified medical care.
5. Into traumatologic unit.
6. A sprain of the left 1st carpophalangeal joint must be differentiated with a fracture of
the thumb‟s proximal phalanx. It is achieved using two dimension plain X-ray
examination.

Task № 4

Answers:
1. A sprain and ligament rapture of the lateral right ankle.
2. A stabilization using bandaging.
3. A "figure-of-eight" bandaging of the ankle.
4. In full dorsiflexion.
5. Yes. In a traumatologic unit.
6. Must be differentiated with a fracture of the malleolus. It is achieved using two
dimension plain X-ray examination of the ankle join.

Task № 5

Answers:
1. Gauntlet bandaging of fingers.
2. A left hand bandaging starts on the 5th finger and finished on the 1st one. A right hand
bandaging starts on the 1st finger and finished on the 5th one. The palmar surface stays
free of bandage turns.
3. A mitten bandaging of the palm.
4. A grasping function of the hand is spared.
5. A mitten bandaging of the palm is needed with separate bandaging of the thumb.

TOPIC 4 NON-OPERATIVE SURGICAL TECHNIQUES

Task № 1
Answers:
1. Malpractice (failure in technique), anatomic variation of a vascular bundle.
2. Remove the needle, apply manual pressure for 5 min, monitor hemodinamic and
breath sounds for hemothorax.
3. Air embolism, pneumothorax, malpositioning, dysrhythmias.
4. Following aseptic technique a puncture is done below clavicle at its middle part. The
area is prepped (with antiseptic) and draped Anesthesia is done with 1% lidocaine 2-
3ml. The needle is passed under the clavicle horizontally, while aspirating, towards the
sternal notch. It is advanced to 5 cm. The venous blood in the syringe appears once
the needle has entered the vein. The Seldinger technique is further used. The J wire is
introduced through the needle, after that the needle is removed and the dilator and
scalpel may be used to increase the size of the skin puncture. Introduce the CV
catheter over the wire and aspirate the blood. Flash the line with sterile solution, suture
the catheter to the skin and apply sterile dressing.
5. Indications: Central venous pressure monitoring; poor peripheral access; long term
infusion of drugs; total parenteral nutrition.

214
Contraindications: a) venous thrombosis; b) coagulopathy (PC below 50,000); c)
sepsis.

Task № 2
Answers:
1. Ischemic digits. Remove catheter and monitor the hand.
2. Catheter thrombosis, septic complications, damage to adjacent structures (nerves,
vein, tendons), poor arterial waveforms.
3. Prep solution - alc 70% (povidon-iodine or chlorhexidine), mask, gown, gloves,
towels, dressings are necessary to secure an aseptic technique. Needles, syringes, local
anesthetic (usually 1% lidocaine 2-3ml), and arterial catheter are collected.The needle
is oriented at 45 degrees towards radial artery till aspiration of the blood. May be used
quick catheter (needle is already covered by the catheter, so the J wire as well as
Seldinger technique are not necessary). Direction must be from the periphery to
center. Then the system is flushed and sensors are attached to monitor to assess arterial
waveforms.
4. Indications: a) continuous hemodynamic monitoring (PR, BP, systemic arterial
pressure, etc); b) those who receive inotropic agents; c) thermodynamically unstable
patient; d) frequent assessment of arterial blood gases – Pa CO2, Pa O2, lactate level;
Contraindications: positive Allen's test (it evaluates the ulnar blood flow through a
palmar arch).
5. Allen's test evaluates the ulnar blood flow through a palmar arch. a) occlude both
ulnar and radial artery till exsanguination; b) release the ulnar artery while keeping the
radial artery compressed; c) if hand color doesn't return to normal in less then 5 sec,
Allen's test is positive and cannulation is aborted.

Task № 3
Answers:
1. Puncture of the bladder is followed by aspiration of the urine (temporary measure).
Percutaneous suprapubic cystostomy.
2. Acute urine retention may be due to urethral stricture, acute prostatitis, traumatic
urethral disruption.
3. Spinal anesthesia may affect normal work of autonomic nervous system responsible
for innervation of the bladder.
4. Shave, prep, and drape the area above symphysis pubis. Puncture of the bladder is
done with spinal needle. After penetration through the second point of resistance
remove the obturator, attach the syringe, and aspirate the urine. Assembled
suprapubic catheter is inserted parallel to spinal needle. The catheter is secured with
skin suture and connected to urinary drainage system.
5. Bowel perforation, hematuria, septic complications.

Task № 4
Answers:
1. The lung is damaged.
2. Right side (unilateral) pneumothorax.
3. Needle aspiration of the air from the pleural cavity is done at the II i.c. space above the
upper border of the rib along the midclavicular line using a large-volume syringe. Care
should be taken to prevent re-entry of air into the pleural space during inspiration
when the syringe is detached from the needle (a one-way valve, stopcock, or plastic
clamped tubing can be used to prevent it).
4. In order to ovoid damage to intercostal neuro-vascular bundle and internal thoracic
artery.

215
5. Hemothorax (due to intercostals neuro-vascular bundle and/or internal thoracic artery
injury), pneumothorax (failure in technique), damage of the lung, heart; septic
complications.

Task № 5
Answers:
1. Right side hydrothorax.
2. Diagnostic indications (to obtain the specimen of effusion); b) treatment indications
(evacuation of the effusion from the pleural cavity to relieve dyspnea).
3. Thoracentesis is done following to aseptic technique at the VII-VIII i.c. space above
the upper border of the rib along the scapulary (posterior axillary) line. The catheter is
introduced according to Seldinger technique (to ensure complete evacuation of large
volume effusion) or alternatively a long needle aspiration may be accomplished (to
obtain the specimen, etc.). A three-way stopcock prevents backflow of fluid once
closed. If one-way valve is not available, the clamp applied onto the plastic tubing
may help to prevent the air to reenter the pleural cavity The catheter is connected to
extension tubing and vacuum apparatus. Having completed an evacuation of the fluid,
remove the catheter and place sterile dressing. X-ray, auscultation, and percussion are
used to assess effect.
4. Hemothorax (due to intercostals neuro-vascular bundle and/or internal thoracic artery
injury), pneumothorax (failure in technique), damage of the lung, heart; septic
complications.

TOPIC 5 ASEPSIS

Task № 1
Answers:
1. Staphylococcus aureus.
2. Contact spread.
3. Too early shaving of the operative area.
4. Preoperative shaving is to be done no later then 6 hours before surgery.
5. Penicillinasa-resistant penicillin (methicillin, oxacillin, or amoxicillin).

Task № 2
Answers:
1. Air-born infection.
2. Streptococcus pyogenes.
3. Postoperative wound infection.
4. The surgeon had to be firmly excluded from the theater.

Task № 3
Answers:
1. First is a surgery of noncomplicated inguinal hernia. It is followed by resection of the
upper lobe of the right lung due to peripheral lung cancer. Finally an incision of the
postinjection abscess of the right buttock should be done.
2. Clean surgical procedures should precede a contaminated and dirty ones because of
possible spread of infection from dirty case to clean one.
3. Incision of the postinjection abscess of the right buttock is a dirty surgery; a
noncomplicated inguinal hernia is a clean surgery, and resection of the upper lobe of
the right lung due to peripheral lung cancer is clean-contaminated surgery.
4. Postoperative infection rate is: a) incision of the postinjection abscess of the right
buttock is higher than 40%; A noncomplicated inguinal hernia is less than 3%;

216
Resection of the upper lobe of the right lung due to peripheral lung cancer should be
less than 10%;

Task № 4
Answers:
1. Yes.
2. Contact spread.
3. If instruments were used at surgery of anaerobic infection the management is the
following: firstly instruments are soaked for 1 hour in special solution containing
H2O2 6% and washing agent 0,5%; then 5 min washing with the brush in the same
solution is done. Further 90 min. boiling is required.

Task № 5
Answers:
1. Yes.
2. No.
3. Yes.
4. No.

TOPIC 6 ANTISEPSIS

Task № 1
Answers:
1. Combined antisepsis (including mechanical, physical, chemical, and biological).
2. chlorhexidine, H2O2, hexachlorophene, aqueous furacillin, dioxidin, Eusol, etc.
3. Surgical debridement represents the procedure of removal of all necrotized, nonviable
tissues (affected parts of the skin, subcutaneous fat, muscles, or even bone). Usually it
is done with sharp excision under local (general) anesthesia. The purpose of the
procedure is to remove all nonviable tissues and create best environment for healing
process and prompt closure of the wound.
4. Pressurized pulsatile irrigation (jet irrigation) helps to fulfill finer debridement,
remove all pus, tiny particles, and foreign bodies from the wound. The procedure
requires 1-7 L of fluid. Common used agents are: saline solution, furacilline,
chlorhexidine, aqueous antibiotics, etc.

Task № 2
Answers:
1. In that situation it is necessary to check possible postoperative complications. If a leak
from a bile duct injury or intraabdominal bleeding is present, it should be evident
through the drain.
2. The drain is normally removed by the second day.
3. The drain may erode through the wall of a blood vessel (bleeding) or viscus
(intraabdominal infection).
4. The drain should be soft, should be firmly attached to the skin and marked with a
radiopaque marker. Time for removal of the drain is determined by its aim, and should
be done timely. Proper dressing helps to prevent skin infection at the area of the drain.

Task № 3
Answers:
1. Chemical.
2. The doctor has chosen wrong topical agent. The mentioned agent should cause
additional trauma to burned area.

217
3. Antiseptics are chemicals which can be applied to living tissue to kill or inhibit the
growth of microbes. Disinfection involves the killing or removal of microbes on an
inanimate objects. After application of both the bacterial spores are not killed, but that
growing, “vegetative” bacteria are.
4. Silver sulfadiazine, aqueous solution of silver, mefenide acetate.

Task № 4
Answers:
1. H2O2.
2. H2O2 contacting with the wound releases an oxygen thereby converting anaerobic
wound condition into aerobic one.
3. Clindamycin or metronidazole are preferred to penicillin.
4. Clindamycin and metronidazole are effective against anaerobic bacteria.

Task № 5
Answers:
1. Monotherapy of the intraabdominal infection can be done with carbapenems
(thienamycin or imipenem- cilastatin); combined therapy with: a) a 3G cephalosporine
+ metronidazole; b) ticarcillin-clavulonate ± aminoglicoside + metronidazole
(clindamycine); c) ampicillin-sulbactam ± aminoglicoside + metronidazole
(clindamycine)
2. These antibiotics are able to cover most likely pathogens responsible for
intrabdominal infection.
3. Immediately
4. No. An empiric therapy is started as soon as possible.
5. No. An antibacterial therapy cannot be used as a substitute of surgical treatment of the
peritonitis. It is necessary adjunctive to surgical repairment of perforated viscus.

TOPIC 7 FLUID-ELECTROLYTE DISTURBANCES

Task № 1
Answers:
1. Water: 2450 ml.
2. Sodium: 70 mEq; potassium: 70 mEq.
3. Approximately 2450 ml of NS or LR.
4. Approximately 1600 ml of D5%W + 800 ml of NS.
5. No.
6. Once the bowel sounds commonly have not yet been resumed at the first postoperative
day the patient is not allowed to take any fluid by mouth.

Task № 2
Answers:
1. Water: 4500 ml.
2. Water: 3500 ml.
3. Water: 1000 ml.
4. Approximately 3500 ml of NS or LR to cover maintenance daily requirements + 1000
ml of LR to cover ongoing loss.
5. Approximately 2400 ml of D5%W + 1200ml of NS + app. 100 mEq KCl to cover
maintenance daily requirements + 1000 ml of LR to cover ongoing loss.
6. No.
7. Due to paralytic ileus.

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Task № 3
Answers:
1. 5000ml if colloid solution is used to replace existing deficit or 7000 ml if crystalloid
solution is used to replace existing deficit,.
2. Water: 3500 ml.
3. Water: 500 ml.
4. Crystalloid solution (NS) 3000 ml or colloid solution (albumin 5%) 1000 ml.
5. Approximately 3500 ml of NS or LR to cover maintenance daily requirements; + 500
ml of LR to cover ongoing loss + 1000 ml if colloid solution to replace existing deficit
(or 3000 ml if crystalloid solution is used to replace existing deficit).

Task № 4
Answers:
1. 4000 ml.
2. Water: 3500 ml.
3. Water: 500 ml.
4. Nil.
5. Approximately 2400 ml of D5%W + 1200 ml of NS to cover maintenance daily
requirements; + 500 ml of LR to cover ongoing loss.

Task № 5
Answers:
1. III degree.
2. Hematocrit, RBC, hemoglobin level, and urine osmolality are increased, CVP is
decreased.
3. 7000 ml; 1/2 NS should be used.
4. Approximately 9400 ml.

TOPIC 8 BLEEDING AND HEMOSTASIS

Task № 1
Answers:
1. Blunt chest trauma complicated by left side hemothorax.
2. II degree of internal bleeding.
3. Approximately 30 to 40%.
4. Hb: 80-120 gm/l; RBC: 3,5-2,5; Ht: 0.25-0.35.
5. Plain AP chest X-ray, US, CT, MRI, thoracentesis.
6. FFP, cryoprecipitate, fibrinogen, platelet mass, angioprotectors (vit. C, rutin, etc.), vit.
K, CaCl, antifibrinolitic agents (γ-aminocaproic acid, etc).

Task № 2
Answers:
1. Blunt abdominal trauma complicated by hemoperitoneum.
2. Spleen.
3. I degree of internal bleeding.
4. Hb: not less then 120 gm/l; RBC: not less then 3,5; Ht: more than 0.35.
5. US, CT, MRI, culdocentesis, paracentesis, diagnostic peritoneal lavage (DPL), and
video assisted laparoscopy may be done.
6. FFP, cryoprecipitate, fibrinogen, platelet mass, angioprotectors (vit. C, rutin, etc.), vit.
K, CaCl, antifibrinolitic agents (γ-aminocaproic acid, etc).

Task № 3
Answers:
1. External venous hemorrhage.

219
2. II degree blood loss.
3. Hb: 80-120 gm/l; RBC: 3,5-2,5; Ht: 0.25-0.35.
4. Tamponade (wound packing) followed by tight application of compressive bandage;
tourniquet application; air-filled cuff application; digital compression of the vessel in
the wound, applying a clamp or forceps on a vessel, pressing of supplying vessel
distally to the bleeding point, elevation of extremity.
5. Ligation of the distal and proximal end of the bleeding vessels (cephalic and basilic
vein).

Task № 4
Answers:
1. External arterial (left femoral artery) hemorrhage.
2. III degree of blood loss.
3. Hb: below 80 gm/l; RBC: below 2,5; Ht: less then 0.25.
4. Digital compression of the femoral artery against the bone at the left groin; tamponade
(wound packing) followed by tight application of compressive bandage; tourniquet
application; air-filled cuff application; flexion of the left thigh at the hip joint.
5. Sewing of the lacerated or cut artery by vascular suturing or reanastamosing of
completely divided artery by vascular suturing.

Task № 5
Answers:
1. Mallory-Weiss tears of the mucous at the area of stomach cardia caused by repeated
vomiting.
2. I degree of blood loss.
3. Flexible oesophagogastroduodenoscopy.
4. Ice swallowing, electrocoagulation of the bleeding vessel during endoscopy,
embolyzation of bleeding vessel during angiography.
5. FFP, cryoprecipitate, fibrinogen, platelet mass, angioprotectors (vit. C, rutin, etc.), vit.
K, CaCl, antifibrinolitic agents (γ-aminocaproic acid, etc).
6. If the bleeding is continuing and conservative measures have failed to control it.

TOPIC 9 TRANSFUSION THERAPY

Task № 1
Answers:
1. Approximately 20 – 30%.
2. Hb: not less then 120 gm/l; RBC: not less then 3,5; Ht: more than 0.35.
3. NS, LR, dextrans (40 or 70), hetastarch, pentastarch, etc.
4. 3000ml of NS or LR + 500 ml of hetastarch (or other combinations).

Task № 2
Answers:
1. Approximately 30 - 40%.
2. No
3. Transfusion of cross-match incompatible blood
4. The doctor must never relay on information from medical records. Before blood
transfusion he had to perform typing, cross-matching, and biological compatibility
testing of the blood himself.
5. Stop transfusion (send the specimen for retyping and cross-matching), obtain blood
and urine samples for free Hb, place a Foley catheter to evaluate hourly UO (maintain
at 60ml/h), administer mannitol 25 to 50 g to maintain UO, start infusion therapy (to

220
maintain UO) using crystalloids, rheolytics, administer antihistamine or steroids,
oxygen supplementation. Consider dialysis.

Task № 3
Answers:
1. Reinfusion of shed blood is also named intraoperative blood salvage.
2. This is readily source of blood in acutely injured patients; no risk of hemolytic, febrile,
or allergic reactions or transmissible diseases; it is already warm and has better
oxygen-transporting properties.
3. The shed blood has lower level of fibrinogen; there is usually insufficient time
available to organize the necessary personnel and equipment.
4. Contraindication for autotransfusion is the contamination of blood by germs.
5. Intraoperative (isovolemic) hemodilution (replacement of IVV before or during
surgery); Predeposited autologous blood (donation and storage of blood before
surgery); use of blood substitutes and recombinant erythropoietin.

Task № 4
Answers:
1. More than 40%.
2. Further i.v. administered solutions beside crystalloids must include colloids (FFP or
albumin 5%), packed RBC, and platelet mass to correct anemia, thrombocytopenia,
and lost clotting factor.
3. Volume of administered solutions should be sufficient to maintain normal CBV
evident by normalization of UO, BP, PR, CVP. Blood components are given at
volume sufficient to reverse of anemia, thrombocytopenia, and lost clotting factor.
4. Rapid and considerable acute blood loss (with rate more then 100ml/min.
5. Hypovolemic (hemorrhagic form) shock after restoration of CV; major surgery with
expected significant blood loss; severe anemia: drop of Hb level below 70-80 g/L
(7g/dL).

Task № 5
Answers:
1. More then 40%.
2. There may be no alteration in the values of Hb, Ht, and RBC until compensatory fluid
shifts have occurred or exogenous red cell-free resuscitation fluid is administered.
The oncotic-induced shifts may take several hours to achieve.
3. No.
4. No.

TOPIC 10 HEMOSTATIC DISTURBANCES IN SURGICAL PATIENTS

Task № 1
Answers:
1. History of previous abnormal bleeding (from wounds, easy bruisability, etc.); Family
history (inherent coagulopathy), drug history (anticoagulants, antiagregants, etc.) to
reveal bleeding tendency.
2. Skin is inspected for petechiae, ecchymoses. Attention is given to liver, hepatic
diseases (jaundice, ascitis, hepatomegaly, or small liver), and spleen (splenomegaly)
to reveal bleeding tendency.
3. Yes, it is. Because the planned surgery possesses high bleeding risk.
4. Bleeding time, PT, aPTT, fibrinogen level, platelet count.

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5. Bleeding time 3-8 min; PT 12-14 sec; aPTT 16-25 sec; fibrinogen 2,0-4,0 g/L; platelet
count is 150-300 000.

Task № 2
Answers:
1. DVT.
2. Yes, it does.
3. Pulmonary embolism.
4. Prophylactic dosage of heparin or LMWH (fraxiparin).
5. Intermittent pneumatic compression of lower limbs, elastic bandaging or compressive
stockings of lower extremities, early ambulation after surgery.

Task № 3
Answers:
1. DIC.
2. Platelet deficiency after massive blood transfusion due to dilution and use of blood
components without platelets; hemolytic reaction due to transfusion of cross-match
incompatible blood; hypothermia-induced coagulopathy; elevated level of circulating
anticoagulants.
3. Can, if the shed blood is not contaminated.
4. Bleeding time, PT, aPTT, are prolonged; D-dimer level is increased; fibrinogen level
and platelet count are decreased.
5. Treatment of the hypovolemic shock, maintenance of circulating volume (transfusion
of blood components or fresh whole blood), if the bleeding has not yet been controlled
the heparin 10 000 IU followed by infusion of FFP and platelet mass are administered.
Antifibrinolytic agents are given concurrently with heparin.

Task № 4
Answers:
1. DVT.
2. Advanced age, female gender, cancer, surgical operation.
3. Taking oral contraceptives, pregnancy, congenital thrombophylia, trauma (fractures,
dislocations, etc,), severe infections, presence of varicose veins, obesity.
4. Intermittent pneumatic compression of lower limbs, elastic bandaging or compressive
stockings of lower extremities, early ambulation after surgery, prophylactic dosage of
heparin or LMWH (fraxiparin).
5. Conventional heparin subcutaneously or i.v. constantly or low molecular weight
heparin (LMWH).
6. aPTT has to be increased to 2 times higher of original; INR has to be increased till 2,5
– 3.

Task № 5
Answers:
1. Yes, it does.
2. Deficiency of vitamin K due to poor absorption.
3. aPTT; PT; fibrinogen level.
4. aPTT and PT are prolonged; fibrinogen level is dicreased.
5. Vitamin K.
6. FFP transfusion.

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TOPIC 11 TERMINAL CONDITIONS. PRINCIPLES OF RESUSCITATION. SHOCK

Task № 1
Answers:
1. Clinical death due to obstruction of an airway.
2. Biological death with irreversible brain damage.
3. Heimlich maneuver, clearing of the airway by the fingers should be done cautiously.
The time is limited by 3-5 minutes.
4. Needle cricothyroidotomy, cricothyroidotomy, or tracheostomy.
5. Having extended the neck by head-tilt, chin-lift, or jaw-thrust maneuver a health care
provider starts mouth-to-mouth, mouth-to-nose, or mouth-to-mouth-to-nose
ventilation. If available it can be done using Ambu bag or mechanical ventilator.
Circulation is maintained by indirect cardiac massage with the ratio 30:2(two health
care providers) or 30:2 (single health care provider).
6. Presence of the pulse on carotic arteries, pupilary constriction.

Task № 2
Answers:
1. Anaphylactic shock.
2. Collect history about previous expose and reaction to local anaesthetics.
3. Contrast agents (radiopaque agents), blood products, some antibiotics, etc.
4. Exposure to allergen → release of proinflammatory cytokines → vasodilation and
increases in vascular permeability → hypotension mostly due to decrease in vascular
tone → pooling in large capacitance vessels → reduction of circulating blood volume
→ hypoperfusion → shock.
5. Epinephrine 5mg/kg subcutaneously followed by additional epinephrine 10-50
ng/kg/min i.v., prednisolone 50 mg i.v., fluids in 20 ml/kg i.v. bolus over five minutes
followed by additional continuous i.v. infusion.

Task № 3
Answers:
1. Nonhemorrhagic form of a hypovolemic shock.
2. Loss of fluid due to vomiting, sequestration of body fluids into the lumen of the
intestine, and paralysis of intestine resulting in inability to absorb fluid.
3. Hematocrit, RBC, hemoglobin level, and urine osmolality are increased.
4. Rapid infusion of NS or LR at volume 2 to 3 liters over 10-30 minutes.
5. Approximately 7000 ml.

Task № 4
Answers:
1. Hemorrhagic form of a hypovolemic shock.
2. Low intravascular volume (bleeding) → diminished cardiac output → drop of blood
pressure → activation of sympathetic system → increase in heart rate, myocardial
contractility and arterial and venous vasoconstriction. Activation of renin-angiotensin
system → additional vasoconstriction and salt and water retention, release of ADH
further increases water retention → centralisation of hemodinamic → microvascular
hypoperfusion → lactic acidosis → cellular injury → SIRS, MODS.
3. Hb: below 80 gm/l; RBC: below 2,5; Ht: less then 0.25 will drop within several
hours. Urine osmolality is increased.
4. Digital compression of the brachial artery against the bone; tamponade (wound
packing) followed by tight application of compressive bandage; tourniquet
application; air-filled cuff application.

223
5. After administration of 2 l of crystalloids further volume resuscitation should include
simultaneous blood transfusion (blood products) and colloids.
6. Sewing of the lacerated or reanastamosing of completely divided artery by vascular
suturing.

Task № 5
Answers:
1. Intrinsic cardiogenic shock.
2. Myocardial infarction → impairment of the heart contractility → diminished cardiac
output → drop of blood pressure → activation of sympathetic system → increase in
heart rate, myocardial contractility and arterial and venous vasoconstriction.
Activation of renin-angiotensin system → additional vasoconstriction and salt and
water retention, release of ADH further increases water retention. Meanwhile, the
increase in heart rate, systemic vascular resistance and contractility, volume overload,
all increase myocardial oxygen consumption and demand. The discrepancy between
myocardial oxygen demand and once delivery further impairs left-ventricular
function and will lead to circulation collapse unless appropriate and timely
intervention interrupt the vicious cycle.
3. Cardiac enzymes, ECG, EchoCG, chest radiograph, pulmonary artery catheter.
4. Inotropic agents (dobutamin, dopamine, norepinephrin), afterload reduction using i.v.
nitroglycerin or sodium nitroprusside prerload reduction through the use of diuretics.
5. Intra-aortic balloon pump, temporary left heart bypass, ventricular assist device may
be considered.

TOPIC 12 CRITICAL CONDITIONS

Task № 1
Answers:
1. Liver failure complicated by upper GIT bleeding.
2. Esophageal varices.
3. FEGDS.
4. Serum bilirubin, AST, alkaline phosphatase are increased, platelet count –
thrombocytopenia, PT, aPTT are prolonged, serum albumin is decreased. Hb: 80-
120 gm/l; RBC: 3,5-2,5; Ht: 0.25-0.35.
5. Iced saline lavage of the stomach, endoscopic sclerotherapy, placement of the
Blakemore balloon, transfusion of blood components (FFP, platelet mass, albumin) or
fresh whole blood if bleeding is continuing. Infusion therapy, administration of
vasopressine or somatostatine i.v.
6. Portocaval (TIPS, etc.), mesocaval, splenorenal anastomoses.
7. Diuretics, repeated paracentesis, a peritoneal venous shunt.

Task № 2
Answers:
1. Liver failure complicated by upper GIT bleeding.
2. Curling ulcer of the stomach.
3. FEGDS.
4. Serum bilirubin, AST, alkaline phosphatase are increased, platelet count –
thrombocytopenia, PT, aPTT are prolonged, serum albumin is decreased. Hb: below
80 gm/l; RBC: below 2,5; Ht: less then 0.25.
5. Iced saline lavage of the stomach, initially FFP, cryoprecipitate, platelet concentrate,
packed RBC, infusion of crystalloids in 1:3 ratio to predicted blood loss, antacids, vit.
K parenterally, folic acid.
6. Removal of gallstones from the choledoch.

224
Task № 3
Answers:
1. Poor renal perfusion (drop of ABP below 80mmHg) due to hypovolemia caused by
bleeding.
2. Prerenal form.
3. replenishment of circulating volume with i.v. bolus of crystalloid in 1:3 ratio to
predicted blood loss, transfusion of blood products, and colloids.

Task № 4
Answers:
1. Hemolytic reaction.
2. Kidney failure.
3. Renal form.
4. Retyping of the blood (donor and recipient) History of blood transfusion, lab changes
- free Hb.
5. 1. Oliguria. 2. The diuretic phase. 3. Recovery.
6. Administer mannitol 25 to 50 g to maintain UO, infusion therapy (to maintain UO)
using crystalloids, rheolytics, administer antihistamine or steroids, oxygen
supplementation. Consider dialysis.

Task № 5
Answers:
1. Secondary ARF.
2. It is caused by intrinsic cardiogenic shock resulted from myocardial infarction →
impairment of the heart contractility → diminished cardiac output → drop of blood
pressure → activation of sympathetic system → increase in heart rate, myocardial
contractility and arterial and venous vasoconstriction. Activation of renin-angiotensin
system → additional vasoconstriction and salt and water retention, release of ADH
further increases water retention. Meanwhile, the increase in heart rate, systemic
vascular resistance and contractility, volume overload, all increase myocardial oxygen
consumption and demand. The discrepancy between myocardial oxygen demand and
once delivery further impairs left-ventricular function and will lead to circulation
collapse unless appropriate and timely intervention interrupt the vicious cycle.
3. Myocardial infarction → impairment of the heart contractility → diminished cardiac
output → raise of LVEDP → rise of PAWP → diffusion of protein-rich fluid into
alveoli due to pressure gradient → decreased compliance and intrapulmonary
shunting.
4. → progression of hypoxia and hypercapnea → respiratory failure.
5. Due to drop of ABP below 80 resulted from poor myocardial contractility (so-called
prerenal form of acute renal failure).
6. Cardiac enzymes, ECG, EchoCG, chest radiograph, pulmonary artery catheter.
7. Inotropic agents (dobutamin, dopamine, norepinephrin), afterload reduction using i.v.
nitroglycerin or sodium nitroprusside prerload reduction through the use of diuretics,
oxygen supplementation.

TOPIC 13 ENDOGENOUS INTOXICATION SYNDROME

Task № 1
Answers:
1. Peritonitis.
2. The source of intraabdominal infection must be treated with open surgery.
3. Creatinin level and BUN are increased. Anuria or oliguria. Changes at the urine
analysis (protein, casts, leukocytes, RBC).

225
4. Albumin and fibrinogen level are decreased, PT and aPTT are prolonged, bilirubin is
increased. Alkaline phosphatase, AST, and ALT are increased.

Task № 2
Answers:
1. Persisted nontreated occult intraabdominal infection (due to negligence at first
surgery, may be occult infection – subhepatic abscess, etc.).
2. The source of intraabdominal infection must be treated surgically (draining, open
surgery, etc.).
3. Acute gastric ulcer (Curling‟s ulcer).
4. Creatinin level and BUN are increased. Albumin and fibrinogen level are decreased,
PT and aPTT are prolonged, bilirubin is increased. Alkaline phosphatase, AST, and
ALT are increased. Signs of anemia in the TBC.

Task № 3
Answers:
1. Severe pancreatitis leads to systemic activation of proinflammatory mediators and
their systemic circulation (SIRS) → direct damage to pulmonary capillaries
(endotelium) → increase of pulmonary vascular permeability → diffusion of protein-
rich fluid into alveoli→ inability of the lungs to expand during inspiration (decreased
complience) → 02 cannot normally pass through alveolo-capillarily membrane (as
well as C02) → the blood passes through capillaries of lungs without receiving 02→
intrapulmonary shunting → progression of hypoxia and hypercapnea → respiratory
failure.
2. Appropriate treatment of underlying pancreatitis; careful infusion therapy;
supplementary 02 or supportive ventilation using positive end-expiratory pressure
ventilation; inotropes may be used; vit C, E, glutamine (decrease of vascular
permeability), extracorporal methods of detoxication.
3. Leukocytopenia, neutropenia, thrombocytopenia, anemia. Bleeding time is prolonged.
4. Kidney dysfunction : Laboratory signs include: creatinin level and BUN are
increased. Anuria or oliguria. Changes at the urine analysis (protein, casts,
leukocytes, RBC). Liver dysfunction is manifested by: Albumin and fibrinogen level
are decreased, PT and aPTT are prolonged, bilirubin is increased. Alkaline
phosphatase, AST, and ALT are increased. Jaundice, lever is enlarged and tender.

Task № 4
Answers:
1. Respiratory rate is more than 35, Pa02 is below 70, PaC02 is higher than 60. Cyanosis,
dyspnea.
2. Laboratory signs: creatinin level and BUN are increased. Anuria or oliguria. Changes
at the urine analysis (protein, casts, leukocytes, RBC).
3. Albumin and fibrinogen level are decreased, PT and aPTT are prolonged, bilirubin is
increased. Alkaline phosphatase, AST, and ALT are increased. Jaundice, liver is
enlarged and tender.
4. Leukocytopenia, neutropenia, thrombocytopenia, anemia. Bleeding time is prolonged.
5. Proper care of the burned area (temporary and permanent closure), sufficient infusion
therapy (crystalloids, colloids, packed RBS transfusion if indicated, etc.), appropriate
antibacterial therapy if evidence of infection are present, analgesia, detoxication
therapy, supplemented oxygen, extracorporal methods of detoxication.

Task № 5
Answers:
1. Liver, neurologic, respiratory, hematologic, and kidney dysfunction.

226
2. Acute gastric ulcer (Curling‟s ulcer).
3. DIC-syndrome.
4. Respiratory rate is more than 35, PaO2 is below 70, PaCO2 is higher than 60. Cyanosis,
dyspnea.
5. Mortality rate is extremely high.

TOPIC 14 PAIN AND ANESTHESIA

Task № 1
Answers:
1. General combined anesthesia.
2. The patient is asked about history and typical cardiac (arrhythmia, etc.), and
respiratory (tb, chronic bronchitis, etc.) complaints, history of diabetes mellitus and
previous anesthesia (allergy, complications, etc.) in order to reveal any coexisting
pathology. History of previous abnormal bleeding (from wounds, easy bruisibility,
etc.); Family history (inherent coagulopathy), drug history (anticoagulants,
antiagregants, etc.) to reveal bleeding tendency.
3. Skin is inspected for petechiae, ecchymoses, jaundice in order to reveal bleeding
tendency. Respiratory (lungs), cardiovascular (heart), and GIT (ascitis, liver and
spleen) system are examined using common methods of inspection, palpation,
percussion, and auscultation in order to reveal any coexisting pathology(arrhythmia,
murmurs, wheezing, hepatomegaly, splenomegaly, etc.).
4. Yes, it is. Because the planned surgery possesses high bleeding risk and possible
thromboembolic complications.
5. Bleeding time, PT, aPTT, fibrinogen level, platelet count, TBC, glucose level, blood
chemistry, urine analysis, blood typing and cross-matching. ESG (or EchoCG), plain
chest X-ray.

Task № 2
Answers:
1. Acquired coagulopathy secondary to LMWH.
2. Protamine sulphate i.v.
3. aPTT.
4. With stomach lavage using Levin tube.
5. Spinal or epidural anesthesia.

Task № 3
Answers:
1. Anaphylactic shock.
2. Local (infection, haematoma), b) systemic: overdosage or accidental intravascular
injection.
3. Epinephrine subcutaneously, prednisolone 50 mg i.v., fluids in 20 ml/kg i.v. bolus
over five minutes followed by additional continuous i.v. infusion.
4. After prepping and draping a tourniquet is applied at the base of the finger. An
injection of local anaesthetic is done at both sides of the finger at volume of 3-5 ml of
1% lidocaine (or other agent).
5. Lidocaine, novocaine, bipuvacaine, trimecaine, dicaine, ropivicaine, laevobupivacaine,
etc.

Task № 4
Answers:
1. The patient is asked about history and typical cardiac (arrhythmia, etc.), and
respiratory (tb, chronic bronchitis, etc.) complaints, history of diabetes mellitus and

227
previous anesthesia (allergy, complications, etc.) in order to reveal any coexisting
pathology. History of previous abnormal bleeding (from wounds, easy bruisibility,
etc.); Family history (inherent coagulopathy), drug history (anticoagulants,
antiagregants, etc.) to reveal bleeding tendency. Skin is inspected for petechiae,
ecchymoses, jaundice in order to reveal bleeding tendency. Respiratory (lungs),
cardiovascular (heart), and GIT (ascitis, liver and spleen) system are examined using
common methods of inspection, palpation, percussion, and auscultation in order to
reveal any coexisting pathology(arrhythmia, murmurs, wheezing, hepatomegaly,
splenomegaly, etc.). Laboratory tests include bleeding time, PT, aPTT, fibrinogen
level, platelet count, TBC, glucose level, blood chemistry, urine analysis, blood typing
and cross-matching. Instrumental investigation consists of ESG (or EchoCG), Plain
chest X-ray. GIT preparation is 6 hours‟ abstinence from food and 4 hours‟ abstinence
from fluids Emptying of the bowel is attained by cleansing enema. Consent for
surgery and anesthesia is to be obtained.
2. Spinal anesthesia - solution of anaesthetic is injected as a „single shot‟ into the
cerebrospinal fluid. Epidural anesthesia is slower in onset than intrathecal anesthesia.
It is injected into epidural space.
3. Multiple dosing and hence prolonged use, as an indwelling catheter may be threaded
into the epidural space (pain relief extending into the postoperative period). Epidural
anesthesia also includes sympathetic blockade, but it is of slower onset, as is the
resulting hypotension, which may be easier to control and can be used to advantage for
the surgery, in reduction of operative blood loss.
4. Bradicardia and hypotension, urinary retention, headache, back pain.

Task № 5
Answers:
1. History of previous anesthesia is obtained, allergic reactions, intake of medicines
promoting bleeding. Laboratory investigation is not required unless is indicated
(positive history of bleeding tendency, coagulopathy, etc.).
2. Lidocaine, novocaine, bipuvacaine, trimecaine, dicaine, ropivicaine, laevobupivacaine,
etc.
3. After prepping and draping a tourniquet is applied at the base of the finger. An
injection of local anaesthetic is done at both sides of the finger at volume of 3-5 ml of
1% lidocaine (or other agent).
4. Ischemia of the toe, infection complications, bleeding, vascular and nerve injury,
allergic (anaphylactic) reactions.

TOPIC 15 WOUND HEALING

Task № 1
Answers:
1. Proliferation stage, granulation.
2. Granulation tissue is present in tissues healing by secondary intension. This tissue is
clinically characterized by its beefy-red appearance, which is a consequence of rich
bed of new capillary network (neoangiogenesis) that have formed from endothelial
cell division and migration. The direct growth of vascular endothelial cells is
stimulated by platelet and activated macrophages and fibroblast products (vascular
endothelial growth factor is secreted by macrophages). Granulation tissues is a dense
population of blood vessels, macrophages and fibroblasts embedded within a loose
provisional matrix of fibronectin, hyaluronic acid and collagen.
3. Two to three weeks for fresh traumatic wounds in normal conditions.
4. It can be caused by underlying venous pathology.

228
5. Underlying venous or arterial pathology.
6. Treatment of underlying pathology – normalization of venous blood flow in the
extremity combined with proper local care.

Task № 2
Answers:
1. Inflammation stage.
2. After injure the lacerated vessels immediately constrict. Exposure of the subendotelial
structures triggers the coagulation cascade. Platelets aggregate and form initial
hemostatic plug. The intrinsic and extrinsic coagulation pathways lead to activation of
prothrombin to thrombin which converts fibrinogen to fibrin, which is subsequently
polymerized into a stable clot, and hemostasis is achieved. Aggregated platelets
degranulate, releasing potent hemoattractants for inflammatory cells activating factors
for local fibroblasts and endothelial cells, and vasoconstrictors. After the transient
vasoconstriction local small vessels dilate secondary to the effects of the coagulation
and complement cascades. Also these factors increase vascular permeability
(bradykinin, anaphylotoxins - directly increase blood vessels permeability and attract
neutrophils and monocytes to the wound). These complement components also
stimulate the release of hystamine and leucotriens from must cells. An efflux of white
blood cells (neutro- and monocytes) and plasma proteins enter the wound site. The
early neutrophyl infiltrate scavenges the cellular debris, foreign bodies and bacteria.
All these processes are oriented on the wound sterilization.
3. There is a stab tidy traumatic wound of the anterior chest wall penetrating into the
pleural cavity.
4. It is complicated by right side open pneumothorax.
5. The wound has to be closed by impermeable dressing to convert open pneumothorax
into closed one and immediately transport the patient into the hospital for further
treatment.
6. Prompt examination of the patient is done to reveal coexisting pathology and extend
of injury. Infusion therapy is started to replenish circulating volume. Consider
aspiration of the air from the pleural cavity. Local wound management includes
anesthesia, wound irrigation, shave and prepping of the wounded area, permanent
hemostasis with wound debridement, wound closure.
7. Direct wound approximation using primary sutures, etc.

Task № 3
Answers:
1. There is a stab tidy traumatic wound of the right posterior chest wall penetrating into
the pleural cavity.
2. It is complicated by hemopericardium with cardiac tamponade.
3. Inflammation stage. After injure the lacerated vessels immediately constrict. Exposure
of the subendotelial structures triggers the coagulation cascade. Platelets aggregate and
form initial hemostatic plug. The intrinsic and extrinsic coagulation pathways lead to
activation of prothrombin to thrombin which converts fibrinogen to fibrin, which is
subsequently polymerized into a stable clot, and hemostasis is achieved. Aggregated
platelets degranulate, releasing potent hemoattractants for inflammatory cells
activating factors for local fibroblasts and endothelial cells, and vasoconstrictors.
After the transient vasoconstriction local small vessels dilate secondary to the effects
of the coagulation and complement cascades. Also these factors increase vascular
permeability (bradykinin, anaphylotoxins - directly increase blood vessels
permeability and attract neutrophils and monocytes to the wound). These complement
components also stimulate the release of hystamine and leucotriens from must cells.

229
An efflux of white blood cells (neutro- and monocytes) and plasma proteins enter the
wound site. The early neutrophyl infiltrate scavenges the cellular debris, foreign
bodies and bacteria. All these processes are oriented on the wound sterilization.
4. Prompt examination of the patient is done to reveal coexisting pathology and extend
of injury. Infusion therapy is started to replenish circulating volume. Consider
aspiration of the blood from the pericardiac cavity or thoracotomy. Local wound
management includes anesthesia, wound irrigation, shave and prepping of the
wounded area, permanent hemostasis with wound debridement, wound closure.
5. Direct wound approximation using primary sutures, etc.

Task № 4
Answers:
1. There is a stab tidy traumatic wound of the anterior abdominal wall (midabdomen)
penetrating into the abdominal cavity.
2. It is complicated by 1st degree internal bleeding (hemoperitoneum).
3. Hb: not less than 120 gm/l; RBC: not less than 3,5; Ht: more than 0.35;
4. Prompt examination of the patient is done to reveal coexisting pathology and extend
of injury. Infusion therapy is started to replenish circulating volume. Consider
emergency laparotomy to find and control bleeding point. Local wound management
includes anesthesia, wound irrigation, shave and prepping of the wounded area,
permanent hemostasis with wound debridement, wound closure.
5. Yes, he does.
6. Direct wound approximation using primary sutures, etc.

Task № 5
Answers:
1. There is an incised nonpenetrating tidy traumatic wound of the left cubital area.
2. It is complicated by 2nd degree of external venous bleeding.
3. Prompt examination of the patient is done to reveal coexisting pathology and extend
of injury. Infusion therapy is started to replenish circulating volume. Local wound
management includes anesthesia, wound irrigation, shave and prepping of the
wounded area, permanent hemostasis with wound debridement, wound closure.
4. Ligation of the distal and proximal ends of transsected cephalic vein.
5. Direct wound approximation using primary sutures, etc.

TOPIC 16 GENERAL ASPECTS OF SURGICAL INFECTION. PURULENT DISEASES


OF THE SKIN, SUBCUTANEOUS TISSUES, AND GLANDULAR ORGANS

Task № 1
Answers:
1. There is a postinjection abscess of the right lateral gluteal region.
2. Failure of aseptic technique before (poor skin preparation, etc.), during (contact of
nonsterile items with the area of injection, etc.), or after (improper care of
postinjection area), etc.
3. Fingers of both hands are placed on both sides of a mass (investigated part). Slight
jerks are produced by the fingers of one hand. Created movements (or waves) of fluid
are transferred from one side of the mass (tissue) to another and, therefore, can be felt
by the fingers of other hand placed at the opposite side of the area.
4. TBC, US (CT, MRI).
5. Puncture of the abscess is done at the area of maximal tenderness (hyperemia and
swelling) orienting the needle towards most likely localization of the pus. It may be
guided by US.

230
6. The abscess should be opened with one or more incisions, puss is evacuated, the
cavity is irrigated, debrided, and drained (may be filled by gauze tampon to stop
bleeding). The wound is covered with dressing soaked with antiseptic (collagenase)
and managed as a wound healing by secondary intention. Otherwise all the abscess
together with its cavity is excised in borders with healthy tissues. And if a surgeon is
confident of completeness of removal of infected tissues the wound may be closed
primary with indispensable active irrigation draining and heal by primary intention.
Antibacterial and anti-inflammatory agents are administered according to common
rules.

Task № 2
Answers:
1. There is a lacerated untidy traumatic wound of the posterior surface of a left lower calf
complicated by phlegmon of the left calf (purulent stage).
1. Inflammation stage. After the transient vasoconstriction local small vessels dilate
secondary to the effects of the coagulation and complement cascades. Also these
factors increase vascular permeability (bradykinin, anaphylotoxins - directly increase
blood vessels permeability and attract neutrophils and monocytes to the wound).
These complement components also stimulate the release of hystamine and
leucotriens from must cells. An efflux of white blood cells (neutro- and monocytes)
and plasma proteins enter the wound site. The early neutrophyl infiltrate scavenges the
cellular debris, foreign bodies and bacteria. All these processes are oriented on the
wound sterilization.
2. Closure of the wound with primary sutures. Primary delayed or secondary closure had
to be done.
3. TBC, blood chemistry – inflammatory changes. B) US (CT, MRI) – pus localization.
4. After anesthesia, prepping, and draping of the affected area the sutures are removed,
wound should be opened, irrigated, and secondary debrided. The phlegmon should be
opened with one or more incisions, puss is evacuated, the area is irrigated, debrided,
and drained (may be filled by gauze tampon to stop bleeding). The wound is covered
with dressing soaked with antiseptic (collagenase) and managed as a wound healing
by secondary intention. Antibacterial and anti-inflammatory agents are administered
according to common rules.

Task № 3
Answers:
1. Facial furuncle.
2. Purulent meningitis or encephalitis.
3. Inflammation changes.
4. Antibiotics are administered according to common rules if the patient has signs of
intoxication.
5. Surgery of furuncle is done if the abscess forms secondary to furuncle.

Task № 4
Answers:
1. There is a lacerated untidy traumatic wound of the left upper calf complicated by
secondary phlegmon (purulent stage), limphangitis and groin lymphadenitis
(infiltrative stage).
2. Closure of the wound with primary sutures. Primary delayed or secondary closure had
to be done.
3. TBC, blood chemistry – inflammatory changes.

231
4. Antibacterial and anti-inflammatory agents, detoxication, infusion therapy are
administered according to common rules.
5. After anesthesia, prepping, and draping of the affected area the sutures are removed,
wound should be opened, irrigated, and secondary debrided. The phlegmon should be
opened with one or more incisions, puss is evacuated, the area is irrigated, debrided,
and drained (may be filled by gauze tampon to stop bleeding). The wound is covered
with dressing soaked with antiseptic (collagenase) and managed as a wound healing
by secondary intention.

Task № 5
Answers:
1. Postoperative wound infection.
2. Failure of aseptic technique before (poor skin preparation, etc.), during (contact of
nonsterile items with the wound, etc.), or after (improper care of postoperative wound)
surgery.
3. If the abscess of the postoperative wound is deeply situated the diagnosis may be
assisted by ultrasound (or other imaging studies). WBC shows leukocytosis with left
shift, rise of ESR.
4. The wound should be opened, sutures removed, irrigated, and debrided if pus or
necrotic tissues are present.
5. Mixed.

TOPIC 17 PURULENT DISEASES OF HAND AND FOOT

Task № 1
Answers:
1. Neuroischemic form of diabetic foot.
2. Poor blood flow (ischemia).
3. Plain foot X-ray (or CT, MRI), hand-held Doppler ultrasound; ankle/brachial index;
duplex scanning with of color coding; pletismography; treadmill; rheovasography;
arteriography.
4. CBC, urine analysis, blood chemistry, glucose level, glycemic profile, coagulogramm,
immunogramm.
5. Control of glucose level with injected form of insulin, vasodilators, antyplatelet
agents, rrheolytics (treatment of claudication), prostagandin based agents, local care of
dry necrosis.
6. Treatment of underlying pathology – normalization of arterial blood flow in the
extremity (surgery)

Task № 2
Answers:
1. Neuropathyc form of diabetic foot complicated by secondary phlegmon of the left
foot.
2. Diabetic sensory neuropathy leads to loss of sensation. It predisposes a patient to
overlooked skin trauma and development of ulcers. Motor neuropathy leads to
changes in the foot muscles resulting in change of gait and appearance of areas of
excessive pressure at the foot during walking causing formation of calluses and ulcers
at the foot. Autonomic neuropathy is caused by sympathetic denervation of vessels
and dilation of arterio-venous shunts, depriving the cells of oxygen. The second event
is a loss of sweating followed by dryness, calluses and cracks of the skin and
development of ulcers and even advanced infection.
3. Secondary groin lymphadenitis.

232
4. Plain foot X-ray (or CT, MRI), hand-held Doppler ultrasound; ankle/brachial index;
duplex scanning with of color coding.
5. CBC, urine analysis, blood chemistry, glucose level, glycemic profile, coagulogramm,
immunogramm, culture and AB sensitivity.
6. Control of glucose level with injected form of insulin, antibiotics, rrheolytics
(treatment of claudication), NSAID, detoxication and infusion therapy.
7. III class.
8. Using anesthesia and following aseptic rules an adequate incision, irrigation, and
debridement of all necrotic tissues is done. The wound is managed as healing by
secondary intention with daily necrectomia and parallel medical treatment. Secondary
closure is done with tissue flap.

Task № 3
Answers:
1. Subcutaneous panaritium of the index finger.
2. Local antiseptics and systemic antibacterial. Elevation and rest for affected part.
3. Digital nerve block anesthesia.
4. Once indicated the surgery is done. The abscess should be opened, pus and necrotic
tissues are evacuated, the area is irrigated and drained. The wound is covered with
dressing soaked with antiseptic (collagenase) and managed as a wound healing by
secondary intention.

Task № 4
Answers:
1. Purulent tenosynovitis of the index finger.
2. No, it is not.
3. Local antiseptics and systemic antibacterial. Elevation and rest for affected part.
4. Digital nerve block anesthesia.
5. Once indicated the surgery is done. The tendon is approached using long midaxial
incision allowing exploration of all the affected sheath. The pus and necrotic tissues
are evacuated, the area is irrigated and drained. The wound is managed as healing by
secondary intention.

Task №5
Answers:
1. Right ring finger pandactilitis.
2. It is not effective against G+ bacteria.
3. Secondary lymphadenitis.
4. Local antiseptics and systemic antibacterial. Elevation and rest for affected part.
5. Surgical options are limited at such advanced stage. Usually it consists of amputation
of the affected finger.

TOPIC 18 SPECIFIC SURGICAL INFECTION. TUBERCULOSIS OF BONES &


JOINTS. ANTHRAX. ACTINOMYCOSIS.

Task № 1
Answers:
1. Pulmonary tuberculosis. Tuberculous gonitis.
2. It should be differentiated from rheumatoid and infective arthritis, hemarthrosis,
ostheomyelitis.
3. Low grade leukocytosis with left shift, rise of ESR, hypoproteinemia, disproteinemia,
anemia.

233
4. Knee arthrocentesis.
5. Mycobacterium tuberculosis.
6. Firmly grasp the thigh just above the patella with one hand, thus forcing fluid out of
the suprapatellar pouch into the space between the patella and femur. With the fingers
of your other hand, push the patella sharply back against the femur. Feel for the
palpable tap. In the absence of fluid none is felt because the patella is already snug
against the femur. When the patella is separated from the femur by excessive joint
fluid, the sharp backward thrust makes it collide against the femur with a palpable tap.
7. After anesthesia, prepping, and draping of the affected area the knee arthrotomy is
performed. All nonviable tissues are removed. Already changed articular surfaces are
resected together with impaired epiphyses of tibial and femoral bone. The rest wound
is drained and closed by primary sutures. Mandatory continuous irrigation of the
wound is done in the postoperative period. Arthrodesis is accomplished using external
fixation device.

Task № 2
Answers:
1. Pulmonary tuberculosis. Tuberculous spondillitis. Cold abscess of the right groin.
2. Primary Tb focus in the lungs → spread of Mycobacterium tuberculosis with the
blood → secondary (metastatic) Tb focus in the spine → vertebral destruction → at
advanced stage two neighboring vertebra collapse forming kyphos → locally
collecting pus may track along the muscular sheaths and be presented in distant area
(groin, Petit triangle) as a “cold abscess”.
3. Plain spine X-ray using two planes, MRI, CT.
4. Very slow, several weeks.
5. a) Triple therapy is administered orally for at least 2-3 months. It includes rifampicin,
isoniazid, pyrazinamide. Further it is followed by 6 months of double therapy with
rifampicin and isoniazid. Appropriate change of antibiotic can be done on the basis of
culture results. b) bone and joint Tb may require 9 month course of triple therapy.
6. Surgery includes access to affected vertebra, evacuation of the pus. Resection of the
affected transverse process is a common part of necrectomy. Surgery is finished by
vertebral fusion using bone graft, etc. once the lesion has been sterilized. If the abscess
has formed it is incised and thoroughly drained three to four weeks after the
commencement of AB therapy.

Task № 3
Answers:
1. Cutaneous form of anthrax.
2. Furuncle, carbuncle.
3. Bacillus anthracis.
4. Bacillus anthracis is a gram positive aerobic rod very resistant to environment and
antiseptics.
5. Penicillin G 2mln every 4 hours i.v.

Task № 4
Answers:
1. Faciocervical form of actinomycosis.
2. Actinomyces israely.
3. Carious teeth.
4. Thoracic, abdominal.

234
5. Penicillin G 10-20mln daily during two-four weeks. Surgery is done according to
common rules. Abscess must be incised and drained. Local roentgenotherapy can be
used.

TOPIC 19 PURULENT DISEASES OF CELLULAR SPACES

Task № 1
Answers:
1. Acute subcutaneous paraproctitis.
2. 1) subcutaneous, 2) ischeorectal, 3) pelviorectal, 4) submucous, 5) retrorectal.
3. Anal cracks, hemorrhoids, trauma or inflammation of rectal and anal mucous, tumor
necrosis, penetrating wounds.
4. WBC shows leukocytosis with left shift, rise of ESR.
5. Antibacterial therapy is done according to common rules. After anesthesia, prepping,
and draping of the affected area an incision (or double incisions) is done at the point of
most hyperemy. The abscess is opened, pus is evacuated, cavity is irrigated, and
secondary debrided. The postoperative wound is drained (may be filled by gauze
tampon to stop bleeding). The wound is covered with dressing soaked with antiseptic
(collagenase) and managed as a wound healing by secondary intension.

Task № 2
Answers:
1. Acute ischeorectal or/and pelviorectal paraproctitis.
2. Hemorrhoids.
3. The doctor should have administered an antibacterial therapy and monitor the patient
frequently.
4. Diagnostic puncture, imaging studies (US, etc.)
5. Medical therapy includes an antibacterial therapy done according to common rules,
correction of circulating volume and improvement of peripheral circulation,
detoxication therapy, correction of fluid-electrolyte changes, immunotherapy. After
anesthesia, prepping, and draping of the affected area an incision (or double incisions)
is done at the point of most hyperemy. The abscess is opened, pus is evacuated, cavity
is irrigated, and secondary debrided. The postoperative wound is drained (may be
filled by gauze tampon to stop bleeding). The wound is covered with dressing soaked
with antiseptic (collagenase) and managed as a wound healing by secondary intension.

Task № 3
Answers:
1. Retroperitoneal abscess.
2. Acute appendicitis (if it is located retroperitoneally).
3. An inflammation is located retroperitoneally.
4. This is a “psoas symptom” caused by irritation of iliopsoas muscle.
5. Imaging studies (US, CT, etc.)
6. Medical therapy includes an antibacterial therapy done according to common rules,
correction of circulating volume and improvement of peripheral circulation,
detoxication therapy, correction of fluid-electrolyte changes, immunotherapy.
Surgery includes retropertitoneal access to the abscess using an incision parallel to
anterior iliac spine. Evacuation of the pus, debridement with irrigation, and draining
are done according to common rules.

Task № 4
Answers:

235
1. Postinjection phlegmon of the right thigh, groin lymphadenitis.
2. An injection was done without aseptic technique. Drug addict persons are always
immunocompromized and therefore predisposed to infection complications.
3. An infection started in the femoral triangle and resulted in deep thigh phlegmon. The
pus may track in the bed of flexor, extensor, and external muscular sheath and can
extend from the thigh onto the calf and ankle along neurovascular bundles.
4. a) WBC shows leukocytosis with left shift, rise of ESR, blood chemistry shows acute
phase proteins, disproteinemia, and possible electrolyte changes. b) Imaging studies
(US, CT) detect localization of the pus.
5. Medical therapy includes an antibacterial therapy done according to common rules,
correction of circulating volume and improvement of peripheral circulation,
detoxication therapy, correction of fluid-electrolyte changes, immunotherapy. After
anesthesia, prepping, and draping of the affected area an incision (or double incisions)
is done. The phlegmon is opened, pus is evacuated, affected area is irrigated and
debrided. The postoperative wound is drained (may be filled by gauze tampon to stop
bleeding). The wound is covered with dressing soaked with antiseptic (collagenase)
and managed as a wound healing by secondary intension. Otherwise, the wound may
be closed primary if all nonviable infected tissues were completely removed. In that
case, the surgery is finished with active wound draining.

Task № 5
Answers:
1. Perforation of the esophagus resulted in mediastinitis.
2. Penetrating wounds (gunshot, etc.), perforation of the esophagus or trachea by foreign
bodies, burns, iatrogenic, anastomotic leak, neck phlegmon, pneumonia, empyema,
osteomyelitis of the breastbone, thoracic spine, hematogenous spread.
3. Esophagoscopy or barium swallow.
4. Both methods may be useful to identify the site of esophageal perforation.
5. Medical therapy includes i.v. administration of broadest and most powerful antibiotics
(carbapenems, etc.), correction of circulating volume and improvement of peripheral
circulation, detoxication therapy, correction of fluid-electrolyte changes,
immunotherapy. Surgery includes access to the area of mediastinitis (different
incisions may be used including sternotomy, laparotomy, etc.), closure of esophageal
perforation, evacuation of the pus, debridement with irrigation, and draining done
according to common rules.

TOPIC 20 PURULENT DISEASES OF BONES AND JOINTS

Task № 1
Answers:
1. Acute hematogenous osteomyelitis of the right femoral bone.
2. Sore throat.
3. Primary focus of infection (sore throat) → bacterial embolus spreads via the blood
leading to embolism of the feeding bone vessel → necrosis and inflammation of the
bone marrow with part of the bone → periostitis → paraosseal phlegmon →
involvement of other nearby tissues
4. TBC, blood chemistry – inflammatory changes.
5. No changes.
6. Medical therapy includes an antibacterial therapy, correction of circulating volume
and improvement of peripheral circulation, detoxication therapy, correction of anemia
and hypoproteinemia, correction of fluid-electolyte and acid-base changes,
immunotherapy. Surgery is done according to common rules with wide incision,

236
exploration of purulent focus, necrectomy, active irrigation of the focus at the
postoperative period.

Task № 2
Answers:
1. Chronic posttraumatic osteomyelitis of the left tibial bone.
2. Inadequate surgical and /or antibacterial treatment of acute posttraumatic
osteomyelitis developed as a complication of the fracture.
3. Open fracture → spread of bacteria through a damaged skin into underlying tissues →
inflammation of tissues surrounding the bone → spread of infection into the bone
marrow → osteomyelitis.
4. Plain X-ray, CT, MRI, radionuclide examination of the left tibial bone (localization
and extent of bone and soft tissues involvement); b) sinography (localization and
extent of bone and soft tissues involvement).
5. Radical surgical debridement of purulent focus in the tibial bone, excision of all
nonviable tissues and necrotized parts of the bone. Surgical debridement is
accompanied by physical methods of antisepsis (pressurized pulsatile irrigation of the
wound using antiseptics, ultrasound, and laser). Adequate active continuous draining
of the wound and bone cavity using special plastic perforated drains after surgery.
Bone plasty using different methods is necessary to restore bone integrity. It may be
done using vascularized tissue flap, Illisarov‟s technique, free distant bone or tissue
flap. Sufficient stabilization of bone fragments using external fixation apparatus is
always necessary. Replacement of the defect of soft tissues is the last part of surgery.
It is accomplished by different types of tissue plasty including local tissues (direct
approximation), method of gradual tissue extension, skin graft, tissue flap (local,
migrating, or free flap). Cateterization of the ipsilateral main artery and intraarterial
administration of antibiotics of diseased extremity may be done.

Task № 3
Answers:
1. There is a lacerated contaminated traumatic wound on the lateral surface of the left
knee joint complicated by secondary purulent arthritis of the left knee joint and groin
lymphadenitis.
2. Closure of the wound with primary sutures. Primary delayed or secondary closure had
to be done.
3. Firmly grasp the thigh just above the patella with one hand, thus forcing fluid out of
the suprapatellar pouch into the space between the patella and femur. With the fingers
of your other hand, push the patella sharply back against the femur. Feel for the
palpable tap. In the absence of fluid none is felt because the patella is already snug
against the femur. When the patella is separated from the femur by excessive joint
fluid, the sharp backward thrust makes it collide against the femur with a palpable tap.
4. Medical therapy includes an antibacterial therapy, correction of circulating volume
and improvement of peripheral circulation, detoxication therapy, correction of anemia
and hypoproteinemia, correction of fluid-electolyte and acid-base changes,
immunotherapy.
5. After anesthesia, prepping, and draping of the affected area the sutures are removed,
wound should be opened, irrigated, and secondary debrided. The wound is covered
with dressing soaked with antiseptic (collagenase) and managed as a wound healing
by secondary intention. Purulent arthritis is treated with repeated aspiration of the pus
from the joint and intraarticular injection of antiseptic agents. Draining of the joint
cavity with plastic tube and continuous irrigation is preferred. It lasts for 20-25 days.

237
Task № 4
Answers:
1. Secondary posttraumatic purulent arthritis of the right knee joint, stage of
osteoarthritis.
2. Serous arthritis, joint empyema, panarthritis, osteoarthritis.
3. Serous arthritis represents inflammation in the synovial bursa and accompanied by
collection of effusion in the joint. Contamination of effusion results in joint empyema.
Further progress of infection onto the joint surfaces, joint‟s capsule, and ligaments
leads to panarthritis. If an inflammation extends onto the bone epypheses and
methaphyses the condition is named osteoarthritis.
4. Medical therapy includes an antibacterial therapy, correction of circulating volume
and improvement of peripheral circulation, detoxication therapy, correction of anemia
and hypoproteinemia, correction of fluid-electolyte and acid-base changes,
immunotherapy.
5. After anesthesia, prepping, and draping of the affected area the arthrotomy is
performed. All nonviable tissues are removed. Already changed articular surfaces are
resected together with impaired epiphyses of tibial and femoral bone. The rest wound
is drained and closed by primary sutures. Mandatory continuous irrigation of the
wound is done at the postoperative period. Arthrodesis is accomplished using external
fixation device.

TOPIC 21 CLOSTRIDIAL MYONECROSIS. TETANUS. NECROTIZING FASCIITIS

Task № 1
Answers:
1. There is a crashed contaminated traumatic wound at the posterior surface of left lower
calf complicated by clostridial myonecrosis.
2. Clostridium perfringens is a gram positive, rod shape anaerobic bacteria with boxcar
appearance.
3. TBC commonly shows an anemia and leukopenia. Blood chemistry reveals
disfunction of the liver and kidneys, electrolyte changes. Gram stain of exudates
shows specific bacteria and absence of WBC. b) CT, Plain X-ray may detect gas at
tissues.
4. Pale or darkened “cooked” appearance of affected muscles.
5. After anesthesia, prepping, and draping of the affected area the sutures are removed,
wound is opened. Exposure of all the affected muscle groups by long incisions is
done. Debridement and excision of all involved muscles (sometime amputation)
irrigation, and wound draining must be attempted. Daily reoperations are done till
complete removal of necrotized tissues.

Task № 2
Answers:
1. Gas gangrene.
2. Chronic vascular obstructive disease, dry gangrene.
3. Gas in tissues.
4. Antibacterial therapy with penicillin (up to 2-4 g 4-hourly) or clindamycin and
metronidazole. Infusion and detoxication therapy, correction of electrolyte changes,
anemia, and hypoproteinemia (if indicated). HBO if available.
5. Pale or darkened “cooked” appearance of affected muscles.
6. Ineffective antiseptic agent, insufficient extent of surgery, and inappropriate
postoperative antibiotic. Exposure of all the affected muscle groups by long incisions

238
had to be followed by excision of all involved muscles, irrigation with oxidizing
agent, and wound draining.

Task № 3
Answers:
1. There is a contaminated traumatic wound in the left calf complicated by tetanus.
2. Clostridium tetani is a gram positive, rod shape anaerobic bacteria with drumstick
spore.
3. It is based on characteristic clinical picture.
4. He had to examine vaccination status of the patient.
5. The patient had to be given 250-500 units of human antitetanus globulin at one site
and initial immunizing dose of toxoid at another site.
6. Respiratory failure and death due to spasm of the diaphragm and the larynx.

Task № 4
Answers:
1. Deep contaminated (agricultural, etc) lacerated (crashed, gunshot, frostbite, etc.)
wounds older then 6 hours.
2. The patient is given 250-500 units of human antitetanus globulin at one site and initial
immunizing dose of toxoid at another site.
3. Further vaccination is not necessary.
4. 1ml of tetanus toxoid (tetanus vaccine, adsorbed, commonly Td).
5. The following clinical forms of the tetanus are known: generalized tetanus, localized
tetanus (ascending), cephalic tetanus (descending), neonatal tetanus. Symptoms
include risus sardonicus, trismus, opisthotonus. Dysphagia, jaw stiffness, severe
pains in the neck and back. The temperature is elevated, the pulse is rapid.
6. Isolation, airway control (endotracheal tube or a tracheostomy), a nasogastric tube is
also passed to feed the patient. Spasm control with diazepam, benzdiazepam or
curarisation. Immunisation of the patient: Human anti-tetanus globulin (e.g. Humotet,
HTIG) i.m. 250- 500 U plus tetanus toxoid 1.0 i.m. Wound toilet, antibiotics
(penicillin and metronidazole).

Task № 5
Answers:
1. Fournier‟s gangrene (Necrotizing fasciitis of the scrotum).
2. Diabetes mellitus and obesity.
3. Coliforms, staphylococci, Bacteroides spp., anaerobic streptococci and pepto-
streptococci, etc.
4. Medical therapy includes wide-spectrum antibiotic therapy (clindamycine plus
aminoglycoside are administered at high doses), aggressive circulatory support and
detoxication therapy, correction of immune deficit (diabetes, etc.).
5. Surgery consists of wide excision of all affected tissue with irrigation and other
methods of antisepsis. The wound is left for healing by secondary intention.
Debridement must be extensive. Daily debridement is necessary in the postoperative
period. Final closure is achieved with skin grafting or tissue flaps.

TOPIC 22 PURULENT DISEASES OF SEROUS CAVITIES

Task № 1
Answers:
1. Secondary diffuse (total) peritonitis, toxic stage.
2. Complicated acute appendicitis.

239
3. Voluntary muscular guarding, involuntary rigidity of the abdominal muscles, rebound
tenderness (Shetkin-Blumberg's sign), Voskresensky's sign (shirt's symptom), Mendel
sign, absence of liver dullness.
4. Free intraabdominal air collecting under the vaults of the diaphragm, air-fluid
levels.US, CT, MRI b) paracentesis, culdocentesis, diagnostic peritoneal lavage
(DPL), video assisted laparoscopy.
5. After prompt preparation the patient is operated. The surgery consists of midline
laparotomy, exploration of intraabdominal organs, treatment of injured organ,
cleansing and draining of the peritoneal cavity, suturing of the surgical wound.
Task № 2
Answers:
1. Secondary diffuse (total) peritonitis, reactive stage.
2. Perforation of duodenal ulcer.
3. Total blood count – hemoconcentration and inflammatory changes; blood chemistry
(inflammatory changes, signs of organ dysfunction, electrolyte disbalance),
bacteriologic studies.
4. Plain abdominal (chest) X-ray (free air), CT (fluid), MRI (fluid), Ultrasound methods
(fluid), diagnostic puncture (peritoneal content), laparocentesis (peritoneal content),
diagnostic peritoneal lavage (peritoneal content), laparoscopy (presence and source of
peritonitis), diagnostic laparotomy (presence and source of peritonitis).
5. Control of infection (AB), correction of hypovolemia by infusion therapy,
detoxication therapy, GIT decompression (NG), oxygen supplementation, analgesia.
6. 3G cephalosporine combined with clindamycine; aminoglycoside combined with
metronidazole; etc.

Task № 3
Answers:
1. The peritonitis had to be treated surgically. The doctor should have chosen a surgical
treatment and other antibacterial agents.
2. Secondary diffuse (total) peritonitis, stage organ dysfunction (terminal).
3. Kidney, liver, neurologic.
4. Control of infection (AB), correction of hypovolemia by infusion therapy,
detoxication therapy, GIT decompression (NG), oxygen supplementation, analgesia.
5. 3rd degree. I.v. LR, NS, and colloids are considered at volume of approximately 10 L.
under control of vital signs, CVP, UO.

Task № 4
Answers:
1. Right side pleural empyema or lung abscess.
2. Already loculated pus will maintain intoxication even if antibiotics are chosen
properly.
3. Plain chest X-ray, CT, MRI, US may detect localized collection of fluid. b)
thoracentesis done under guidance of imaging studies.
4. Total blood count – hemoconcentration and inflammatory changes; blood chemistry
(inflammatory changes, electrolyte disbalance), bacteriologic studies of aspirated
fluid.
5. Control of infection (AB), correction of hypovolemia by infusion therapy,
detoxication therapy, ventilatory support (oxygen supplementation), mucolytics.
6. Percutaneous drainage of the empyema with one or more chest tube (catheter) The
cavity is irrigated (intermittently). Enzymatic therapy can be added. Tubes can usually
by withdrawn when the drainage is less then 50 ml/day and the cavity is less then 50
ml.

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Task № 5
Answers:
1. Right side pleural effusion caused by liver cirrhosis.
2. It is wrong. antibiotics and drainage are not necessary.
3. pH higher than 7,2, glucose higher than 40mg/dl, LDH less than 1000 IU/liter,
negative culture, protein level less than 3,0mg/dl and a specific gravity less than
1.018.
4. pH less then 7,2, glucose less than 40mg/dl, LDH at least 1000 IU/liter, positive
culture, protein level higher than 3,0mg/dl and a specific gravity higher than 1.018.
Visible changes – pus.
5. thoracentesis; b) antibiotics and drainage.
6. The patient should have been treated by thoracentesis.

TOPIC 23 SURGICAL SEPSIS AND SEPSIS SYNDROME

Task № 1
Answers:
1. Because the patient has signs of sepsis and evidence of altered organ perfusion. The
attributes of sepsis in our case are a) evidence of infection (infected traumatic wound)
and b) systemic response of the body manifested by drop of body temperature (35,2
C0), increased heat (140) and respiratory (28) rate, leucopenia (3 000 cells/mm3), left
shift (11 band forms). The evidence of altered organ perfusion are oliguria (200ml
UO) and mental confusion.
2. Sepsis is a clinical situation in which there is evidence of infection (infected traumatic
wound) plus a systemic response of the body manifested by: a) an elevated body
temperature more than 380C or less than 360C; b) heart rate more than 90; c)
respiratory rate more than 20 or PaCO2 less than 32mm Hg; d) WBC more than 12
000 cells/mm3 or less than 4 000; or more than 10 band forms. Two or more have to
be alternated. Sepsis syndrome is a sepsis plus evidence of altered organ perfusion
with at least one: hypoxemia, elevated lactate, oliguria, or altered mental status.
3. Clostridial myonecrosis.
4. Antibacterial therapy with penicillin (up to 2-4 g 4-hourly) or clindamycin and
metronidazole. Infusion and detoxication therapy, correction of electrolyte changes,
anemia, and hypoproteinemia (if indicated). HBO if available.
5. After anesthesia, prepping, and draping of the affected area the sutures are removed,
wound is opened. Exposure of all affected muscle groups by long incisions is done.
Debridement and excision of all involved muscles (sometime amputation), irrigation,
and wound draining must be attempted. Daily reoperations are done till complete
removal of necrotized tissues.

Task № 2
Answers:
1. Because the patient has signs of sepsis. The attributes of sepsis in our case are a)
evidence of infection (moist cough with sputum, chest pain) and b) systemic response
of the body manifested by rise of body temperature (39,2 C0), chills, increased heat
(120) and respiratory (30) rate, leukocytosis (25 000 cells/mm3), left shift (15 band
forms).
2. Right side pleural empyema or lung abscess.
3. No, it will not. It will be positive only in approximately 40% of cases.
4. Thoracentesis with culture of the aspirate. Culture of the sputum, blood.
5. A 3G cephalosporine (+ metronidazole); or ticarcillin-clavulonate ± aminoglicoside;

241
or ampicillin-sulbactam ± aminoglicoside; or piperacillin-tazobactam ±
aminoglicoside.
6. Percutaneous drainage of the empyema with one or more chest tube (catheter). The
cavity is irrigated (intermittently). Enzymatic therapy can be added. Tubes can usually
by withdrawn when the drainage is less then 50 ml/day and the cavity is less then 50
ml.

Task № 3
Answers:
1. Because the patient has signs of sepsis associated with organ disfunction,
hypoperfusion, and hypotension. The attributes of sepsis in our case are a) evidence of
infection (peritonitis is manifested by abdominal pain, vomiting, signs of peritoneal
irritation) and b) systemic response of the body manifested by rise of body
temperature (39,4 C0), chills, increased heat (140) rate. The evidence of altered organ
perfusion are oliguria (150ml UO), increased lactate level, PaO2 is 65, and mental
confusion. The evidence of organ disfunction is the following: yellowish sclera,
increased liver span, increased level of creatinine and bilirubine, mental confusion.
Hypotension is manifested by low arterial BP (70 mmHg). Adequate fluid
resuscitation has failed to increase arterial blood pressure.
2. Severe sepsis is sepsis associated with organ disfunction, hypoperfusion, and
hypotension. Septic shock is sepsis with hypotension despite adequate fluid
resuscitation with evidence of perfusion abnormalities (that may include acidosis,
oliguria, and altered mental status).
3. Because started infusion therapy has failed to increase arterial blood pressure during 1
hour.
4. Peritonitis.
5. After prompt preparation the patient is operated. The surgery consists of midline
laparotomy, exploration of intraabdominal organs, treatment of injured organ,
cleansing and draining of the peritoneal cavity, suturing of the surgical wound.
6. Kidney, liver, and neurologic disfunction.

Task № 4
Answers:
1. No, we cannot.
2. Even though the patient has signs of organ hypoperfusion (confusion, increased lactate
level, low UO), refractory to infusion therapy hypotension (90 mmHg arterial blood
pressure), and a systemic response of the body manifested by elevated body
temperature (38,5) and increased heart rate (140), yet the patient has no infection.
3. Severe burn causes direct release of proinflammatory cytokines (TNFα and IL 1).
They stimulate release of other mediators: thromboxanes, leukotriens, platelet-
activating factor, prostaglandins, complement and nitric oxide (NO). Effects of
mediators are responsible for SIRS (rise of body temperature, confusion, etc.). Signs
of hypovolemy (increased pulse rate, low blood pressure, low UO) are also caused by
the effect of proinflammatory cytokines and loss of fluid through direct evaporation,
tissue destruction, loss of vascular tone, rise of endothelial and vascular permeability
accompanied by the loss of intravascular fluid into the interstitium.
4. Systemic antibiotics are not necessary until infection has started. Although they may
be used with prophylactic purpose the risk of bacterial résistance increases
significantly.
5. Synusitis, indwelling line infection, wound infection, lung infections (lung abscess,
empyema), bacterial endocarditis, acute cholecystitis and cholangitis, peritonitis,
necrotizing pancreatitis, ischemic bowel necrosis, gut bacterial translocation,
genitourinary infection, etc.

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Task № 5
Answers:
1. The patient still has untreated (or recurrent) source of infection which is responsible
for negative changes in patient‟s condition.
2. He should have started to search a possible reason (localization of infection)
responsible for aggravation of patient‟s condition using different diagnostic tools.
Antibiotics are not effective if a patient still has untreated source of infection.
3. Operative wound (incisional abscess), intraabdominal infection (recurrent peritonitis,
subphrenic, subhepatic, Douglas pouch abscess).
4. If intraabdominal infection is excluded the doctor should consider other sources of
infection like pulmonary infection (postoperative pneumonia, etc.), genitourinary
infection, indwelling line infection, etc.

TOPIC 24 SURGICAL PATIENT EXAMINATION

Task № 1
Answers:
1. Penetrating chest injury complicated by a right side pneumothorax.
2. Data of the percussion and auscultation are necessary for more precise clinical
diagnosis.
3. CBC, blood typing for ABO and Rh, cross-matching, plain chest X-ray.
4. Surgical ward or department of a thoracic surgery.
5. Thoracentesis.
Task № 2
Answers:
1. Posterior neck carbuncle.
2. CBC, glucose blood level, urine test for acetone and glucose, blood typing for ABO
and Rh, cross-matching, endocrinologist and therapist consultations.
3. Excision of the carbuncle.
4. General i.v..
5. Dynamic of the general status, complaints, body temperature, vital signs.

Task № 3
Answers:
1. Gastric ulcer complicated by a GIT bleeding.
2. Information about history of the gastric ulcer, previous medical therapy and its effect,
data of the previous diagnostic results.
3. Current medication, exposure to risk factors for gastric ulcer, family history,
coexisting illnesses, etc.
4. Digital examination of the rectum.
5. CBC, blood typing for ABO and Rh, cross-matching, fibroptic EGDS.

Task № 4
Answers:
1. Acute appendicitis.
2. Anamnesis morbi.
3. Anamnesis vitae.
4. Laparoscopy.
5. The patient.

Task № 5

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Answers:
1. Acute colecistitis.
2. Anamnesis morbi.
3. Anamnesis vitae.
4. Diary of the disease.
5. Premedication is recorded before surgical protocol.

TOPIC 25 ARTERIAL DISORDERS

Task № 1
Answers:
1. Intermittent claudication is a sign of chronic arterial ischemia of lower extremities.
2. Smoking, hypertension.
3. Ratshov's maneuver, Samuel's maneuver, capillary refilling time, Oppel's sign,
Panchenko's phenomenon.
4. Hand-held Doppler ultrasound; ankle/brachial index; duplex scanning with color
coding; pletismography; rheovasography; treadmill; arteriography.
5. Vasodilators, antyplatelet agents, rheolytics (treatment of claudication), statins.

Task № 2
Answers:
1. Burger disease.
2. 4th degree of chronic arterial ischemia, distal block.
3. Hand-held Doppler ultrasound; ankle/brachial index; duplex scanning with color
coding; pletismography; treadmill; rheovasography; arteriography.
4. Vasodilators, antyplatelet agents, rheolytics (treatment of claudication),
corticosteroids.
5. Sympathectomy.

Task № 3
Answers:
1. Acute arterial ischemia of the left upper extremity.
2. Mitral stenosis caused by rheumatic fever, implantation of an artificial valve.
3. 2nd “b” degree of acute arterial ischemia, blockage at the level of division of the left
brachial artery.
4. Heparin i.v 10.000 IE; Vasodilating drug papaverin 4ml; narcotic analgesic promedol
2ml; antihistamine drug dimedrol 2ml.
5. Embolectomy from the left brachial artery.

Task № 4
Answers:
1. Atherosclerosis of arteries of both lower extremities.
2. 2nd degree of chronic arterial ischemia, aortoiliac blockage.
3. Duplex scanning and arteriography: occlusion (stenosis) of aortic bifurcation and iliac
arteries; ankle/brachial index: decrease of index.
4. Aortobifemoral bypass grafting.

Task № 5
Answers:
1. Atherosclerosis of arteries of right lower extremity.
2. Aortoiliac blockage (aortic bifurcation).
3. Moist gangrene of the right foot.

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4. Preoperative preparation is followed by emergency right thigh amputation.

TOPIC 26 VENOUS AND LYMPHATIC DISORDERS

Task № 1
Answers:
1. Varicose disease of both lower extremities.
2. Acute superficial varicothrombophlebitis of the right lower extremity.
3. Duplex scan (with or without color coding).
4. Duplex scan has to show features of venous thrombosis (incompressibility and the
absence of blood flow within the venous lumen) of the superficial varicose veins in the
right thigh.
5. Emergency crossectomy of the right great saphenous vein.
Task № 2
Answers:
1. DVT.
2. Homan's sign, Mozese's sign, Opit's sign, Bischard's sign, Valsalva sign.
3. Duplex scan (with or without color coding).
4. Duplex scan (with or without color coding) has to show features of venous
thrombosis (incompressibility and the absence of blood flow within venous lumen) of
the left leg deep veins.
5. Direct anticoagulants (conventional heparin or LMWH), NSAID (ibuprofen, etc.),
spasmolytics (papaverine), rheolytics (pentoxiphillin).

Task № 3
Answers:
1. Primary varicose veins (disease) of right lower extremity.
2. GSV.
3. 1st degree of CVI.
4. Trendelenburg test, cough impulse, Delbe-Perts test.
5. Sclerotherapy, radiofrequency endovenous obliteration, laser endovenous obliteration,
venectomy (phlebectomy).

Task № 4
Answers:
1. Chronic venous insufficiency, III degree.
2. DVT.
3. Postthrombotic syndrome of the right lower extremity, CVI of III degree.
4. PTT, PT, bleeding and clotting time, INR, platelet count, duplex scan (with or without
color coding), phlebography.
5. Avoid severe physical exertions to lower limbs, elevation of the extremity, elastic
compressive stockings, venotonic drugs (detralex, etc.), rheolytic drugs (pentoxifillin,
etc.), antiplatelet drugs (ACC), NSAID (sodium diclofenak, etc.), topical antiseptic
agents (sodium hypochloride, etc.).

Task № 5
Answers:
1. Lymphedema of the left lower extremity.
2. Congenital hypoplasia or aplasia of lymphatics; Acquired lymphedema due to trauma
or surgical removal of lymphatics, repeated acute infections, chronic infections
(elephantiasis, erysipelas, fungy, Tbc, etc), advanced malignant disease.
3. Lymphography.

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4. Avoid severe physical exertions to lower limbs, elevation of the extremity, elastic
compressive stockings, lymphotonic drugs (detralex, etc.), rheolytic drugs
(pentoxifillin, etc.), NSAID (sodium diclofenak, etc.), treatment of the cause
(antibiotics for recurrent infections, etc.).

TOPIC 27 THERMAL INJURIES

Task № 1
Answer:
1. Partial thickness burn (2nd degree).
2. 36%.
3. Remove the patient from the heat, extinguish burning cloth, ice or cold water soaks
locally, i.v. fluid replenishment through venous cannulation is started, the patient is
wrapped in clean sheets or blankets, analgesics are given.
4. Approximately 10L. (10080ml).
5. LR or NS.

Task № 2
Answer:
1. Full-thickness burn (3rd degree).
2. 54%.
3. I.v. fluid replenishment through venous cannulation is started, a catheter in the
bladder is placed, a nasogastric tube to decompress the dilated stomach is necessary,
analgesics are given, tetanus prophylaxis is considered, primary care of the wound
with local antiseptics.
4. Approximately 21L (21600 ml) of crystalloid solutions.
5. Colloids.

Task № 3
Answer:
1. Full-thickness burn (3rd degree).
2. 27%.
3. Respiratory injury. It is treated with inhalation of 100% oxygen at the scene of injury,
sometime an endotracheal intubation with assisted ventilation may be required.
4. Airway evaluation is done using flexible bronchoscopy.
5. Aggressive pulmonary toilet, use of mucolytics, early identification and treatment of
infection with AB.

Task № 4
Answer:
1. Circumferential burn of the trunk.
2. Escharotomy.
3. No.
4. Split-thickness and full-thickness skin grafting .
5. Allograft skin from cadavers, synthetic membranes (Biobrand, Silastic), autologus
keratinocytes, skin substitutes (Integra artificial skin, Alloderm), Pigskin, Biograne,
TransCyte, etc.

Task № 5
Answer:
1. III or IV degree.

246
2. Remove constricting clothes, wrap in warm blankets, give hot fluids, rewarming of
injured area (40 C0 20 to 30 minutes). Vesicles are left intact (not leaking or
infected), bed rest, foot cradle, lamb's wool is inserted between affected digits,
cleansed daily with an AB solution in a whirlpool bath.
3. In several weeks, after clear demarcation of nonviable tissues.
4. Presence of wet gangrene.
5. Evaluate patient's immunization status. Patients who have undergone previous active
immunization within 5 years of the time of injury require no further prophylaxis.
Patients who have received their most recent booster injection more than 5 years
before injure should be administered a booster dose of toxoid. Patients who have not
undergone prior immunization or without history of immunization should be given
250-500 units of human antitetanus globulin at one site and initial immunizing dose
of toxoid administered at another site.

TOPIC 28 GENERAL TRAUMA

Task № 1
Answers:
1. Dislocation of the right shoulder joint.
2. Fracture, contusion, sprain, and rapture of the right shoulder joint.
3. AP and lateral plain X-ray of the right shoulder
4. Closed joint reduction using one of the following methods: Matson‟s method,
Stimson‟s method, Dzhanelidze‟s method Motais, and Kocher‟s methods.
5. After reduction the shoulder has to be immobilized for 3-4 weeks. It may be done
using Velpau or Desault bandaging, or using specially designed commercial splints for
shoulder area.

Task № 2
Answers:
1. Simple fracture of the right radial bone.
2. AP and lateral plain X-ray of the right forearm.
3. Closed reduction of the right radial bone using closed method performed under
anesthesia.
4. Gravity methods (collar and cuff, “hanging cast”), traction (fixed or sliding),
operation.
5. Plaster of Paris or plastic (made of fiberglas) cast.
6. External fixation, internal splint (screws, plate, nail), continuous traction (“hanging
cast”), fixed or sliding traction (skin or skeletal).

Task № 3
Answers:
1. Ligament sprain of the right ankle joint.
2. Fracture, contusion, dislocation, and rapture of the right ankle joint.
3. AP and lateral plain X-ray of the right ankle joint.
4. First 24-48 hours – ice or chemical cold pack, elevation of the extremity, elastic
bandage, after two days heat may be used, NSAID, no weight bearing, removable
splint or light cast, progressive active exercises after healing.

Task № 4
Answers:
1. Crash-syndrome.
2. Compartment syndrome of lower extremities muscles.
3. Subcutaneous or open fasciotomy of lower extremities.

247
4. Acute kidney failure, renal form.
5. Elastic bandaging of both lower extremities (to decrease postischemic edema),
aggressive antishock and detoxication therapy (infusion therapy with crystalloids,
colloids, etc), antibacterial therapy, analgesics, immobilization of affected limbs,
treatment of ARF, anemia, hypoproteinemia, etc.

Task № 5
Answers:
1. Airway management is done. Depending on situation a removal of debris, the "chin
lift" or "jaw thrust" maneuvers, endotracheal intubation, or cricothyroidotomy may be
required.
2. Breathing (ventilation) is the next priority. An assisted ventilation using Ambu bag or
with the help of mechanical ventilator may be necessary if a patient cannot breath
himself.
3. Circulation (perfusion) is maintained by control of the bleeding which precedes
placement of the i.v. lines. (compressive dressing, tourniquet, or placement of
pneumatic antishock garment (pelvic injuries) may be required. Minimum two i.v.
lines should be placed percutaneously, or with venous cut-down, or internal jugular
(subclavian) vein cannulation. Fluid resuscitation begins with a 1000 ml bolus of LR.
Response to therapy is monitored by skin perfusion, UO, or CVP.
4. Neurologic assessment is done to determine a) level of consciousness (GCS),
b) pupillary condition c) movement of extremities (paralysis).
5. Tension pneumothorax.

TOPIC 29 HEAD, CHEST, AND ABDOMINAL TRAUMA

Task № 1
Answers:
1. Blunt chest trauma complicated by left side hemothorax.
2. Hb: 80-120 gm/l; RBC: 3,5-2,5; Ht: 0.25- 0.35.
3. Plain AP chest X-ray, US, CT, MRI, thoracentesis.
4. Underexposed area (white shadow) of fluid in the left pleural cavity collected at the
lower part of the space.
5. Placement of the chest tube (tube thoracostomy) to monitor whether the bleeding is
continuing or not.
6. Continuous bleeding may require thoracotomy for repair of the injured vessel which is
evident by: primary collection of large volume of blood (approximately 1,5-2L with
first aspiration); continuous hemorrhage via the chest drain at a rate of 100 to 400
ml/hr.

Task № 2
Answers:
1. Penetrating lacerated chest wound complicated by right side tension pneumothorax.
2. Plain AP chest X-ray.
3. Overexposed area (dark shadow) of air in the right pleural cavity without typical
pulmonary tissue structure.
4. A chest wound is dressed with material impermeable to air (to stop further
accumulation of the pneumothorax).
5. Needle aspiration of the air from the pleural cavity is done according to general rules
(aseptic technique, 2nd intercostals space, midclavicular line, etc.). If after needle
aspiration the air collects again the situation requires placement of the chest tube using
anterior tube thoracostomy according to general rules (aseptic technique,

248
2nd intercostals space, midclavicular line, connection of the tube to underwater-sealed
drainage system).

Task № 3
Answers:
1. Penetrating stab chest wound complicated by cardiac tamponade.
2. Compression of the heart by blood collected at the pericardiac sac.
3. Plain AP chest X-ray (increased, round heart shape).
4. Echocardiography, CT, and MRI may detect pericardial fluid, pericardiocentesis.
5. Pericardiocentesis is used with diagnostic aim and to relieve the cardiac tamponade. If
it is ineffective a treatment may require emergency thoracotomy to control bleeding.
Task № 4
Answers:
1. Incised wound of the occipital area. Contusion of the brain, mild degree.
2. Craniograprhy (exclude fracture of the skull), CT or MRI to exclude ICH.
3. Primary surgical wound debridement is followed by primary suturing of the wound
done according to common rules.
4. Treatment includes monitoring, bed rest, sedative and antihistamine drugs,
vasodilators, nootropic agents.
5. Diuretics (mannitol i.v.), hyperventilation, Fovler‟s position, maintenance of normal
circulating volume, monitoring of ICP is possible.
Task № 5
Answers:
1. Blunt head trauma complicated by right side expanding intracranial hematoma.
2. At admission GCS score was 15 points, b) during last examination GCS score is 10
points.
3. CT or MRI to find localization of the ICH.
4. Placement of exploratory burr holes at the same side with dilated pupil or CT data
(right side), craniotomy, evacuation of the hematoma and control of bleeding vessels.

TOPIC 30 BASIC PRINCIPLES OF SURGICAL ONCOLOGY


Task № 1
Answers:
1. Cancer of the esophagus.
2. Anemia (decreased level of Hb, Ht, and RBC), low grade inflammatory changes (left
shift, leukocytosis, rise of ESR).
3. Fibrooptic flexible esophagogastroduodenoscopy, transesophageal US, barium meal,
CT, MRI.
4. CT (MRI), X-ray of bones, plain chest X-ray, US of internal organs.
5. Resection of the esophagus with replacement by the bowel (or small intestine or
greater curvature of the stomach).
Task № 2
Answers:
1. Due to pyloric stenosis.
2. Fibrooptic flexible esophagogastroduodenoscopy, translumenal US, barium meal, CT,
MRI.
3. CT (MRI), X-ray of bones, plain chest X-ray, US of internal organs.
4. IV group.
5. Gastrojejunoanastomosis or jejunostomy.

Task № 3

249
Answers:
1. Cancer of the sigmoid part of the bowel.
2. Anemia (decreased level of Hb, Ht, and RBC), low grade inflammatory changes (left
shift, leukocytosis, rise of ESR).
3. Fibrooptic flexible colonoscopy, transluminal US, barium enema, CT, MRI.
4. Permanent colostomy.
5. Left hemicolectomy.

Task № 4
Answers:
1. Rectoscopy, sigmoidoscopy, transluminal US, barium enema, CT, MRI.
2. CT (MRI), X-ray of bones, Plain chest X-ray, US of internal organs.
3. By biopsy.
4. Permanent colostomy.
5. Abdominoperineal resection.

Task № 5
Answers:
1. Subcutaneous lipoma of the back.
2. Normal values.
3. Commonly the local examination is sufficient to define localization and extent of the
lipoma.
4. Biopsy with cytologic examination of the tissue sample. Needle, aspiration, incisional,
excisional.
5. Excision of the lipoma.

TOPIC 31 MALFORMATION SURGERY

Task № 1
Answers:
1. Pyloric stenosis due to antral muscular hypertrophy.
2. Palpation of lump in abdomen, US, barium swallow, FEGDS
3. III degree.
4. Hematocrit, RBC, hemoglobin level, and urine osmolality are increased, CVP is
dicreased, metabolic alkalosis, hypokaliemia.
5. cristalloids are administered in sufficient volume to reverse signs of hypovolemia (till
restoration of normal values of UO, urine osmolality, CVP, electrolytes, PR, RR, BP,
skin moisture, etc.).
6. Pyloroplasty (Ramstedt‟s operation).

Task № 2
Answers:
1. Hirschsprung's disease.
2. It results from a failure of migration of neuroblasts that form the mysenteric plexus
(parasympathetic ganglia). The result is intestinal obstruction in affected neonates.
3. Colonoscopy (sigmoidoscopy), biopsy for ganglion, barium enema.
4. Resection of aganglionic part is followed by anastomosis of the rectum with
ganglionic part of the colon.
5. Infection during pregnancy (Rubella, syphilis, HIV), ionizing radiation, pollution,
drugs, hereditary predisposition, alcohol and smoking, advanced age of parents.

Task № 3
Answers:

250
1. Cryptorhism of the right testicle.
2. Intraabdominal, inguinal canal, superficial inquinal pouch.
3. May cause sterility, pain in trauma, malignancy, psychological problems.
4. Clinical data, US, laparoscopy.
5. Orchidopexy – operation to descend testes to normal position.

Task № 4
Answers:
1. Coarctation of the aorta.
2. Aortic stenosis results in left ventricular hypertrophy with hypertension proximal to
the site of aortic coarctation and hypotension distal to it.
3. Chest X-ray, aortogram, CT.
4. Chest X-ray reveals notching of artery at lower margin of ribs; aortogram and CT
localize an area of stenosis.
5. Percutaneous Balloon Dilation, resection of coarctation with aortic reanastomosis.

Task № 5
Answers:
1. Accessory cervical rib.
2. Vascular and nerve pressure symptoms are caused by compression of the
neurovascular bundle by accessory cervical rib.
3. Plain neck X-ray.
4. Accessory cervical rib.
5. Sling and exercise, scalenotomy, or removal of the cervical rib.

TOPIC 32 PLASTIC SURGERY AND TRANSPLANTATION

Task № 1
Answers:
1. The muscle flap is commonly used. Also the synthetic sealants can be used.
2. Axial musculocutaneous flap.
3. Two types of distant flap can be used: either direct flap (crossleg flap) or free flap.
4. May be useful at closure of remote areas where local tissues are limited and
advancement or pivot flaps are not convenient. It requires special microvascular
technique, skillful personnel, possesses a high number of complications (vascular
thrombosis, necrosis, infection, etc.).

Task № 2
Answers:
1. The bone flap is commonly used.
2. Axial musculocutaneous flap.
3. Two types of distant flap can be used either direct flap (crossleg flap) or free flap.
4. May be useful at closure of remote areas where local tissues are limited and
advancement or pivot flaps are not convenient, it does not require special
microvascular anastomosing and skillful personnel. Avoid risk associated with free
flap. The patient should be bedridden for several weeks.

Task № 3
Answers:
1. A musculocutaneous flap is commonly used.
2. This size of defect especially in elderly debilitated patients can heal only with the help
of a tissue flap. It should provide sufficient bulk of tissue to cover denuded bone.
3. Advancement flap or pivot transposition flap (S-plasty flap or bilobed flap).

251
4. By skin suturing or grafting.

Task № 4
Answers:
1. By full-thickness or split-thickness skin autograft.
2. Advantages: easy to harvest, the donor site may be reused in 10-14 days, can be
expanded. Disadvantages: less cosmetic effect.
3. Advantages: better cosmetic results, absence of contraction, Disadvantages: limited
donor sites, require closure of the donor site.
4. Where the functional result is of most importance (area of joints)
5. Contralateral extremities, buttocks, trunk.
Task № 5
Answers:
1. Living related donor (siblings, children) or cadaver donor.
2. Living related donor/
3. The donor should have normal history, free of illness, malignancy, other disorders.
The function of transplanted organ must be normal.
4. They are preserved for up to 48 h by cold storage in ice with no perfusion, using a
concentrated potassium solution or with pulsatile perfusion using plasma-like solution.
An additional surface cooling with iced saline packs is necessary.
5. Heterotopic transplantation with positioning of the kidney into the iliac fossa. The
renal artery and vein are connected to iliac vessels. The ureter is connected to the
bladder.
6. Progressive decrease of urine output, rise of creatinine level, changes of the urine test
(casts, protein, leukocytes, etc.), thrombosis of vessels (evident by duplex scan,
angiography).

TOPIC 33 PARASITIC INFECTION SURGERY

Task № 1
Answers:
1. Secondary lymphedema of the right lower extremity due to filariasis.
2. Duplex US.
3. Nocturnal blood smear, leukocyte formula.
4. Nocturnal blood smear – presence of the microfilaria, leukocyte formula -
eosinophilia.
5. Antiparasitic drug Banocide (diethilcarbamazine-citrate) with multiple 3 to 4 week
courses 2 mg/kg 3times a day. Avoid severe physical exertions to lower limbs,
elevation of the extremity, elastic compressive stockings, lymphotonic drugs (detralex,
etc.), rheolytic drugs (pentoxifillin, etc.), NSAID (sodium diclofenak, etc.). Surgery
may be done to remove excessive sclerosed subcutaneous tissue at advanced cases.

Task № 2
Answers:
1. Hydatid disease of the liver.
2. Eggs are injested. Oncosphere emerges in the small intestine and penetrate the wall
passing into portal circulation and further seeding in the liver (most cases).forming
hydatid cyst maturates. It is filled with protoscolices. The definitive host (dog) is
infected by consuming a hydatid cyst (usually from seep carcass). Each protoscolex
can produce an adult worm within the canine intestine.

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3. Leukocyte formula - eosinophylia, positive Casoni‟s skin test (not reliable), positive
serological tests (complement fixation, indirect immunofluorescence test,indirect
hemagglutination) against echinococcus antigens.
4. Imaging studies (US, CT), angiography show the cyst in the liver.
5. Medical treatment (adjuvant to surgery) Albendazole 4 tab daily for three 28 courses
with 2 week rest periods between courses (20-40% success); Percutaneous aspiration
followed by injection of scolicidal agent (alc, HS).
6. Surgical treatment is a standard management. Surgical Approach may be done through
the cyst (protect cavity) or through meticulous separation of the entire cyst. Liver
resection my sometime be required. Scolicidal agents are commonly used during
surgery to limit a chance of abdominal contamination with protoscolices.
Task № 3
Answers:
1. Amoebic infection complicated by liver abscess.
2. Perforation of bowel wall followed by secondary peritonitis.
3. Encysted amoeba is ingested in contaminated food or water and swallowed.
Excystation occurs in small intestine. It may invade an intestinal wall or other organs
(liver). Encystment occurs in the colonic lumen. Cysts passed in feces.
4. Laboratory investigation: TBC; Stool sample; Serological tests - indirect
hemagglutination; Instrumental investigation: Imaging studies (US, CT), Plain chest
X-ray.
5. TBC – leukocytosis, maybe anemia; Stool exam shows amoeba and cysts; Serological
tests are positive; Imaging studies (US, CT) - abscess in the liver, Plain chest X-ray -
pleural effusion.
6. Metronidazole 800 mg 3 times daily for 7-10 days, Percutaneous aspiration of the
abscess is reserved for refractory to medical therapy abscess or very large one.

Task № 4
Answers:
1. Intestinal obstruction.
2. Perforation of bowel wall followed by secondary peritonitis, ascaris associated
appendicitis, obstruction of common bile duct followed by mechanical jaundice,
cholongitis, cholecystitis, pyogenic liver abscess, or pancreatitis.
3. Humans are infected by eating food contaminated by mature ova. The released larva
migrate through intestinal wall and carried into the lungs. Further the parasite ascends
into upper airway and is swallowed into intestine where the adult worm maturates
starting to shed the eggs with the stool.
4. Plain abdominal X ray shows characteristic air-fluid levels in the intestinal loops.
5. Treatment consists of laparotomy, resection of the part of the intestine with
reanastomosing of both ends. Sometimes enterotomy and removal of the “ball of
worms” causing obstruction may be attempted.
6. Approximately 6 liters.

Task № 5
Answers:
1. Amoebic infection complicated by secondary peritonitis due to perforation of
intestinal wall.
2. Hemoconcentration is evident by rise of Hb, RBC, and Ht level. Leukocytosis with
left shift, rise of ESR, disproteinemia, oliguria.
3. US, CT, MRI (intraabdominal fluid) b) paracentesis, culdocentesis, diagnostic
peritoneal lavage (DPL) – evidence of intraabdominal infection (pus, effluent), video
assisted laparoscopy – site of perforation and signs of peritonitis.
4. Free intraabdominal air collecting under the vaults of the diaphragm, air-fluid levels.

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5. Infusion therapy is started to correct hypovolemia and intoxication. Antibacterial
therapy, GIT decompression using NG tube, oxygen supplementation. After prompt
preparation the patient is operated. Surgery consists of midline laparotomy,
exploration of intraabdominal organs, treatment of injured organ, cleansing and
draining of the peritoneal cavity, suturing of the surgical wound.

TOPIC 34 OUT-PATIENT SURGERY. PREOPERATIVE PERIOD. SURGICAL


OPERATION

Task № 1
Answers:
1. General combined anesthesia.
2. The patient is asked about history and typical cardiac (arrhythmia, etc.), and
respiratory (TB, chronic bronchitis, etc.) complaints, history of diabetes mellitus and
previous anesthesia (allergy, complications, etc.) in order to reveal any coexisting
pathology. History of previous abnormal bleeding (from wounds, easy bruisability,
etc.); Family history (inherent coagulopathy), drug history (anticoagulants, antiplatelet
drugs, etc.) to reveal bleeding tendency.
3. Skin is inspected for petechiae, ecchymoses, jaundice in order to reveal bleeding
tendency. Respiratory (lungs), cardiovascular (heart), and GIT (ascitis, liver and
spleen) systems are examined using common methods of inspection, palpation,
percussion, and auscultation in order to reveal any coexisting pathology (arrhythmia,
murmurs, wheezing, hepatomegaly, splenomegaly, etc.).
4. Bleeding time, PT, aPTT, fibrinogen level, platelet count, TBC, glucose level, blood
chemistry, urine analysis, blood typing and cross-matching. ESG (or EchoCG), Plain
chest X-ray, spirometry.
5. Yes, he has.
6. Preoperative shaving of area of planned surgery is to be done no longer than 6 hours
before surgery.

Task № 2
Answers:
1. Yes, he has.
2. Yes, it does.
3. Pulmonary embolism.
4. Prophylactic dosage of heparin or LMWH (fraxiparin).
5. Intermittent pneumatic compression of lower limbs, elastic bandaging or compressive
stockings of lower extremities, early ambulation after surgery.

Task № 3
Answers:
1. Yes, it is.
2. Life-saving indications.
3. Amputation of right lower extremity after short preoperative preparation with infusion
therapy to correct hypovolemia.
4. Cleansing enema and stomach lavage using Levin tube.
5. Spinal (or epidural) anesthesia is preferred to general one. It has a lower risk of
complications comparing to general anesthesia.
6. Significant risk.

Task № 4
Answers:
1. Yes, it is.

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2. Life-saving indications.
3. Emergency.
4. Percutaneous transhepatic cholecystostomy or conventional cholecystostomy. It has a
lower risk of complications comparing to conventional open cholecystectomy.
5. Local anesthesia is preferred. It has a lower risk of complications comparing to
general anesthesia.
6. Moderate risk.

Task № 5
Answers:
1. Yes, it is.
2. Elective.
3. Relative.
4. Open or endoscopic cholecystectomy because it will completely cure the patient of
gallstones.
5. General combined anesthesia is preferred. It gives sufficient musculary relaxation and
depth of narcosis.
6. Moderate risk.

TOPIC 35 POSTOPERATIVE PERIOD. NUTRITION OF SURGICAL PATIENTS

Task № 1
Answers:
1. NPO restriction.
2. Approximately 3500ml of NS or LR to cover maintenance daily requirements + 1000
ml of LR to cover ongoing loss.
3. Approximately 2400 ml of D5%W + 1200 ml of NS + app. 100 mEq KCl to cover
maintenance daily requirements + 1000ml of LR to cover ongoing loss.
4. Analgesics (promedol or NSAID), prophylactic anticoagulants (heparin or LMWH),
vitamins, broncholytic agents.

Task № 2
Answers:
1. DVT of the right low extremity.
2. Pulmonary embolism.
3. Plain chest X-ray (wedge-shape shadow), ECG, EchoCG, a ventilation-perfusion scan
followed by angiography. Duplex scan of deep veins of affected extremity.
4. CPR, supplemented 02, fluid resuscitation, inotropes, heparin.
5. aPTT has to be increased to 2 times higher of original; INR has to be increased till 2,5
– 3.

Task № 3
Answers:
1. Distended urinary bladder.
2. Acute urinary retention could be caused by surgery and trauma of urinary bladder
during appendectomy or effect of spinal anesthesia (if was done).
3. Place the patient in upright position.
4. Foley catheter is placed into the bladder.

Task № 4
Answers:

255
1. Postoperative wound infection.
2. Failure of aseptic technique before (poor skin preparation, etc.), during (contact of
nonsterile items with the wound, etc.), or after (improper care of postoperative wound)
surgery.
3. If the abscess of the postoperative wound is deeply situated the diagnosis may be
assisted by ultrasound (or other imaging studies). WBC shows leykocytosis with left
shift, rise of ESR.
4. The wound should be opened, sutures removed, irrigated, and debrided if pus or
necrotic tissues is present.
5. Appropriate AB administration following wound cultures, treat surrounding cellulitis.

Task № 5
Answers:
1. Postoperative hypostatic left side pneumonia.
2. Failure of proper postoperative prophylaxis of hypostatic pneumonia in elderly
patients.
3. WBC, ESR, Blood chemistry. Culture of the sputum with bacteriologic studies. Plain
chest X-ray, CT, MRI.
4. Suction of mucus from the nose and mouth (unconscious or unable patients);
encourage coughing and deep-breathing; - change the client's position every 2h; use
the spirometer. Coughing and deep-breathing ordered every 1 to 2h. Intermittent
positive-pressure breathing is performed two or more times per day. The oxygen
delivered by means of mechanical ventilator may be ordered. It also may be useful to
administer medication by the aerosol method into the lungs.
5. Once the diagnosis is established the patient is administered appropriate antibacterial
treatment, mucolytics, aerosol administered agents.

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