By Dr. Tatyana Kravchenko from Surgery Department# 1

1. O.O. Bogomolets National Medical University
Department of General Surgery N1
“Approved”
at the Methodist General Surgery
Department #1 Council
“___“________2006, protocol #________
Head of General Surgery Department #1
Professor _________O.Dronov
Study Guide for Practical Work for Teachers and Students
Topic: “Examination of surgical patient (part II).
Objective examination of surgical patient.
Methods of diagnosis establishment”
Course 3
Foreign Students’ Medical Faculty
Duration of the lesson – 90 min.
Worked out by
assistant
S.V. Zemskov, MD
Kyiv
2006

2. I. Priorities of the subject
Objective examination of the surgical patient is one of the most important steps in
establishment of correct diagnosis, especially if the patient is unconscious. The diagnosis should
always be proved by data of objective examination. These data are also a basis for indications for
surgical treatment. Compilation of data of subjective and objective examination brings one to the
diagnosis establishment. Life and health of the patient depends on knowledge and attentiveness
of the doctor who manages with his objective examination.
II. The aim of training
A.1. Student should be acquainted with the following subjects:
– symptoms of surgical diseases
– main acute abdominal surgical pathology
– differentiating diagnosis
– pattern of investigation of surgical patient
– systems of evaluation of objective status of the patient (APACHE, RANSON,
SAPS)
A.2. Scope of the knowledge:
– basic method of objective examination of the patient
– definition of local status and its role in surgery
– consequence of objective examination
– inspection
– palpation
– percussion
– auscultation
– additional methods of investigation of surgical patient
– method of establishment of diagnosis
A.3 Student should be able to:
- perform an inspection of patient
- perform a palpation
- percussion percussion
- perform auscultation
- write down the results of objective examination into the patients natural
history
III. Training and educational objectives
1. To facilitate understanding the importance of complete objective examination of the
patient in order to establish correct diagnosis and indications for surgical treatment
2. To facilitate learning the principles of the medical ethics and the deontology in
patients’ examination.
3. The exemplify the importance of the knowledge of the subject.
IV. Interdisciplinary integration
Subject for study and Scope of knowledge Scope of skills
corresponding chair
Anatomy Topography of visceral organs To be able to define the size
and margins of the organs by
objective examination
Biochemistry and Normal rates of in biological To be able to comment rates
organic chemistry liquids of organism. Reasons and of biological liquids of

3. effects of deviation of this rates organism
Physiology Physiological rates of Comment the rates of
hemodynamics and breathing hemodynamics and breathing
Propedeutics Methodic of investigation of the Gather anamnesis, perform
patient inspection and objective
examination
V. Content of training
The patient’s objective examination (status praesens objectivus) is performed by means
of inspection (inspectio), palpation (palpatio), percussion (percussio), auscultation (auscultatio),
and measuring. This topic is thoroughly studied by students during the course of Propaedeutics
of internal diseases.
Performing the objective examination doctor should use all his sense organs, he should
take into consideration the patient’s status and the time that surgeon has.
The peculiarity of the surgical patient’s objective examination, especially in urgent
situations, consists in examination of the morbid area (locus morbi, status localis). Through the
examination of the morbid area the form, symmetry, presence of pathological formations should
be discovered. The inspection should be performed either during daytime or in the well-lighted
room. Usually, status localis demonstrates the symptoms typical for proper disease or its
complications. Data, obtained at diseased area examination should be separately filled in the case
history.
The second important task of surgeon is to determine the severity of the patient’s general
state, which can be satisfactory, medium severe (bad) and bad. Determination of the patient’s
state severity is important for admission to the intensive care unit.
The patient’s inspection (inspectio) is quite an informative method of examination which
starts with the moment of surgeon’s and patient’s meeting. Doctor should pay attention at the
peculiarities of patient’s walk, his face expression, body position, manner of speech, color of
sclera and skin, presence of rash and hemorrhages.
Palpation (palpatio) should be performed carefully and started with the body areas not
damaged by p0athoological process. Palpation can reveal presence, localization and intensity of
the tenderness in different body zones, muscles contraction and tension, local temperature rising
and falling, presence, consistence, configuration and size of pathological malformations, special
symptoms etc.
Measuring – is an important method to determine the extremities’ real length, joints’
mobility, extremities’ edema, tumor size and others.
The laboratory and instrumental examination methods provide the objective confirmation
of the diagnosis.
Diagnosis (identification) – is an accurately determined definition of the patient’s disease
based on the examination results and according to the State register of the diseases nomenclature.
A. Laboratory tests
Basic laboratory tests for surgical patient are:
- hemoglobin, hematocrit, leucocytes, platelets
- fibrin, fibrinogen, prothrombin index, partial activated thromboplastin time
- blood coagulation time
- sodium, potassium, chloride, transaminases (AlT, AsT)
- blood glucose
A. Chest X-ray

4. - indicated to all patients with cardiovascular and pulmonary pathology,
immune suppression, malignancies, specific anamnestic data (imprisonment,
homeless), as well as to all patient indicated for major surgical procedures.
B. Electrocardiography
Indicated to all patients elder then 40 years, as well a to all patients with signs of cardiac
insufficiency, rhythm disorder, coronary diseases (inc. myocardial infarction). In
cardiosurgical patients cardiosonography and coronaroangiography.
C. Spirometry
Is performed in order to define vital capacity of lungs and forced expiratory volume ( per
1 second). These test together wit blood gas analysis are important in patients who undergo
laparoscopic procedures. Methods as perfusion and inhalation scintigraphy, whole body
platismography, loaded blood gas analysis, pulmonary artery barometry, bronchoscopy are
indicated to patients who undergo pulmonary surgery.
D. Ultrasonography
Abdominal and pelvic ultrasound is very valuable method in investigation of parenchymal
organs. It is also a golden standard in diagnosis of cholelithiasis. Doplerography allows
examination of blood flow in major vessels and in organs.
E. Endoscopy
Is standard in investigation of hollow organs. These methods are:
fibroesophagogastroduodenoscopy, rectoscopy, colonoscopy, bronchoscopy. Modern
endoscopes allow investigation of choledochus, pancreatic duct and air sine of skull.
Endoscopy also allows performance of microsurgical manipulations.
F. Other visualization methods
Accept for ultrasound and X-ray, there are radioscintigraphy, computer tomography, magnet-
resonance tomography, positron-emission tomography (golden standard in diagnostics of
malignancies). These methods investigate either precise size, localization of organ or lesion,
or its function and character.
In all surgical patients endocrine pathology should be excluded (diabetes mellitus, hypo-
or hyperthyroidism, pathology of adrenal glands) because it may provoke bench of complications
intra- and postoperatively.
VI. Structure and Organization of the Lesson:
6.1. Duration of the lesson – 3 academic hours
6.2. Lesson Stages (table)
№ Basic lesson stages and their Study Training and Materials for the Tim
contents objectives control methods methodic supply e in
and their min
mastering
level
I Preliminary stage Students’ assessment
1. Lesson organization A-I register 2’
2. Study objectives setting 9’
3. Control of basic A - II Oral questions Control questions on 25’
knowledge, experiences, A - III on topic, test topic, A- Form tests
skills computer or
standard-paper

5. program
II Basic stage
1. Objective examination A - III Individual
Surgical patient 30’
together with the teacher of A - IV control
the surgical patient
2. Individual students’ A - III Individual
Surgical patient 45’
examination of the surgical A - IV control
patient
III Final stage
1 Control and correction of A - III 5’
professional skills and A - IV
experience
2 Making conclusion of the A - II Out-patient card of the 15’
lesson (individual A – III in-patient, students’
questioning, discussion of A - IV assessment register, A-
the examined patient’s Form questions
cases, revision of the
establishment diagnosis
methods) Theme outline of
3 Home task A - IV practical lessons, study 5’
guides for practical
work
V11. Materials for the methodic lesson supply.
1. Materials for the lesson preliminary stage.
A. Lesson topic control questions:
The surgical patient’s objective examination, diagnosis and its substantiation
1. What are the counterparts and peculiarities of the surgical patient’s objective examination?
2. What is a sequence of the surgical patient’s objective examination?
3. Give the definition of the term and meaning of “locus morbi” in the surgical patient’s
objective examination.
4. What instrumental methods of examination are important for establishing the diagnosis of the
surgical patient?
5. What are the indices to determine the severity of the patient’s general status?
6. Give the definition of the term “diagnosis”.
7. What types of diagnoses are there?
8. What is a sequence of the diagnosis establishment?
9. Name the diagnoses related to the urgent surgical pathology.
B. Format A tests
1 45 years old male presents pale skin on one foot and shank. Puls on a. dorsalis pedis
and a. tibialis posterior is absent. Puls on a. femoralis is preserved. Which artery is
affected?
A. A. Genis descendes
B. A. Iliaca externa
C. A. Fibularis
D. A. Femoralis profunda.
E. A. Poplitea

6. 2 60 years old male presents dilatation of subcutaneous vein of anterior abdominal
wall. Circulation in which vein is affected?
A. v. cava superior
B. v. hemiazigus
C. v. portae hepatis
D. v. mesenterica superior
E. v. mesenterica inferior
3. 48-years old male presents dilated subcutaneous veins in paraumbilical region (head of
medusa). Chronic alcohol consumptions in anamnesis. Which organ is affected and through
which venous anastomoses venous blood flows?
A. Liver. Porto-caval anastomosis of v. mesenterica
B. Pancreas. Cava-caval anastomosis of v.mesenterica
C. Spleen. Cava-caval anastomosis of gastric vein system
D. Liver. Cava-caval anastomosis of superior and inferior mesenteric vein system
E. Stomach. Porto-caval anastomosis of gastric
4. Patient presented swelling on medial side of the hip, increase in subcutaneous veins volume,
venous nodes formation. Which vein is affected?
A. . V. poplitea
B. V. saphena parva
C. V. femoralis
D. V. saphena magna
E. V. iliaca externa
5. Emergency case: patient presents bloody vomiting at admission. The patient has liver
cirrhosis in anamnesis. Which veins are affected?
A. liver portal vein
B. superior mesenteric vein
C. hepatic veins
D. esophageal veins
E. splenic veins
6. Female presented sign of acute abdomen at admission. After the investigation abdominal
pregnancy is suspected. Which anatomical region should be punctured in this case?
A. Excavatrio rectouterina
B. Excavatio vesicouterina
C. excavatio rectovesicalis
D. Fossa ishiorectalis
E. Processus vaginalis peritonei
7. X-ray examination shows the signs of air in stomach of a patient. In which part of the stomach
is it located?
A. corpus
B. fundus
C. cardia
D. pylorus
E. small curvature
8. What is the anatomical feature in duodenum that helps identifying the papilla Vateri during
gastroduodenoscopy?

7. A. duodenal glands
B. circular plicae of duodenum
C. bulbus of duodenum
D. longitudinal plicae of duodenum
E. ligamentum hepatoduodenalis
9.45 years old male presented acute severe pain in epigastrium at admission. After examination
diagnosis is established: Perforation of ulcer of posterior wall of stomach. Where is gastric
content localized after the perforation?
A. bursa omentalis
B. bursa hepatica
C. bursa antegastrica
D. left mesenterial sac
E. right mesenterial sac
10. In which peritoneal space first spreads transudate in patient with acute necrotizing
pancreatitis?
A. bursa omentalis
B. bursa subhepatica
C. bursa antegastrica
D. left lateral chanal
E. right lateral channel
Correct answers:
Правильні відповіді:
1–E 4–D 7–B 10 - A
2–C 5–D 8-D
3–A 6–A 9–A
VIII. Supporting materials required for teaching
1. Participation in clinical duties on admission
2. Working in library
IX. Literature
1. „ Загальна хірургія”, ред. С.П.Жученка, М.Д. Желіби, С.Д.Хіміча – Київ,
„Здоров”я”, 1999 р.
2. „ Загальна хірургія”, ред. М.П.Черенька – Київ, „Здоров”я”, 1996 р.
3. „Методичні рекомендації до практичних занять з загальної хірургії з доглядом за
хворими”. В.О.Шидловський. – Тернопіль, 1994 р.
4. „Пропедевтика хірургічних захворювань”. В.О.Шидловський.- Тернопіль, 1999 р.
5. „Общая хирургия”, В.К.Гостищев,М., „Медицина”,1997 р.
6. „Общая хирургия”, В.С.Голованов,М., „Медицина”,1997 р.
7. „Практика хірургії”, ред. К.В.Манна, Р.Г.Русселя, Н.С.Вільямса, пер. з англ. М.,
„Медицина”, 2000 р.
8. Тематичний лекційний матеріал та тематичний цикл практичних занять кафедри
загальної хірургії №1 НМУ.