Physical examination (examination): what is it. Deep Lymph Nodes What is a Physical Exam

Physical examination- a set of medical diagnostic measures performed by a doctor in order to make a diagnosis. All methods related to the physical examination are carried out directly by the doctor using his senses. These include:

§ Inspection
§ Palpation
§ Percussion
§ Auscultation

These methods require minimal equipment for the doctor and can be used in any conditions. Currently, with the help of these methods, a primary examination of the patient is carried out and, based on the results obtained, a preliminary diagnosis is made, which is subsequently confirmed or refuted using laboratory and instrumental examinations.

If at the beginning of the 20th century physical examination methods were the only way for a doctor to obtain data on the patient's condition, then by the end of the 20th century the situation had changed, almost all physical examination data can be obtained using instrumental methods.

Currently, in connection with this trend, the skills of physical examination are gradually being lost, this is especially pronounced in countries with a good supply of high-tech medical equipment. However, even in these countries, physical examination has not lost its importance as a basic method to determine the suspected disease. An experienced clinician, using only physical examination methods and history taking, in many cases can make the correct diagnosis. If it is impossible to make a diagnosis only on the basis of physical examination data, an in-depth diagnosis and differential diagnosis are carried out with the involvement of laboratory and instrumental research methods.

Physical methods sometimes give more information than instrumental ones. The symptoms of the disease, detected using the clinical method, are the primary factual material on the basis of which the diagnosis is built.

During the clinical examination of the patient, as noted by I. N. Osipov, P. V. Kopnin (1962), vision is most widely used, with the help of which the examination is carried out. Visual stimuli have a very low threshold, as a result of which even a very small stimulus is already capable of causing visual perceptions, which, due to an insignificant difference threshold, make it possible for the human eye to distinguish an increase or decrease in light stimulus by a very small amount. Percussion and auscultation are based on auditory perceptions, palpation and partially direct percussion are based on touch, which also makes it possible to determine the humidity and temperature of the skin. The sense of smell may also be of some importance in the diagnosis, and ancient doctors even tasted the presence of sugar in the urine in diabetes. Most of the symptoms detected by sight, such as skin color, physique, gross changes in the skeleton, rashes on the skin and mucous membranes, facial expression, eye shine, and many others, belong to the category of reliable signs.

General inspection:

? Assessment of the general condition of the patient
? position in bed
? State of consciousness
? Facial expression
? Age (in appearance)
? Physique (constitution)
? Anthropometric data: height, weight, BMI kg/m2

Thermometry.

? Skin and visible mucous membranes
? Hairy integuments
? Nail condition
? Nutritional status: subcutaneous fat
? Edema
? Regional lymph nodes
? Muscular system
? Skeletal system
? joints
? The size and consistency of the thyroid gland
? Evaluation of some neurological symptoms

Palpation(from lat. palpation"feeling") - a method of medical examination of the patient. As a way to study the properties of the pulse, palpation is mentioned in the writings of Hippocrates. As a method for examining internal organs, palpation became widespread in Europe only from the second half of the 19th century after the works of R. Laennec, I. Shkoda, V.P. Obraztsov and others.

Palpation is based on the tactile sensation arising from the movement and pressure of the fingers or palm of the groping hand. With the help of palpation, the properties of tissues and organs are determined: their position, size, shape, consistency, mobility, topographic relationships, as well as soreness of the organ under study.

Distinguish superficial and deep palpation. Superficial palpation is carried out with one or both palms laid flat on the examined area of the skin, joints, heart, etc. Vessels (their filling, wall condition) are felt with fingertips at the place of their passage. Deep palpation is carried out by special techniques, different in the study of the stomach, intestines (sliding palpation, according to Obraztsov), liver, spleen and kidneys, rectum, vagina, etc.

Auscultation(lat. auscultatio) - a method of physical diagnostics in medicine, veterinary medicine, experimental biology, which consists in listening to sounds generated during the functioning of organs. Method auscultation was open René Laennec back in 1816

Auscultation can be direct - applying the ear to the organ being listened to, and indirect - using special devices (stethoscope, phonendoscope)

When examining a patient, one should not forget that the basis of diagnosis is a survey and a physical examination of the patient. Special research methods play only an auxiliary role. Examination of the patient begins with the clarification of the patient's complaints (and they should be identified as fully as possible). Next, proceed to the collection of an anamnesis of the disease and an anamnesis of life. Particular attention should be paid to the presence of concomitant diseases. Then proceed to the physical examination (examination, palpation, percussion, auscultation). As a rule, after questioning and physical examination of the patient, it becomes possible to form an idea of a likely diagnosis.

The use of special research methods is determined by what disease is suspected in a given patient. These research methods confirm or refute the initial diagnostic assumption. The patient may need, in addition to the necessary minimum laboratory tests (OAC, OAM, stool tests for worm eggs, blood for RW), and a biochemical blood test, a coagulogram, determination of the blood group and Rh factor, a blood and urine test for α -amylase. Also, when examining a surgical patient (especially with purulent pathology), it is important to conduct a complex of microbiological studies, including microscopy, bacteriological examination to determine the sensitivity of the isolated microflora to antibiotics.

To instrumental research methods include endoscopic, x-ray, ultrasound, as well as tomography (computer and magnetic resonance).

Endoscopic research methods. 1. Laryngoscopy.2. Bronchoscopy.3. Mediastinoscopy.4. Esophagogastroduodenoscopy.5. Retrograde cholangiopancreatography (ERCP) .6. Fibrocolonoscopy.7. Sigmoidoscopy.8. Cystoscopy.9. Laparoscopy.10. Thoracoscopy.

X-ray methods of research.

1. Minimally invasive: 1) fluoroscopy behind the screen; 2) radiography of various areas of the body; 3) tomographic research methods.

2. Invasive (require strict indications, since they give a high percentage of complications): 1) angiography; 2) percutaneous transhepatic cholangiography (PCH); 3) fistulography; 4) excretory urography; 5) intraoperative radiological methods of investigation.

Ultrasonic research methods. 1. Scanning.2. Echolocation.3. Dopplerography.

59 Abdominal injury. Classification. Etiology and pathogenesis. Symptomatology. Diagnostics. Treatment is general and local.

Classification of abdominal injuries

injury can be: mechanical ; chemical; ray; combined. Considering that surgeons are mainly engaged in mechanical injury, in the future we will talk about it. It includes: A. Open injuries (wounds). I. By the nature of the damage to the abdominal wall. 1. Non-penetrating wounds of the abdomen: a) with damage only to the tissues of the abdominal wall; b) with damage to internal organs under the influence of the force of a side impact. 2. Penetrating wounds of the abdomen: a) without damage to internal organs; b) with damage to hollow organs; c) with damage to parenchymal organs; d) with damage to hollow and parenchymal organs; e) with damage to retroperitoneal organs and vessels. II. By the mechanism of application and the nature of the injuring object. 1. Injuries with sharp tools and objects: a) Cut wounds; b) Stab wounds; c) Stab wounds; d) Chopped wounds; e) Lacerations; f) Bitten and scalped wounds. 2. Gunshot wounds: a) shot wounds; b) bullet wounds; c) shrapnel. B. Closed injuries. I. Without damage to internal organs. II. With damage to internal organs and blood vessels: a) with damage to parenchymal organs; b) with damage to hollow organs; c) with damage to hollow and parenchymal organs; d) with damage to retroperitoneal organs and vessels. Differential diagnosis: It is necessary to dynamically monitor the condition of the victim in a hospital setting. With a closed abdominal injury, it is difficult to exclude damage to hollow or parenchymal organs. Dynamic observation and laboratory and instrumental examination of the victim (laparoscopy, laparocentesis with a groping catheter, etc.) are methods that allow you to develop the best treatment option. In doubtful cases, exploratory laparotomy should be performed.

Symptoms of damage to parenchymal organs

Liver damage. The main task is to stop bleeding, remove crushed non-viable tissues, pack the wound with an omentum, and suture. Damage to the spleen. With a gross destruction of the organ, it is removed. With minor injuries, the organ is tried to be preserved (organ-preserving operations). The main task is to stop the bleeding. Damage to the stomach. When the wall is ruptured, economically excise non-viable tissues, apply two-story silk sutures in the transverse direction to the wound. Damage to the duodenum. Careful revision, including the posterior wall of the intestine. With a small gap, economically excise non-viable tissues and apply a two-story silk suture in the transverse direction. Damage to the small intestine. Revision of all intestinal loops. Gut ruptures (4-5 mm) are sutured with two-story silk sutures in the transverse direction. Colon damage . The revision starts from the ileocecal angle. Small tears of the serous cover are sutured with silk serous sutures. Kidney damage. With incomplete single ruptures of the parenchyma and pelvis, with separation of one of the poles of the kidney, organ-preserving operations are indicated. With extensive crushing of the parenchyma or detachment of the kidney from the supply vessels, a nephrectomy is performed. Damage to the ureters. Non-viable edges are cut economically and ureter patency is restored by applying circular interrupted catgut sutures to the ureter on the catheter.

Treatment of closed abdominal injuries First aid

First aid on the battlefield (in the lesion): removing the victims from the rubble, cleansing (if necessary) the oral cavity and nasopharynx, restoring breathing and cardiac activity, giving the victim a horizontal position, administering painkillers using a syringe tube. Evacuation to the WFP is urgent.

First aid

In addition to first aid measures, analgesics and cardiac drugs are administered. In case of combined injuries of other anatomical regions (skull, chest, limbs), first aid is provided (see the relevant sections above). Evacuation to the WFP in the first place.

At present, the diagnostic value of, for example, auscultation of the heart is not opposed to the modern version of ultrasound examination (ultrasound) of the heart. Each method has its advantages and disadvantages, indications and contraindications for diagnostic use. At a certain stage in the development of medicine, when in the era of highly developed physical diagnostics methods of instrumental diagnostics, which were imperfect for that period of time, gradually began to be introduced, there were discussions about the primacy of both directions. However, the real medical and diagnostic work has proved the vital need for a combination of physical and instrumental research methods.

The physical methods of examining the patient include: examination (inspection), palpation (palpation), percussion (tapping) and auscultation (listening).

You should stop at the place of the general examination in the algorithm of the study of the patient. Examination almost always precedes all subsequent research methods, since with the help of it the doctor solves a number of primary tasks that guide him in further diagnostic actions. For example, the forced position of the patient in bed revealed during the examination makes one think about several diseases, then the specific condition is specified by physical methods.

Examination of the patient

State of consciousness

In critically ill patients, their consciousness is assessed. In milder cases, it is clear when the patient is clearly oriented in time and serves himself, is communicative, adequately answers questions. There are four degrees of impaired consciousness:

confusion, when the patient reasonably answers the questions posed, but the answers sound slow;
stupor, or stunning;
stupor (stupefaction);
coma is characterized by complete loss of consciousness. Severe, sometimes irreversible disorders of cerebral circulation (cerebral hemorrhage, vascular thrombosis) cause cerebral coma. All comas have a serious unfavorable life prognosis, most often being irreversible.

The opposite variant of the considered disorders of consciousness is the excitation of the central nervous system caused by irritative disorders of consciousness. Initially, the patient is restless, excited, overreacts to the environment, in the future, his ideas about the world and others may be distorted. With deeper disorders of consciousness, delirium (delirium) occurs, in which an extreme degree of excitement sets in: the patient tries to escape from the ward, to run somewhere, completely distorted representations that do not correspond to reality], so-called hallucinations, appear in his mind.

Facial expression

Facial expression may be normal, calm, or have features that increase with the course of the disease (for example, suffering, "mitral face", etc.). The suffering face is sometimes called the face of Hippocrates. It is observed in patients with diffuse peritonitis, perforation of the intestine or stomach, intestinal obstruction, in an agonal state. At the same time, all facial features are pointed, the eye sockets are sunken, dimmed, extinct eyes, small drops of sweat protrude on the forehead.

A kind of "mitral face" of patients with bicuspid valve defects, more often mitral stenosis (MS). It is youthful (tissue hypoxia), slightly edematous, with a blue blush, violet-blue color of the lips, tip of the nose and auricles.

The face of a patient with Graves' disease (thyrotoxicosis) looks unusual. It is distinguished by the richness of facial expressions, extreme liveliness. There is bulging eyes (exophthalmos), an unusual gleam in the eyes, the face looks angry, irritated, and sometimes frightened.

Skin and mucous membranes

During the inspection, the color of the skin, scars, changes in the hairline and nails, which are skin derivatives, as well as the presence of damage to the skin in the form of bedsores or trophic ulcers, are determined. Palpation makes it possible to assess the degree of dryness or moisture of the skin and turgor.

Red coloration of the skin (diffuse or spotty) as a physiological phenomenon occurs under the influence of emotional arousal, feelings of anger or shame. Pathological, transient red coloration of the skin occurs with fever and is usually accompanied by a gleam in the eyes (feverish face). As a persistent phenomenon, a red color with a purple-bluish tint is observed in polycythemia, accompanied by a sharp increase in the number of erythrocytes in the peripheral blood (above 5-6 x 1012 in 1 mm 3).

Limited hyperemia on various parts of the body occurs with erysipelas. Often, against this background, phlegmon develops.

The bluish coloration is most often due to an increased content of reduced hemoglobin in the blood. When poisoned by some poisons (nitrobenzene, etc.), hemoglobin is transformed into methemoglobin, which causes the development of cyanosis.

Skin rashes. A number of common diseases of the internal organs, as well as acute infections, are accompanied by the appearance of rashes on the skin, which are distinguished by a certain originality. This redness is erythema (erythema), a more limited area is a spot (macula), roseola (roseola), nodule (papula), bladder (vesicula), abscess (pustula), blister (urticaria), small, punctate skin hemorrhage (petechia) . Accurate recognition of skin rashes has a very significant diagnostic value in the practice of an infectious disease specialist. Various, extremely similar to the above rashes occur in allergic reactions to various allergens (household, food, medicinal). Most often they manifest themselves in the form of the so-called urticaria.

petechial rash(often abundant and thick) occurs in diseases combined in the group of hemorrhagic diathesis. These include essential thrombocytopenia, Werlhof's disease, hemorrhagic vasculitis, or Shenlein-Genoch disease, etc. On the extremities, the rash is usually symmetrical, massive, thick (reminiscent of a stocking).

Separate vesicles (vesicles) may appear as isolated rashes on the face, lips, and wings of the nose. Such rashes are called "herpes" (herpes).

When wounds are healed by primary intention, linear scars are formed, and when healed by secondary intention, stellate, wide, pigmented, irregularly shaped scars are formed. Sometimes scars have the appearance of small light lines in the region of the lateral sections of the abdomen in women who have given birth, more often who have repeatedly given birth (striae gravidarum).

Skin elasticity. After examining the skin, one should proceed to the palpation and determination of skin turgor, or elasticity, which is determined by the development of subcutaneous fatty tissue. Normal skin is elastic. Loss of skin elasticity as a physiological phenomenon occurs in the elderly. In other cases, this is a pathological sign, observed with severe exhaustion (cachexia), dehydration of the patient against the background of profuse diarrhea and vomiting (cholera, etc.).

Hairline change. During a general examination of the patient, the degree of hair development in places where their presence is a manifestation of secondary sexual characteristics is of some importance. In women, hair growth is limited to the pubic area. The male type of hair growth in women, as well as hair growth in unusual places (face, chest) - the so-called hirsutism - indicates an endocrine pathology. With iron deficiency anemia, dryness and brittle hair, as well as their early gray hair, take place.

Changing nails. With a number of diseases of the internal organs, a change in the nail plates is observed. Normally, the nail has a pinkish color, a shiny convex surface, has no striation. With iron deficiency anemia, due to changes in the activity of cellular respiration enzymes containing iron in the nail plates, the nails become thinner, become dull and brittle, and become striated (koilonychia). In infective endocarditis (IE), the nail plate acquires the features of a bird of prey claw, dramatically changing its shape.

Similar changes in nails can occur during prolonged work with metal.

Power state. This concept implies the degree of development of the subcutaneous layer. For evaluation, the palpation method is used - the thickness of the skin fold on the abdomen, next to the navel, is determined. Normally, this fold should not exceed 2 cm. With obesity, its thickness increases, with exhaustion, weight loss, on the contrary, it decreases and may be completely absent.

Edema

If you press on the area of the skin located above the surface of the bone, then a depression and a hole are formed), which persists for some time after the removal of the pressing finger. Edema can be dense and loose. A slight degree of swelling, in which there is no clear indentation from finger pressure, is called pastosity. Edema of all fiber is called anasarca (anasarca). There are peripheral and abdominal edema (ascites, hydrothorax and hydropericardium). They can be cardiac (heart failure), renal (kidney pathology), hungry (malnutrition). It is necessary to be able to differentiate edema according to clinical signs.

The lymph nodes

Significant diagnostic value in the process of general examination has an assessment of the lymph nodes located in the subcutaneous fat layer. Normally, they are not palpable. In some diseases of the internal organs, the lymph nodes increase and they can be felt. The soft consistency of the nodes indicates a fresh, active pathological process in them, dense - about sclerosis (fibrosis) of the nodes - their germination with connective tissue. The tuberosity of the nodes, along with their dense consistency, is characteristic of malignant neoplasms (metastases).

Thyroid

Normally, the thyroid gland cannot be felt. Its increase (goiter), along with bulging eyes (exophthalmos) and tachycardia, refers to the characteristic manifestations of thyrotoxicosis (Graves' disease). The enlarged thyroid gland is palpated with the thumbs and II-III fingers of both hands, which are located on the front surface of the neck in the thyroid gland, the patient is asked to take a sip - then it is clearly defined.

joints

An objective examination of the joints begins with their examination, during which changes in the configuration, the presence of functional restrictions during movement, the state of the tissues surrounding the joints, the color and nature of the skin over the joint, and swelling of the surrounding areas are established.

One of the most important signs is a change in the normal configuration of the joints.

The general examination is completed with an assessment of some neurological symptoms. In this case, the state of the pupils is assessed: their size, symmetry, reaction to light, which can change with certain pathological processes in the central nervous system. Further, dermographism is determined (white, red, rapidly or slowly advancing), which very roughly characterizes the predominance of sympathetic and parasympathetic (vagal) autonomic reactions. For this purpose, a line is drawn with any object along the anterior surface of the chest and the color of the resulting stripe is assessed. Finally, it is necessary to check the symptom of stiff neck and Kernig's symptom, which is more common in neurological practice and, being positive, indicates the "interest" of the spinal membranes. To assess the stiffness of the occipital muscles, the doctor raises the patient's head with both hands, determining the degree of resistance of the posterior cervical muscles, which is normally absent. In the case of a positive symptom, he feels a distinct muscular resistance.

An objective examination of the patient, in addition to a general examination, includes some special (additional) research methods. Among the methods of general importance, anthropometry and thermometry should be singled out.

Anthropometry and thermometry

In many infectious diseases, the type of fever remains the same for almost the entire period of illness, in others it may change from day to day (fever of the wrong type). This type of fever is possible with sepsis, exudative pleurisy, etc. Often, the body temperature rises and falls several times during the day, and each time the range exceeds 2-4 ° C. Such fluctuations in temperature, which greatly exhaust the patient, are called hektigeska, or debilitating fever. It occurs in sepsis, suppurative lung diseases, and some severe forms of tuberculosis.

This classical staging is drastically disrupted by the early use of antibiotics for both infectious and internal diseases. The drop in body temperature can be rapid, critical, accompanied by profuse sweating. Along with this, a gradual (lytic) decrease in temperature is possible, lasting several days.

A professionally collected anamnesis and a detailed general examination of the patient play an important role in making a preliminary diagnosis - creating a reasonable preliminary diagnostic hypothesis. Both of these methods are important and complement each other, contributing to an objective assessment of certain pathological conditions. The student comprehends the basics of these methods, gets used to the systematization of facts, and only with time, becoming an experienced doctor with a broader outlook, does he get all the opportunities for their active use for the correct recognition of a particular disease. Probably, Xenophanes was right when, as far back as 500 BC. e. wrote that "the doctor is all vision, all hearing and thinking." Any acquaintance with the patient always begins with the collection of an anamnesis and a general examination of it. This determines their special value and importance among other diagnostic methods.

percussion method

The percussion method was proposed in 1761 by the Austrian physician L. Auenbrugger. One and | hypotheses for the discovery of the method is that the father of the future doctor was a brewer and determined the level of beer in closed barrels by tapping them. This was the associative moment in the thinking of a young doctor who set out to determine the level of fluid in the pleural cavity. A proven historical fact is the long-term non-recognition of the method by colleagues. Only in 1808, through the work of the famous French physician J. Corvisart, the percussion method was “reanimated” and became widespread throughout the world. Some doubts about the advisability of percussion arose at the initial stage of the use of x-rays in diagnostic work. Even then, an opinion was formed that the method is indicative, but the simplicity and general availability of its implementation make it indispensable for the initial examination of the patient.

Mastery of percussion technique is essential. If the founders of the method percussed with fingers folded in a pinch directly over the patient's body, then in subsequent years it was possible to improve the accuracy of the method by introducing the technique of tapping with a special percussion hammer and a plessimeter - a thin plate placed on the skin over the area under study.

The next stage in the development of the tapping technique was the use of the finger-finger percussion method, when the role of the hammer is played by the index finger of the right hand, and the role of the plessimeter is the middle phalanx of the third finger of the left hand. It is currently the most commonly used percussion technique.

In an alternative order, mention should be made of the percussion technique developed by Professor F. G. Yanovsky, who proposed one-finger percussion. It consists in percussion directly on the skin with a bent finger. The method of Professor V.P. Obraztsov is not forgotten, when percussion is carried out with a kind of click, due to slipping of the II finger from the side surface of the III finger.

The physical substantiation of percussion is based on the different ability of the structures and tissues to be studied to conduct vibrations that occur when tapping. Moreover, it should be remembered that we do not have the opportunity to feel the difference between the sound leaving the plesimeter finger deep into the body, and the vibrations returning to the plesimeter finger after the corresponding transformation in the underlying structures. It is this moment that is the key to understanding acoustic and tactile (with a finger-plessimeter) sensations. In order to enhance tactile perception, a minimal, or quietest, percussion technique was proposed. The volume of the percussion tone with this type of percussion barely exceeds the threshold of its audibility, therefore the term "above-threshold percussion" is its synonym.

When percussion over the surface of the human body, three types of percussion tone can be distinguished: femoral (determined above the muscle masses), gastrointestinal (detected above the places of gas accumulation) and pulmonary (determined above the surface of the lungs).

A detailed study of the application of the percussion method in clinical practice is presented in the relevant chapters of the textbook.

Auscultation method

The history of this research method goes back to Hippocrates, in whose writings the noise that occurs when a patient with pyopneumothorax is shaken is described. In its modern form, the method was proposed by the physician of Napoleon Bonaparte, the French physician Rene Laennec in 1818. As in the case of the discovery of the percussion method, associative moments played a certain role here. The following story, which preceded the discovery of the method, has come down to the present: Laennec, driving along the streets of Paris, drew attention to the play of children - one lightly tapped on the end of a dry wooden beam, the second child had fun listening to tapping from the opposite edge. Another version suggests a metal pipe instead of a wooden beam, and the whisper of one of the children as a source of vibrations, which was enthusiastically perceived by another child who put his ear to the opposite end of the pipe. Prepared by years of medical practice for the perception of fundamentally new information, R. Laennec realized that it was possible to make a device that would be able to conduct sound from the surface of the patient's body to the ear of the researcher. The first stethoscope was a sheet of thick paper rolled into a tube. Two years later, Laennec made a report at the French Academy of Sciences on the diagnostic application of the auscultation method in diseases of the heart and lungs. In subsequent years, an enormous amount of clinical material on the application of the method was accumulated, and numerous modifications of the stethoscope were made.

The physical basis of the auscultation method is ^! the ability of the human ear to perceive vibrations in the range from 16 to 20,000 Hz, which occur during the work of the heart, lungs and other structures. The human hearing organ is able to maximally distinguish sounds with a frequency of about 2000 Hz, a decrease in frequency by 50% leads to a decrease in sensitivity by the same amount. The maximum energy of heart sounds is in an unfavorable range for perception by the human ear. The second feature of subjective perception is the fact that a weak sound after a strong sound is perceived with difficulty. This is important during auscultation of the heart, when, after relatively loud heart sounds and systolic murmur, a weak diastolic murmur is heard, which, due to the inexperience of novice doctors, can often be missed. Between the membrane of the phonendoscope, pressed against the skin above the organ under study, and the eardrum of the researcher, a closed column of air arises, which is capable of transmitting skin vibrations to the organ of hearing. The development of constructive developments of modern stethophonendoscopes is aimed at reducing distortion and attenuation of sound, reducing the amount of extraneous noise, and increasing the convenience of the device.

Before purchasing a stethophonendoscope, the doctor should keep in mind that this instrument will be used for many years. Then the question of whether the size of the olives corresponds to the shape of the external auditory canal is decided: the spring connecting the olives must be of sufficient strength, but not put pressure on the ears. Flexible tubing should be of optimal length, since an excessively long tube is uncomfortable and generates extraneous noises, while a too short one makes one bend over the patient's bed unnecessarily.

During auscultation, the room should be kept as quiet as possible. Low air temperature can cause the patient to become chilly, trembling in the body, which will lead to listening to artifacts. Auscultation of severe bedridden patients (especially the posterior parts of the lungs) is significantly hampered by the inevitable presence of a large number of extraneous noises. The only way to improve the result of the study is to gain experience in examining such patients.

Activities performed by a doctor in order to make a diagnosis. All methods related to the physical examination are carried out directly by the doctor using his senses. These include:

Currently, in connection with this trend, the skills of physical examination are gradually being lost, this is especially pronounced in countries with a good supply of high-tech medical equipment. However, even in these countries, physical examination has not lost its importance as a basic method to determine the suspected disease. An experienced clinician, using only physical examination methods and history taking, in many cases can make the correct diagnosis. If it is impossible to make a diagnosis only on the basis of physical examination data, an in-depth diagnosis and differential diagnosis are carried out using laboratory and instrumental methods of research (see also).

additional literature

Kukes V.G., Marinin V.F., Reutsky I.A., Sivkov S.I. Medical diagnostic methods. - M. : Geotar-Media, 2006. - 720 p.
Larinsky N.E., Abrosimov V.N. A History of Physical Diagnosis in Biographies, Portraits, and Facts. - Ryazan, 2012. - 500 p.
Tetenev F.F. Physical research methods in the clinic of internal diseases. - Tomsk: Tomsk State. un-t, 2001. - 391 p.

Deep lymph nodes (LNs) can only be palpated when they are greatly enlarged. In their study, it is necessary to use instrumental methods - radiography, lymphography, laparo- or mediastinography, ultrasound echolocation.

In the chest, the main ones are intercostal, thoracic, diaphragmatic, anterior and posterior mediastinal, bronchial, bronchopulmonary, pulmonary and tracheobronchial lymph nodes.

In the abdominal cavity there are mesenteric, gastric (on the lesser and greater curvatures of the stomach), pancreatic-splenic, hepatic, celiac, paraaortic, LU.

In the pelvis are localized external and internal iliac, sacral and lumbar nodes. They collect lymph from the lower extremities and pelvic organs, including the genitals.

With an increase in paratracheal lymph nodes, stagnation may occur in the upper body; paresis of the phrenic and age nerve (may be against the background of coughing, difficulty in swallowing, hoarseness or aphonia, hiccups). An increase in the mediastinal LU can be indirectly judged by the following symptoms:

Koranyi de la Campa - dullness over the spinous process below the 3rd thoracic vertebra in infants and below the 4th-6th - in older children.

D΄Espina - the presence of bronchophony below the 2nd-3rd thoracic vertebrae, the presence of loud tracheal breathing in infants above the 5th-6th vertebrae.

Filatov-Filosofov bowls - dullness on the handle of the sternum and on its sides.

An increase in retroperitoneal lymph nodes is the cause of pain in the back.

With an increase in abdominal LU, abdominal pain, urination disorders, nausea, intestinal obstruction, and swelling of the legs are possible. The method of palpation of the mesenteric lymph nodes is described in the section on the study of the digestive organs.

STUDY OF THE LOCOMOTOR SYSTEM

Osteo-articular system

General inspection

When examining a child with a suspected disease of the musculoskeletal system, the pediatrician pays attention to the state of the musculoskeletal system as a whole, assessing the compliance of the patient's height with his age and body proportions, as well as the ratio of various departments and parts of the skeleton (for example, the size of the head and the whole body, limbs and torso, facial and cerebral parts of the skull). In addition, the features of the child's statics and motor skills (presence or absence of lameness, "duck gait") are taken into account. Pain in the affected joint can lead to the so-called sparing lameness.

After a general examination, the doctor proceeds to a more detailed examination of individual parts of the body. In this case, the dimensions and shape of the skull, the ratio of its facial and brain sections are determined. In a newborn and a child in the first months of life, the brain part is much more developed compared to the facial part. Moreover, the skull consists of paired and unpaired (occipital) bones, separated from each other by sutures. The latter close by the end of the neonatal period, but are completely overgrown only by school age. There are fontanelles at the junction points of the bones of the skull: a large one - between the frontal and parietal bones (its normal size in a newborn is no more than 2.5--3 cm when measured between the edges of the bones; closes at the age of 1-1.5 years), small - - between the parietal and occipital bones (closed by the time of birth in 75% of healthy children, in the rest it closes by the end of the 3rd month), lateral - two on each side (open after birth only in premature babies).

Palpation of the head is done with both hands. For this purpose, the thumbs are placed on the forehead, the palms on the temporal regions, after which the parietal bones, occipital region, sutures and fontanelles are examined with the middle and index fingers, the condition of the sutures (divergence, compliance) is necessarily assessed.

On palpation of the latter, their size (distance between two opposite sides), level (bulging or retraction), tension (hardness, softness, elasticity), state of the edges (density, pliability, serration) are determined.

Palpation of the bones of the skull can reveal soreness, softening of the bones, which is especially well detected in the region of the scales of the occipital bone.

Changes in the shape of the skull can be of a very different nature. The subacute course of rickets is accompanied by the growth of the osteoid tissue of the skull bones and the formation of an "Olympic forehead", a "square" head. Open lateral, enlarged large and small fontanelles, pliable or divergent sutures may indicate hydrocephalus. Premature closure of the large fontanelle and fusion of the sutures may be an individual feature, and sometimes are the cause of microcephaly and craniostenosis.

Next, evaluate the number and condition of the child's teeth. In healthy children, teeth begin to erupt from the 6-7th month of life. Moreover, milk teeth appear first: two internal lower and upper incisors, then two external upper and lower incisors (by the year all 8 incisors erupt), at 12-15 months the front small molars (premolars) appear, at 18-- 20 - fangs, and at 20-24 months - back premolars. By the age of 2, a complete set is formed - 20 milk teeth. The eruption of permanent and change of milk teeth occurs in the following order: at 5-7 years old, large molars (molars) appear, 7-8 - internal, 8-9 - external incisors, 10-11 - front, 11 -12 - rear premolars and second molars, at 19-25 years old - wisdom teeth (sometimes absent altogether). Violation of this order is most often associated with the development of rickets. In children with increased reactivity, teething is sometimes accompanied by sleep disturbances, subfebrile temperature, and stool disorders.