The examination begins with a general examination, assessment of the state of consciousness and motor activity of the child. Next, pay attention to the position of the patient, the color of his skin and mucous membranes (for example, note pallor or cyanosis).

When examining the child's face, attention is paid to the preservation of nasal breathing, bite, the presence or absence of pastosity, discharge from the nose or mouth.

Examination of the nasal cavity. If the entrance to the nose is blocked with secretions or crusts, it is necessary to remove them with a cotton swab. Inspection of the nasal cavity should be carried out carefully, as children easily experience nosebleeds due to tenderness and abundant blood supply to the mucous membrane.

Features of the voice, screaming and crying of the child help to judge the condition of the upper respiratory tract. Usually, immediately after birth, a healthy baby takes the first deep breath, straightens the lungs, and screams loudly. Hoarseness of voice is noted with stenosing laryngotracheitis.

Throat inspection

The pharynx is examined at the end of the examination, since the anxiety and crying of the child caused by this may interfere with the examination. When examining the oral cavity, pay attention to the condition of the pharynx, tonsils and posterior pharyngeal wall.

In children of the first year of life, the tonsils usually do not extend beyond the anterior arches.

In preschool children, hyperplasia of the lymphoid tissue is often observed, the tonsils extend beyond the anterior arches. They are usually dense and do not differ in color from the mucous membrane of the pharynx.

If, during the collection of anamnesis, complaints of coughing are revealed, during the examination of the pharynx, it is possible to induce a cough by irritating the pharynx with a spatula.

Chest examination

When examining the chest, pay attention to its shape and the participation of the auxiliary muscles in inhalation.

Assess the synchronism of movements of both halves of the chest and shoulder blades (especially their angles) during breathing. With pleurisy, atelectasis of the lung and bronchiectasis with unilateral localization of the pathological process, one can notice that one of the halves of the chest (on the side of the lesion) lags behind when breathing.

It is also necessary to evaluate the rhythm of breathing. In a healthy full-term newborn, rhythm instability and short (up to 5 s) respiratory arrests (apnea) are possible. Before the age of 2 years (especially during the first months of life), the rhythm of breathing may be irregular, especially during sleep.

Pay attention to the type of breathing. For young children, the abdominal type of breathing is characteristic. In boys, the type of breathing does not change in the future, and in girls, from the age of 5-6 years, a chest type of breathing appears.

NPV (Table 7-3) is more convenient to calculate for 1 minute during the child's sleep. When examining newborns and young children, you can use a stethoscope (the bell is held near the child's nose). The younger the child, the higher the NPV. In a newborn, the shallow nature of breathing is compensated by its high frequency.

The ratio of NPV and HR in healthy children in the first year of life is 3-3.5, i.e. one respiratory movement accounts for 3-3.5 heart contractions, in children older than a year - 4 heart contractions.

Palpation

For palpation of the chest, both palms are symmetrically applied to the examined areas. By squeezing the chest from front to back and from the sides, its resistance is determined (Fig. 7-9). The younger the child, the more pliable the chest. With increased resistance of the chest, they speak of rigidity.

Voice trembling is a resonant vibration of the patient's chest wall when he pronounces sounds (preferably low-frequency), felt by the hand during palpation. To assess voice trembling, the palms are also placed symmetrically (Fig. 7-10). Then the child is asked to pronounce the words that cause the maximum vibration of the vocal cords and resonant structures (for example, "thirty-three", "forty-four", etc.).

Percussion

When percussion of the lungs, it is important that the position of the child is correct, ensuring the symmetry of the location of both halves of the chest. If the position is incorrect, the percussion sound in symmetrical areas will be uneven, which may give rise to an erroneous assessment of the data obtained. When percussion of the back, it is advisable to invite the child to cross his arms over his chest and at the same time bend forward slightly; with percussion of the anterior surface of the chest, the child lowers his arms along the body. The anterior surface of the chest in young children is more convenient to percuss when the child is lying on his back. For percussion, the child's back is planted, and small children must be supported by someone. If the child does not yet know how to hold his head, he can be percussed by laying his stomach on a horizontal surface or on his left hand.

Distinguish between direct and indirect percussion.

Direct percussion - percussion with a bent finger (usually the middle or index finger) percussion directly on the surface of the patient's body. Direct percussion is more often used in the study of young children.

Indirect percussion - percussion with a finger on the finger of the other hand (usually on the phalanx of the middle finger of the left hand), tightly attached with the palmar surface to the examined area of ​​the patient's body surface.

Traditionally, percussion strikes are applied with the middle finger of the right hand (Fig. 7-І I).

- Percussion in young children should be carried out with weak blows, since due to the elasticity of the chest and its small size, percussion tremors are too easily transmitted to distant areas.

Since the intercostal spaces in young children are narrow (compared to adults), the plessimeter finger should be placed perpendicular to the ribs (Fig. 7-I2).

lung sound. At the height of inhalation, this sound becomes even clearer, at the peak of exhalation it is somewhat shortened. In different areas, the percussion sound is not the same. On the right in the lower sections, due to the proximity of the liver, the sound is shortened; on the left, due to the proximity of the stomach, it takes on a tympanic shade (the so-called Traube space).

Determining the boundaries of the lungs

Determining the height of the tops of the lungs in front. The plessimeter finger is placed over the clavicle, with the terminal phalanx touching the outer edge of the sternocleidomastoid muscle. Percussion is performed on the plessimeter finger, moving it up until the sound is shortened. Normally, this area is 2-4 cm above the middle of the clavicle. The boundary is drawn along the side of the plessimeter finger facing the clear sound (Fig. 7-14a).

Determination of the standing height of the tops of the lungs from behind. Posteriorly, percussion of the apexes is performed from the spine of the scapula towards the spinous process of CVII. At the first appearance of a shortening of the percussion sound, percussion is stopped. Normally, the standing height of the apexes behind is determined at the level of the spinous process CVII. The upper border of the lungs in preschool children cannot be determined, since the tops of the lungs are located behind the collarbones (see Fig. 7-146).

The determination of the lower boundaries of the lungs is carried out along all topographic lines (Fig. 7-15). The lower borders of the lungs are presented in Tables 7-4.

Percussion borders of the lower edges of the lungs
body line	On right	Left
midclavicular	VI rib	Forms a recess corresponding to the borders of the heart, departs from the chest at the height of the VI rib and descends steeply
anterior axillary	VII rib	VII rib
Middle axillary	VIII-IX ribs	VII-IX ribs
Posterior axillary	IX rib	IX rib
scapular	X rib	X rib
Paravertebral	At the level of the spinous process TX1

Mobility of the lower edge of the lungs. First, percussion find the lower border of the lung along the middle or posterior axillary line. Then, having asked the child to take a deep breath and hold his breath, the position of the lower edge of the lung is determined (the mark is made on the side of the finger facing the clear percussion sound). In the same way, the lower border of the lungs in the exhalation state is determined, for which the patient is asked to exhale and hold his breath.

Auscultation

On auscultation, the position of the child is the same as on percussion (Fig. 7-16). Auscultate symmetrical sections of both lungs. Normal at

children up to 3-6 months listen to weakened vesicular breathing, from 6 months to 5-7 years - puerile (breathing noise is louder and longer during both phases of breathing) (Fig. 7-17).

The structural features of the respiratory organs in children, which determine the presence of puerile breathing, are listed below.

Narrow lumen of the bronchi.

Great elasticity and small thickness of the chest wall, increasing its vibration.

Significant development of interstitial tissue, reducing the airiness of lung tissue.

After 7 years, breathing in children gradually becomes vesicular.

Bronchophony - auscultation of a sound wave from the bronchi to the chest. The patient whispers words containing the sounds “sh” and “h” (for example, “a cup of tea”). Bronchophony must be examined over symmetrical sections of the lungs.

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Physical examination

It includes a general examination, examination and palpation of the heart area, percussion and auscultation of the heart, examination of the arterial pulse, measurement of blood pressure, as well as examination of other organs and systems.

General inspection

General examination of patients with diseases of the circulatory organs includes an assessment of the general condition of the patient, his consciousness, position, physique, measurement of body temperature, determination of features of facial expression characteristic of certain diseases, as well as an assessment of the condition of the skin, nails, hairline, visible mucous membranes, subcutaneous fat cellulose, lymph nodes, muscles, bones and joints. The data obtained by the doctor during a general examination are of the most important diagnostic value, making it possible to identify characteristic (although often non-specific) signs of the disease and to give a preliminary assessment of the severity of the pathological process and the degree of functional disorders.

Consciousness

Consciousness in patients with diseases of the circulatory system may be clear and confused. Disturbances of consciousness develop, as a rule, in patients who are in serious and extremely serious condition [heart failure III-IV FC according to the classification of the New York Heart Association (NYHA), cardiogenic shock, acute cerebrovascular accident, severe respiratory failure, acute post-hemorrhagic anemia etc.] or in case of poisoning with drugs, toxic substances or alcohol surrogates. There are several options for the oppression of consciousness: stunning, stupor, coma.

Stun - a state from which the patient can be brought out for a short time by talking with him. The patient is poorly oriented in the environment, answers questions slowly, with a delay.

Sopor (hibernation) - a more pronounced violation of consciousness. The patient does not respond to others, although sensitivity, including pain, is preserved, does not answer questions or answers in monosyllables (“yes” or “no”), and responds to examination.

Coma - the most severe impairment of consciousness, which is associated with an extremely poor prognosis. The patient is in an unconscious state, does not respond to speech addressed to him, to the doctor's examination, a decrease or disappearance of the main reflexes is characteristic.

The position of the patient

Of greatest practical interest is the definition of a forced position. which somewhat alleviates the suffering of the patient (pain, shortness of breath, and so on). Sometimes the forced position of the patient is so characteristic of a particular disease or syndrome that it allows a correct diagnosis to be made at a distance. For example, during an attack of cardiac asthma and pulmonary edema due to overflow of blood vessels of the pulmonary circulation, the patient tends to take a vertical position (sitting) with his legs down, which reduces blood flow to the right heart and makes it possible to "unload" the pulmonary circulation [position orthopnea (orthopnoe)]. With dry (fibrinous) and exudative pericarditis, patients sit in bed with the body slightly tilted forward, which somewhat reduces pain in the heart and shortness of breath.

Body type

Assessment of the constitutional type has a certain diagnostic value. The correct physique can correspond to the asthenic, normosthenic and hypersthenic type of constitution.

Asthenic type. People of this type of constitution have a relatively small heart, located vertically (“hanging heart”), a lower standing of the diaphragm, lungs, liver, stomach, kidneys. They are characterized by hypotension, decreased secretory and motor activity of the stomach, hyperfunction of the thyroid gland and pituitary gland, lower levels of hemoglobin (Hb), cholesterol, blood glucose. They are more likely to suffer from duodenal ulcer, thyrotoxicosis, neurosis, and tuberculosis.

hypersthenic type. For people of this type, the presence of a relatively large size of the heart and aorta, a high standing of the diaphragm, a tendency to a higher level of blood pressure, an increased content of Hb, cholesterol, and blood glucose are characteristic. They are more likely to suffer from obesity, coronary artery disease, hypertension, diabetes mellitus, metabolic-dystrophic diseases of the joints.

Leather

When examining the skin, pay attention to its color, moisture, elasticity, condition of the hairline, the presence of rashes, hemorrhage. vascular changes, scars and so on. The practitioner most often encounters several options for changing the color of the skin and visible mucous membranes: pallor, hyperemia, cyanosis and jaundice.

Paleness of the skin. It can be due to two main causes: anemia and impaired peripheral circulation.

- Anemia characterized by a decrease in the number of erythrocytes and the content of Hb per unit volume of blood and can occur for various reasons.

- Pathology of the peripheral circulation. It can be due to several reasons: a tendency to spasm of peripheral arterioles in patients with aortic heart disease, hypertensive crisis, some kidney diseases; redistribution of blood in the body in acute vascular insufficiency (fainting, collapse, shock) in the form of blood deposition in the dilated vessels of the abdominal cavity, skeletal muscles and, respectively. a decrease in blood supply to the skin and some internal organs.

Cyanosis - cyanotic staining of the skin and visible mucous membranes, due to an increase in the peripheral blood (in a limited area of ​​​​the body or diffusely) in the amount of reduced Hb (more than 40-50 g / l). In accordance with the main reasons, there are three types of cyanosis: central, peripheral and limited.

- Central cyanosis develops as a result of insufficient oxygenation of blood in the lungs with various diseases of the respiratory system. accompanied by respiratory failure. It is characterized by diffuse cyanotic coloration of the face, torso, and extremities. The skin is warm to the touch (“warm cyanosis”), often has a peculiar grayish tint.

- peripheral cyanosis (acrocyanosis) appears when blood flow slows down in the periphery, for example, with venous congestion in patients with right ventricular heart failure. In these cases, the extraction of oxygen by tissues increases, mainly in the distal regions (cyanosis of the tips of the fingers and toes, the tip of the nose, ears, lips). At the same time, the limbs are cold to the touch due to a sharp slowdown in peripheral blood flow.

- Limited (local) cyanosis may develop as a result of stagnation in the peripheral veins when they are compressed by a tumor, enlarged lymph nodes or deep vein thrombosis (phlebothrombosis, thrombophlebitis).

Skin elasticity (turgor)

To determine elasticity (turgor), the skin, together with subcutaneous tissue, is grasped with two fingers and a fold is formed. Normal skin elasticity is characterized by the rapid spreading of the skin fold after unclenching the fingers. With a decrease in skin elasticity, the fold persists for some time.

Decreased skin elasticity occurs in elderly and senile patients, as well as in dehydration of the body (uncontrollable vomiting, diarrhea, etc.).

Increasing skin elasticity and an increase in its tension often indicate fluid retention in the body, which is accompanied by some swelling of the skin (hidden edema).

Nails

In many diseases of the internal organs, as a result of trophic and other disorders, various changes in the nails appear, more often in the form of transverse and longitudinal striation, increased fragility, etc.

A.V. Strutynsky
Complaints, history, physical examination

The condition of the prostate gland is assessed using a digital rectal examination. The most characteristic symptom is pain of varying intensity. In acute prostatitis, the gland is significantly enlarged, sharply painful, often dense and homogeneous. With abscessing, a focally convex area is noted, and after the breakthrough of the abscess, on the contrary, retraction. Chronic inflammation without exacerbation or CPPS is characterized by little or no pain. The consistency is homogeneous or heterogeneous, elastic or somewhat compacted, sometimes atonic.

Microscopic examination of prostate secretion allows you to confirm the inflammatory process in the prostate gland, as well as to judge its functional state. With microscopes of prostate secretion, the main indicators are recorded:

White blood cell count

The number of lecithin grains;

Presence and type of microflora.

Before starting the procedure, the patient partially urinates to remove the contents of the urethra. Then perform a prostate massage. If the secret of the prostate cannot be obtained, then the urine sediment obtained immediately after prostate massage (no later than 30 minutes) is examined.

The most objective information about the state of the lower urinary tract is given by 4-glass sample, described E. M. Meares and T. A. Stamey in 1968. It is one of the main research methods that allows not only to establish a diagnosis, but also to determine the treatment tactics. The test consists in microscopic and bacteriological examination of urine samples obtained from different parts of the genitourinary tract and prostate secretion, which makes it possible to determine the source of inflammation.

Patient preparation:

Full bladder;

Before the examination, it is advisable for the patient to refrain from sexual intercourse during the day to easily obtain prostate secretion

The rod head must be clean and treated with a 70% alcohol solution.

Obtaining samples for research is carried out in 4 stages:

1. After preparing the patient, collect the first 10 ml of urine in a sterile container (I - urethral portion).

2. After partial emptying of the bladder in a volume of 150-200 ml, 10 ml of urine is also collected in the same way (II - bladder portion).

3. The next step is to perform prostate massage to obtain prostate secretion (III - prostate portion).

4. Collect the first 10 ml of urine after prostate massage (II / - pislyamasage portion). Interpretation of results:

The first portion of urine (I) reflects the condition of the urethra. Urethritis is characterized by an increase in the number of leukocytes and bacteria in 1 ml compared with the vesicular portion (II).

The presence of leukocytes in the first and second portions of urine (II) makes it possible to diagnose cystitis or pyelonephritis. Detection of leukocytes and uropathogenic bacteria in the secret of the prostate (III) or in a portion of urine (IV) obtained after prostate massage allows the diagnosis of bacterial prostatitis if bacteria are not present (or are determined in a lower concentration) in the first (I) and second portions urine (II).

The absence or isolation of non-pathogenic bacteria, the presence of more than 10 leukocytes in the secretion of the prostate (III) or urine obtained after prostate massage (IV), means that these patients have inflammatory CPPS (non-bacterial prostatitis).

The absence of inflammatory changes in the microscopy of all portions of urine and prostate secretions, as well as the sterility of prostate excretions, is the basis for establishing the diagnosis of non-inflammatory CPPS (prostatodynia).

Ejaculate examination allows

In some cases, differentiate between inflammatory and non-inflammatory CPPS;

Determine the inclusion of the organs of the reproductive system in the inflammatory process (vesiculitis).

TRUS significantly expanded the diagnostic capabilities of the urologist. Indications for its use:

Acute bacterial prostatitis - exclusion of prostate abscess in the absence of positive dynamics against the background of antibiotic therapy;

Identification of pathological changes in the prostate that can affect treatment tactics (cysts, stones)

Suspicion of prostate cancer on digital rectal examination or after PSA testing;

In the presence of pain associated with ejaculation, to exclude obstruction or cysts of the ejaculatory duct and pathogenic changes in the seminal vesicle.

If clinically significant diseases are suspected (prostate abscess, prostate and bladder cancer, benign prostatic hyperplasia, lesions of the musculoskeletal system, simulates symptoms of prostatitis, etc.), CT and MRI are used.

Treatment of prostatitis. Antibacterial therapy today is a generally accepted method of treating chronic prostatitis. One of the factors that significantly complicate the choice of antibiotics for the treatment of chronic prostatitis is the limited number of drugs that can penetrate the hematoprostatic barrier and accumulate in the prostate gland in concentrations sufficient to eradicate the pathogen. The most priority in this regard are drugs of the fluoroquinolone group.

Treatment of acute prostatitis. In acute prostatitis, in contrast to a chronic inflammatory process, beta-lactam antibiotics and aminoglycosides are able to accumulate in the prostate tissue at concentrations sufficient to suppress most pathogens due to increased prostate perfusion and increased permeability of the hematoprostatic barrier. It should be remembered that the ability of antibacterial drugs of these groups to penetrate into the prostate gland decreases when the inflammatory process subsides. Therefore, when a clinical effect is achieved, one should switch to oral administration of fluoroquinolones.

Treatment of chronic bacterial prostatitis. Fluoroquinolones (norfloxacin, levofloxacin, ciprofloxacin) are currently the drugs of choice. In patients allergic to fluoroquinolones, doxycycline is recommended. It is generally recognized among urologists in Europe and the United States that antibiotic therapy for chronic prostatitis requires a long time, and, unlike the practice prevailing in our country, therapy is usually carried out with one drug. The tradition of changing antibiotics every 7-10 days has no scientific justification and is unacceptable in most clinical situations. Optimal now consider a 2-4-week course of treatment. Therefore, drugs that are administered once a day, such as fluoroquinolones such as levofloxacin, deserve special attention.

Treatment of chronic non-bacterial prostatitis. Despite the absence of isolated bacteria, antibiotic therapy for inflammatory CPPS is the most commonly recommended treatment.

Reason for prescribing antibiotics is

The probable role of cryptogenic (important cultivation) microorganisms in the etiology of chronic non-bacterial prostatitis and the high frequency of their detection in this category of patients;

Antibacterial therapy brings relief to patients with CPPS.

Antibacterial therapy for chronic non-bacterial prostatitis (inflammatory CPPS) is prescribed according to the following scheme:

Antibacterial therapy with fluoroquinolones, doxycycline for 2 weeks

Then a re-examination is carried out and, with positive dynamics (decrease in pain), continuation of antibiotics for a total duration of up to 4 weeks.

Non-inflammatory CPPS. There is still no consensus on the role of antibiotic therapy in the treatment of patients with this form of prostatitis.

Asymptomatic prostatitis. Such patients do not require treatment despite laboratory, cytological, or histological signs of inflammation.

Treatment of patients in this category is carried out according to certain indications:

Infertility

Identification during microbiological examination of pathogenic microorganisms;

With an elevated PSA level and positive results of microbiological examination (before determining indications for prostate biopsy)

Before surgical treatment on the prostate gland.

For this, the same antibacterial drugs are used, and for the treatment of chronic bacterial prostatitis. In addition to antibiotics, drugs of other groups are also used to treat patients with prostatitis of any origin. Moreover, in the case of abacterial forms of prostatitis, these drugs are of paramount importance compared to antibiotics.

Physical examination is a technique for preliminary assessment of a person's condition in order to determine the primary diagnosis. The procedure does not involve the use of instrumental measures, it is based on the doctor's senses.

This type of research is currently relegated to the background by technical and instrumental medical equipment. But in the absence of such devices, physical examination is the only possible and affordable one.

Features of the

The principle of action lies in the collection of anamnesis and evaluation of the patient in appearance.

For an experienced doctor, the above actions will be enough to determine the diagnosis and prescribe appropriate therapy.

In the absence of the necessary data to determine the disease, the patient is prescribed an instrumental, laboratory examination.

In the process of physical examination, physical and visual contact occurs through a number of manipulations that are important for the prehospital stage:

• general assessment of consciousness;
• study of mucous tissues, skin;
• percussion;
• auscultation;
• palpation.

This examination precedes the full examination.

With its help, objective data concerning the general condition of a person are established.

In some cases, this is quite enough to provide emergency assistance.

Consciousness

Among the many types of examination of the heart, consciousness deserves special attention.

Often the psychological component is an important factor in which therapeutic intervention is indicated.

There are 4 stages of altered consciousness, characterized by spatial disorientation:

• coma;
• sopor;
• stupor;
• obscuration.

Coma represents the absence of any signs of consciousness. It is hazardous to health. It is the cause of irreversible processes.

The remaining states are expressed in the form of a slow reaction to everything that happens, its complete absence.

These are passive disturbances of consciousness, but there are also opposite ones. They are manifested not only by the lack of a sound assessment of what is happening. Accompanied by aggression, fear, obsession.

It is these violations that a physical examination reveals.

Dealing with the skin

When deciding how to check the heart, the doctor examines the mucous membranes of a person, the epidermis, which can be important when taking anamnesis.

Many pathological processes, and cardiovascular pathologies are no exception, rash, irritation, peeling and dryness, redness, cyanosis (cyanosis).

Such data complement the assessment of the patient's condition, indicate the correctness of the diagnosis.

Of the additional features

Such aspects, captured visually, are important for determining the preliminary diagnosis of the suspected disease.

If there are no changes, signs, consciousness remains clear, this does not indicate the absence of the disease. Additional methods will be needed for a detailed examination of a person and determining his condition.

Among these, auscultation, palpation, percussion differ in functionality. They complement the ongoing examination, indicate an accurate clinical picture.

The principle of palpation

Physical examination of the patient. In which the doctor can more specifically identify diseases after a study of the internal organs, the features of their position.

The action lies in the fact that the specialist examines with fingers, palms the skin in the area of ​​​​large arteries, veins, heart.

When pressing under a certain pressure on a particular organ, part of the body, the severity of pain is determined. Possible deformation in their location, other symptoms that are not the norm.

Palpation is deep and superficial. Most of all, it is effective in case of damage to muscles and internal organs.

More about percussion

In everyday life, this method of examination is called tapping. It is used in practice not so often, due to the presence of a huge number of modern methods.

In order to correctly determine the change on the part of the face, the specialist must be fluent in percussion, the technique is quite complex and multifaceted.

It is represented by light tapping of varying intensity and analysis of the responding return sounds. Does not cause pain or discomfort.

A true professional will determine the defeat of internal organs by sound alone.

The physical technique includes several types of percussion, when percussion is performed with one or more fingers. Sometimes a tool is involved.

In most cases, percussion is used in the diagnosis of pathologies of the heart muscle and lungs.

Sometimes suitable for examination of the digestive tract.

Auscultation

This procedure is also called listening, when the condition of the alleged damaged organ is determined by the emitted sound vibrations.

To this end, instrumental methods for studying the cardiovascular system are being used today. Previously, manipulation was performed manually, without additional devices.

The main task is to determine the dynamics of the oscillating sounds that come from the internal organ. In their comparison for deviations from the norm and the development of pathology.

A little history

A physical examination, along with a thorough questioning, helps to create a voluminous and complete clinical picture for the doctor. Decide on the final diagnosis.

Questioning about the diseases present in the anamnesis is of great importance. They tend to recur, manifest themselves in complex forms.

Based on verbally received information, a specialist can approximately assume the duration of the course of the pathological process, its main symptoms and characteristics of possible complications.

This method of research is convenient in that it is possible to interview other persons who have been surrounded by the patient for a long time. They have information about the diseases they have suffered.

It will not be possible to use the procedure for collecting an anamnesis if the person is unconscious. He cannot clearly indicate the states that concern him, state complaints in detail.

But here, too, there is a way out. A doctor with extensive experience in physical therapy may limit himself to examining the face in order to suggest one or another pathology from the cardiovascular system.

What are the indications for a physical examination?

We can safely say that it is carried out at any convenient moment by a specialist with certain skills and knowledge in this therapeutic area.

Today, such events are losing their relevance, being replaced by more accurate and convenient instrumental devices.

Real professionals in the shortest possible time with the help of physical methods can make an accurate diagnosis of a person, alleviate his general condition, or even save a life in emergency situations.

After all, situations often occur when specialized devices are not at hand, and it is impossible to conduct laboratory, instrumental diagnostics.

Useful video: How is the physical examination

and in the position on the side with the lower leg extended and the leg slightly bent at the knee from above (Fig. 195). The mice should be as relaxed as possible. After superficial palpation, localization is more clearly defined. peaks big spit. Then, having gone down from it by 5-7 cm, they begin deep palpation according to the principle "from the periphery to the center". A similar palpation is carried out retreating from the trochanter to the sides by 5-7 cm. pay special attention to the posterior superior angle of the trochanter- the place of attachment to the trochanter of the tendon of the middle and small gluteal muscles, their tendons and synovial bags are located here.

In healthy patients, palpation of the greater trochanter is painless. Pain above the greater trochanter, below and in front of it indicates inflammation of the trochanter or synovial bags. Local pain at the posterior-superior angle of the trochanter is characteristic of the pathology of the tendons and synovial bags of the middle and small gluteal muscles. Via "anvil symptom"(Fig. 196) and weight load (standing on the interested leg), it is possible to exclude or confirm the pathology of the trochanter.

Rice. 196. Identification of pain in the hip joint by tapping on the heel of the outstretched leg (anvil symptom).

Rice. 197. Feeling the femoral head in the femoral (Skarpov) triangle.

The hip joint due to its deep location is almost inaccessible to palpation. Only in femoral triangle(it is bounded from above by the inguinal fold, from the outside by the inner edge of the sartorius muscle, from the inside by the outer edge of the long adductor muscle) it is possible to palpate part of the anterior surface of the femoral head, a narrow strip of the anterior edge of the acetabulum and partially the joint space. The palpated part of the joint is perceived like tight resistance to the fingers, trying to penetrate into the depth of the femoral triangle. Palpation carried out as follows (Fig. 197). The subject lies on his back on a hard surface. The doctor places the thumb of the right hand on the anterior surface of the ilium, the rest on the greater trochanter of the thigh. Then the thumb or II and III fingers move along the inguinal fold to the place where the femoral artery pulsates in depth - this is approximately the lower third of the ligament. After that, the fingers are slightly displaced outward from the femoral artery. In this place, when pressing inward, the fingers rest against the head of the femur, which lies outside the cavity, and a little more medially at the acetabulum there is a joint space, but it is not always possible to clearly palpate it. On palpation of the joint space, the fingers turn perpendicular to its edge. (Fig. 198).