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State Medical and Pharmaceutical University ,, Nicolae Testemitanu

Surgery course Stomatological Faculty

The practical skills in surgical phathology

Chişinău 2012
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Intoduction

The prezent note are destinated for students of stomatology faculty and content the
main practical skills that is necesary to be known by a future doctor in his own
practical work, not just a dentist but as a general doctor. The doctor, in general,
must to have knwledge not only from it future occupation but also from another
fields of medical activities.
The more important things it is the practical implimentation of the knowledge that
students have accumulated during their practoical clasis and lessons. We hope that
prezent practical note will be usefill not only for passing the practical part of the
exam in surgical desease but also in his future work in general.
The publication content the illustration informations about main surgical sign and
symptoms in emergency surgical and same planic surgical desease. The publication
writing according with surgical analitic programme for students of stomatological
faculty.

GOOD LUCK!!!
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ACUTE APPENDICITIS
1. Delafoua triade - cutaneous hyperesthesia often overlies the region of
maximal tenderness and pain. (figure N. 1 and 2.)
Figure N. 1

Figure N. 2.

2.The Rovsing’s sign Continuous deep palpation starting from the left iliac fossa
upwards (anti clockwise along the colon) may cause pain in the right iliac fossa, by
pushing bowel contents towards the ileocaecal valve and thus increasing pressure
around the appendix. (Figures N. 3 and N. 4.)
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Figure N. 3.

Figure N. 4.

3. Psoas sign or Coupe 1 sign

With the patient lying on the left side, slow extension of the right hip causes local
irritation and pain. A positive psoas sign indicates retroperitoneal inflammation.
( Figures Nr. 5 and 6)

Figure Nr. 5
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Figure Nr. 6.

4. Obturator sign or Coupe 2 sign. With the patient supine, passive internally
rotation of the flexed right hip causes hypogastric pain. (mean the pelvic position
of the inflanated appendix). (Figures Nr. 7 and Nr.8.)

Figure Nr. 7.
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Figures Nr. 8.

5. Kocher (Kosher)’s sign. The classic history - The appearance of pain in the
epigastric region and migrating or subsequent shift to the right iliac region occurs in
only 50 percent of patients. Figures Nr. 9. and Nr. 10)

Figure Nr. 9. Figure Nr. 10.

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6. Sitkovskiy’s sign Increased pain in the right iliac region as patient lies on his/her
left side. (Figures Nr. 11.)
Figures Nr. 11.)

7. Bartomier-Michelson’s sign. Increased pain on palpation at the right iliac region

as patient lies on his/her left side compared to when patient was on supine position.
(Figures Nr. 12.)

Figure Nr. 12.

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8.Voscresenshi’s sign —increased pain in the right ileac area during the slipering
with the hand on the shirt. (Figures Nr. 13.)

Figure Nr. 13.

ACUTE PANCREATITIS
9 Grey Turner's sign. - flanks ecchymoses (indicative of hemorrhagic
pancreatitis.) (Figure Nr. 14.)

Figure Nr. 14.

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10.Cullen's sign - periumbilical (indicate extravasation of hemorrhagic exudates in

hemorrhagic pancreatitis) ecchymoses. Figures Nr. 15. and Nr. 16.

Figure Nr. 15.

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Figure Nr. 16.

11 Voscresenski sign – the absens of the aortic abdominal pulsation (connected

with the oedema of the tissuie near aorta abdominalis)

12.Meio – Robson sign – the pain in the left costo-vertebral ungle. (Figure Nr.
17.)

Figure Nr. 17.

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13. Korte symptom - mild-to-moderate muscular rigidity and pain may be present
in the upper abdomen, (Figure Nr. 18 and Nr. 19)

Figure Nr. 18.

Figure Nr. 19.

ACUTE CHOLECYSTITIS

14. Murphy's sign - consisting of inspiratory arrest and pain during deep palpation
of the right upper quadrant. (Figure Nr. 20.)
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Figure Nr.20.

15.Ortner's sign - tenderness when hand taps the edge of right costal arch.
(Figure Nr.21.)

Figure Nr. 21.

16. Georgievskiy-Myussi's sign (phrenic nerve sign) - pain when press between
edges of sternocleidomastoid muscle. (Figure Nr.22.)
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Figure Nr. 22.

17. Kher symptom - increasing of the pain during deep breath and palpation of the
anterior abdominal wall. (Figure Nr. 23.)

Figure Nr. 23.

18. Charcot's sign

Intermittent right upper abdominal pain, jaundice, and fever (Choledocholithiasis).

19. Determination of the X- ray sign of choledocholithiasis. (Figures Nr. 24; 25;
26. 27.)
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Figure Nr. 24. RCPG
Stone in the enlarge choledochus.

Figure Nr. 25. Contrast fistulocholangiografy investigation. ( contrast was

inserted in the CBD by draine, during operation.). 2 Stones inside the
common bile duct, one in the supraduodenal part and another in the
proection of the sphincter Oddi.
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Figure Nr. 26. Contrast fistulocholangiografy investigation.

Figure Nr. 27. Contrast fistulocholangiografy investigation. Stone in the

retroduodenal pert of the CBD.
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PERITONITIS
20. Diffuse abdominal rigidity ("washboard abdomen") is often present,
especially in generalized peritonitis

21. Blumberg sign - deep palpation of the viscera over the suspected inflamed
organs followed by sudden release of the pressure causes the severe pain in the
abdomen.
22. Mondor sign – absens of the intestinal peristaltic during auscultation.
Auscultation reveals a silent abdomen or minimal peristalsis.

23. Hipokrates faces – palenees with acrocyanosis of the faces.

INTESTINAL OBSTRUCTION

24. Shlanghe sign - hyperactive, high-pitched peristalsis

25. Vahle sign - dilated loops of bowel are palpable

26. Obuhov hospitals sign - the rectum is usually empty.
27. Konig sign - loud borborygmi during auscultation.
28. Clearn enima, hypertonic enima, Ognevs enima determination and application.
29.X – ray film interpretation of the intestinal obstruction (figure NR.28., 29.,30.)

Figure Nr. 28. Irigoscopic investigation of the colon, contrast mass inserted inside

the colon by enima.

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Figure Nr. 29. X ray sign of high intestinal obstruction

Figure Nr. 30. X ray sign of low intestinal obstruction

Complications of gastric and duodenal ulcers.

PERFORATED ULCER
30. Delafoua sign - a perforated peptic ulcer usually present with a sudden onset of
severe, sharp, intense and steady epigastrical pain, like knife heat.
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31. Eleken sign – the pain irradiated toward clavicula.

32. Mondore triade – ulcer history, the epigastrical pain that beginning like knife
heat , muscule tenderness.
33. The Klark sign – the ,,absens,, of the liver tisuie during percution.( Figure Nr.
31.)
Figure Nr. 31

34.Mandel sign – the increasing of the abdominal pan during perecution in the
proiection of the perforation.
35. Shlange sign – sign of abdominal silent, the absens of the intestinal peristaltic
36.Kulenkamf sign – the presens of painfull pelvic swelling during rectal
examination.
37. X-RAYS EXAM. Look for a thin linear gas shadow between his diaphragm
and his liver or stomach. (Figure Nr. 32.) If he cannot sit or stand, take a lateral
decubitus film and look for air under his anterior abdominal wall.CAUTION ! (1)
An ulcer can perforate almost silently in the very old, or in the course of another
disease. (2) The absence of gas does not exclude the presence of a perforated ulcer.
(Figure Nr. 33.)(3) Gas can also come from a ruptured diverticulum or an
appendix (uncommon).

Figure Nr. 32. Linear gas shadow between diaphragma and liver
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Figure Nr. 33. Petresu test is negative, after the insertion of the air inside the
stomach, the aer don,t pass into peritoneal cavity

38. Forrest endoscopic classification of peptic ulcer activity interpretation

Figure Nr. 34.

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Acute hemorrhage

 Forrest I a (Spurting hemorrhage)

 Forrest I b (Oozing hemorrhage)
 Forrest I c (capillary hemorrhage)

Signs of recent hemorrhage

 Forrest II a (Visible vessel)

 Forrest II b (Adherent clot)
 Forrest II c (Hematin on ulcer base)

Lesions without active bleeding

Forrest III (Lesions without signs of recent hemorrhage)

39. The using of the puls, arterial blood presure, Hb, Ht, RBC levels in the
determination of the peptic ulcer bleeding degree.

40. Vizual determination of coffy grind (Figure Nr.35), melena.

Figure Nr.35
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41.Direction and aplication of the Blakmore tube.

Tamponade devices
Bleeding from varices may temporarily be reduced with tamponade balloon tubes.
However, the benefit is temporary, and prolonged tamponade causes severe
esophageal ulceration and has a high rebleeding rate.
The Blakmore tube is recommended. It has a gastric balloon and long esophageal
balloon (Figure Nr.36.) The tube is kept in esophagus while preparations for
endoscopic or radiologic treatment are being made. (Figure Nr.37.)

Figure Nr.36. General image of the Blakmore tube.

Figure Nr.37. Bleeding from esophagus vain,

hemostasis by using of the Blakmoore tube.
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42. X-ray film interpretation in piloric stenosis

Figure Nr.38. First degree stenosis
Retension of the contrast drug inside the stomach till 6 - 12 hours

Figure Nr.39. Second degree stenosis

Stenosis of the piloric chanal, retension of the barium mass inside the stomach
more than 12 - 24 hours
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Figure Nr.40. Third degree stenosis.
Huge stomach, situated in the pelvis position, retension of the barium mass inside
the stomach more than 24 hours.

Lung and pleural iliness

43. Clinical interpretation of the lung percussion and auscultation.
44. X-ray film interpretation of the emergency lung and pleural iliness
Figure Nr.41.
Right lung abceses
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45. Direction and aplication of the Boulau toracic drain
Figure Nr.42.
Posttraumatic pneumothorax. Drain of the pleural cavitz in the 2 intercostal space
on the middle claviculare line.

44. Pleural puncture carry out.

Figure Nr.43.
Drain of the right pleural cavity by Biulau method.

Abdominal wall hernia

46. Determination and investigation of the most common hernial gate of the
anterior abdominal wall (external inghinal rings, femoral area, ombilical area).
(Figures Nr.44, 45, 46, 47)
]
Figure Nr.44.
Umbilical hernia( general view), enlagement of the umbilical ring.
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Figure Nr.45.
Umbilical hernia, umbilical ring palpation.

Figure Nr.46.
Right inghinal hernia. Palpation of the right external inghinal ring.
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Figure Nr.47.
Ventral hernia, general view.

Disorder of the arterial system

47. The femoral, popliteal, dorsal, pedal and posterior tibial pulses determination.
Figures (Nr.48, 49, 59,51,52)
Figure Nr.48.
Femoral artery puls determination
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Figure Nr.49
Determination of the puls in the proection of the arteria carotis dextra

Figure Nr.50.
Determination of the puls in the proection of the arteria dorsalis pedis
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Figure Nr.51.
Determination of the puls in the proection of the arteria tibialis posterior

Figure Nr.52.
Determination of the puls in the proection of the arteria poplitea

48. Arterial function test (Opel sign of plantar ischemia, finger compres sign,
Pancenco sign).
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Figure Nr.52.
Opel sign the paleness of the leg in the high position of the foot.

]
49. Disorder of the venosis system
Figure Nr.53.
Varicouses deases of the right inferior extremity, general veiw
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Figure Nr.54.
The retrograde -feeling test described by Trendelenburg The patient in the supine
position, the leg to be examined is elevated 30 to 45 ° to ensure maximal
venous emptying. An elastic tourniquet is adjusted around the thigh just below the
inguinal area

Figure Nr.55.
If after the tourniquet was removed the vein become rapidly full with blood that
remark the failure of the ostial valve.
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Perthe’s first test

Perthe’s first test has been used to assess deep venous patency. Superficial
varicose are compressed by tourniqet in the upper 1/3 of the thigh. Upon exercise,
the development of increasingly severe crampy leg pain suggests a deep venous
obstruction.(figures Nr.56, 57)

Figure Nr.56.
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Figure Nr.57.

The Prate test (Figures Nr. 58, 59. 60. 61, 62)
Figure Nr.58.
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Figure Nr.59.

Figure Nr.60.
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Figure Nr.61.

Figure Nr.62.

The thyroid gland iliness

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50. Tests to evaluate thyroid function
Blood tests can determine the amount of hormones produced by pacient thyroid and
pituitary glands. If pacient thyroid is underactive, the level of thyroid hormone will be
low. At the same time, the level of thyroid-stimulating hormone (TSH) will be
elevated because pacient pituitary gland tries to stimulate pacient thyroid gland to
produce more thyroid hormone. Goiter associated with an overactive thyroid usually
involves a high level of thyroid hormone in the blood and a lower than normal TSH
level.

51. Steliwag, Graeffe, Mebius clinical sign determination

Figure Nr.63.
Stelvage sign – rare blink, or wolf look

Moebius sign – convergation destroy

Graeffe sign – the superior eyelid don,t cover completely the eye
52. Thyroid gland palpation and groiter classification.
Figure 64.
Thyroid gland palpation
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Groiter classification by size

Class 0 – normal sizeof the thyroid gland
Class 1– palpation struma, in normal posture of the head, it cannot be seen, it is
only found by palpation.
Class 2 – the struma is palpative and can be easilz seen, but don.t change the shape
of the neck.
Class 3 – the gland we can see diring inspection, change the shape of the neck,
thick neck.
Class 4 – the struma is very large, sometimes retrosternal.
Class 5 the gand has enormeous size, pressure results in compression marks.