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1. Patient S., 38 years old, was admitted to the surgical department with complaints of burning pain in
stomach leading to fainting. 3 hours after the onset of pain, vomiting and loose stools mixed
with blood appeared.
Objectively: the condition is serious. Pulse 110 in 1 minute, A/D 90/60 mm. rt. Art. The tongue is dry, the nose
is pointed, the tip of the nose and lips are cyanotic. The abdomen is moderately swollen. On palpation, there is
pain in the anterior abdominal wall to the right of the navel. There is no peristalsis.
In the study of blood leukocytosis, ESR 45 mm/h.
X-ray: pneumatosis in a small area of the small intestine, small bubbles of gas and
liquid levels.
Solution: Formulate a diagnosis.
Surgical tactics.
Management in the postoperative period.
Acute thrombosis of the branches of the superior mesenteric artery.
Donkey: Acute small bowel obstruction. Peritonitis.
2. Patient B., 68 years old, was admitted to the clinic 2 days after the onset of the disease with
complaints of constant pain in the left iliac region, frequent false urge to defecate, discharge
of mucus and blood from the rectum. These complaints appeared immediately after eating
fresh cabbage salad. The patient took analgin, after which the pain decreased, but appeared
frequent, every 15-20 minutes. false urge to defecate. Within 2 days he was treated on his
own, but there was no effect, he asked for medical help.
On admission he was in a state of moderate severity. Pulse 92 in 1 min., rhythmic, A/D 140/90
mm. rt. Art. The tongue is dry, the abdomen is swollen, soft on palpation, painful in the left iliac
region. The sigmoid colon is palpated in the form of a dense spasmodic cord. On digital
examination of the rectum, the ampoule is empty. At a height of 8-9 cm, a tumor-like formation is
determined, moderately painful, mobile, covered with an altered mucous membrane.
Solution: 1. Formulate a presumptive diagnosis.
2. Additional research methods.
3. Final diagnosis.
4. Tactics.
Answer.
Tumor of the rectosigmoid department with the development of colonic obstructive obstruction.
Radiography of the organs of the cavity, rectoscopy.

Most likely cancer.
Abdominal-anal resection (because the op is located at a distance of 8-9 cm).
3. Patient E., 37 years old, was taken to the clinic 3 hours after the incident. She was pressed against the
gate by a truck. Upon admission, the patient's condition was extremely severe, he was agitated, his skin
was pale, and there was cold sweat on his forehead. The pulse on the radial artery is not determined, A/
D 60/0 mm. rt. Art. The abdomen is painful on palpation in the lower sections and tense. During
catheterization of the bladder, about 30 ml were released. urine intensely stained with blood. On
radiographs of the pelvic bones, a fracture of the pubic and ischial bones with displacement of
fragments is found.
Solution: 1. Formulate a preliminary diagnosis.
2. What additional research needs to be done to clarify

diagnosis.
3. Tactics.
Blunt abdominal trauma. Peritonitis. Intra-abdominal bleeding. Kidney injury?

Urinary injury? Fracture of the pelvic bones with displacement of fragments.
4. Patient B., 78 years old, was hospitalized 6 times with a diagnosis of myocardial infarction
on the basis of complaints of severe pain behind the sternum, which was not stopped by nitroglycerin,
morphine injections and antispasmodics, lasted for several hours, was accompanied by vomiting, a
decrease in blood pressure. According to the patient, pain often occurred immediately after eating,
especially plentiful. The strict bed rest prescribed at that moment worsened his state of health. Despite
the prohibition of doctors, the patient sat up in bed, which led to relief. Repeated ECG did not reveal
fresh focal or cicatricial changes in the myocardium. Upon careful questioning of the patient, it was
possible to find out that he periodically had regurgitation, heartburn, salivation, and bitter belching with
air.
2. What additional research needs to be done to clarify

diagnosis.
3. Tactics
Answer.
Diaphragmatic hernia. Herb. Hernia of the esophageal opening of the diaphragm. Reflux - esophagitis.
Esophagogastroscopy. X-ray of the esophagus. Intraventricular pH-metry

Lech-concer + chir
5. Patient I., 34 years old, was delivered to the clinic with complaints of weakness, dizziness, vomiting of the
“coffee grounds” type twice during the day. From the anamnesis: for 10 years suffers from chronic duodenal
ulcer; in the autumn-spring period notes exacerbations, which is expressed by pain in the epigastrium. He is
not registered with the dispensary and has not received regular treatment. Three days before admission to
the hospital again noted pain in the epigastrium.
Objectively: the patient's condition is severe. Severe pallor of the skin. Pulse 116 beats per 1
minute, rhythmic, weak filling. A / D - 80 and 40 mm Hg. Art. The tongue is dry. The abdomen is
soft and slightly painful in the epigastrium. The liver and spleen are not palpable. When
examining the rectum on a glove, black feces. Additionally: Ht-23%, v-2.1 y. e.
Solution: Formulate a preliminary diagnosis.
Determine the deficiency of circulating blood.
Determine the source of bleeding.
Formulate the final diagnosis.
Surgical tactics.
Answer.
Yab 12 PC, exacerbation. Gastrointestinal bleeding.
Osl: posthemorrhagic anemia 3-4 tbsp.
DC = 1000* V+ 60* hematocrit (%) - 6700m(6060g) (Barovsky)
Treatment: transfusion. Therapy, operations (excision of an ulcer of the anterior wall with pyloroplasty and
vagotomy)
Fgds, if it bleeds, then an emergency operation, if not, then the restoration of the bcc, then the operation.
6. Patient K., aged 28, was taken to the clinic from the scene.
Complaints of weakness, pain in the left lumbar region.
From the anamnesis it was established that the victim was hit by a car 2 hours ago. The
blow fell on the left lumbar region.
Objectively: the patient's condition is severe. Severe pallor of the skin. Pulse 116 beats per 1
minute, rhythmic, weak filling. A / D 80 and 40 mm Hg. Art.
On examination, there is a skin abrasion in the left lumbar region. The abdomen is painful in
the left hypochondrium, there is no muscle tension and peritoneal signs. Dullness is noted
percussion sound in the left side of the abdomen. Sharp pain in the left lumbar region.
Macrohematuria.
Determine the set of necessary additional
laboratory and instrumental methods
research.
final diagnosis.
Surgical tactics.
Answer. Closed blunt trauma to the left lumbar region, contusion of the left kidney. Traumatic shock 2.
Rupture of the left kidney?. Extensive retroperitoneal hematoma. Osl: anemia posthemorrhagic 3-4 tbsp.
Ultrasound, laparoscopy, removal of the left kidney and stop bleeding
7. Patient L., 82 years old, was taken to the clinic 8 hours after the onset of illness with complaints of
nausea, repeated vomiting of food mixed with bile.
From the anamnesis, it was established that the pain arose after errors in the diet.
Similar attacks were noted before, for which she was repeatedly hospitalized in the clinics of
the city. Suffering from hypertension, had an ischemic stroke and 4 months ago transmural
myocardial infarction.
Objectively: the patient's condition is severe. Moaning in pain. Pulse 96 beats per minute, arrhythmic. AD 190
and 95 mm. Hg Body temperature 38.4. Dry tongue. The abdomen is not swollen, participates in the act of breathing
to a limited extent. Soreness and tension of the abdominal muscles in the right hypochondrium were noted, here are
positive symptoms of Shchetkin-Blumberg.
What complex of additional laboratory and
instrumental methods of research is necessary
to clarify the diagnosis.
surgeon tactics.
Answer.
Zhkb, acute destructive cholecystitis, local peritonitis.
Examination: ultrasound, rhpg, oral cholecystography

Treatment: non-narcotic analgesics, anticholinergics, antispasmodics, cholecystectomy
8. Patient N., 67 years old, was taken to the clinic 2 days after the disease with complaints
for cramping abdominal pain, bloating, nausea and repeated vomiting. Within 5 days, gases do not
go away, and there is no stool.
From the anamnesis it was established that the patient had been suffering from constipation for about 3 years. During the
act of defecation, he periodically noted the release of a large amount of mucus and streaks of blood in the feces.
Objectively: the patient's condition is severe. Pulse 120 per minute, rhythmic. AD 120 and 70 mm. rt.
Art. Dry tongue. The abdomen is swollen, slightly tense and painful in the left hypochondrium and
mesogastrium, swollen bowel loops are contoured. Splash noise is determined. In the left iliac region, a
dense, rounded formation is palpated. Peristalsis is sluggish, sometimes gurgling. When examining the
rectum, the sphincter gapes, the ampoule is empty. Diuresis is reduced to 500.0 ml.
Specify the necessary complex of laboratory and
instrumental research methods that allow
clarify the diagnosis.
Determine the degree of intoxication.
Specify the sequence of stages in the treatment of the patient.
A set of activities at each stage.
Answer.
Acute obstructive colonic obstruction. Tumor of the sigmoid colon.
Investigation: x-ray.
St intoxication - weak heart rate less than 100, diuresis more than 700, strong - heart rate more than 140,
diuresis less than 300, orientation by the leukocyte index of intoxication is possible.
Treatment: hemicolectomy (removal of a part of the transverse descending colon and part of the sigmoid colon) with the
imposition of a transverse sigmoid anastomosis
9. Patient N., 44 years old, was admitted to the clinic 5 hours after the disease with
complaints of sudden acute pain in the epigastrium, single vomiting.
From the anamnesis it was established that for 15 years the patient in the autumn-spring
period occasionally had moderate pain in the epigastrium, which after taking antispasmodic
drugs stopped. The patient had not applied for medical help before and was not examined.
Objectively: the patient's condition is grave, he is pale, covered with cold sweat. The position is
forced on the side with the knees pulled up to the stomach. Pulse 60 beats per minute, rhythmic. BP 110
and 70 mmHg Dry tongue. The abdomen is not swollen, painful in all parts, “board-like” tension of the
muscles of the anterior abdominal wall, positive phrenicus symptom. Percutere: hepatic dullness is
absent.
What laboratory and instrumental methods
investigations to clarify the diagnosis.
Choice of method of treatment of the patient.
Answer.
perforated ulcer
Examination - X-ray, FGDs
Ulcer suturing
10. Patient V., aged 34, was admitted to the clinic 9 hours after the onset of the disease with complaints of
constant pain in the pigastric region, which migrated to the right side of the abdomen. From the anamnesis it
was established that 9 hours ago he had acute, sudden pains in the epigastric region, from which he took a
forced position on his side. There was a single vomiting. Reception of antispasmodic drugs had no effect.
Then the pains decreased, but did not completely disappear, their migration to the right half of the abdomen
was noted.
Objectively: the patient's condition is relatively satisfactory, active position. Pulse 90 per minute,
rhythmic. BP 120 and 80 mmHg The tongue is dry. The abdomen is involved in breathing, painful in the
epigastrium and the right side of the abdomen. Moderate tension of the muscles of the anterior abdominal
wall. Percussion hepatic dullness is absent, dullness is determined in the sloping parts of the abdomen on
the right.
Specify Additional Methods
research to clarify the diagnosis.
surgeon tactics.
Answer.
perforated ulcer. Diffuse peritonitis.
Ulcer suturing, cavity toilet, drainage
11. Patient S., 38 years old, was admitted to the clinic a day after the onset of the disease with complaints of
pain throughout the abdomen, nausea and repeated vomiting. From the anamnesis, it was established that a
day ago, sharp pains in the epigastrium suddenly appeared, from which the patient took a forced position.
After a few hours, the pain decreased, but did not completely disappear and spread throughout the abdomen.
Then again the pain intensified, nausea and vomiting appeared. Ulcer history for 10 years.
Objectively: the patient's condition is severe. Facial features are sharpened. Pulse 116 beats per minute,
rhythmic. BP 100 and 60 mmHg Body temperature increased to 38.00C. Thirst, dry mouth. Tongue dry, lined.
The abdomen is somewhat swollen, participates in the act of breathing to a limited extent. Palpation: soreness
and tension of the muscles of the anterior abdominal wall in all departments. Shchetkin-Blumberg's symptom
is positive. Percussion hepatic dullness is absent. Dullness in sloping parts of the abdomen. There is no
peristalsis.
What additional methods
investigations to clarify the diagnosis.
Indicate the sequence of stages of treatment of the patient and
a set of activities at each stage.
Answer.
perforated ulcer. Diffuse peritonitis.
Ulcer suturing, cavity toilet, drainage
12. Patient A., aged 76, was admitted to the clinic 4 days after the disease with complaints of a
hernial protrusion in the right inguinal region, which did not disappear on its own. Education is
painful. From the anamnesis it was established that the patient has been a hernia carrier for 20
years. All this time, the hernial protrusion both appeared and disappeared on its own. However, 4
days ago, a hernial protrusion appeared and has not disappeared to date.
Objectively: the patient's condition is moderate. Pulse 92 beats per minute, rhythmic. BP 150 and 90
mmHg Body temperature 38 o. The tongue is dry. When viewed above the inguinal ligament on the right,
there is a painful hernial protrusion, which does not self-reset into the abdominal cavity. The skin over
the hernial protrusion is hyperemic and edematous. The abdomen is soft and painless. Peristalsis is
heard. The gases are leaving.
Surgical tactics.
The order in which the steps are performed.
Answer.
Strangulated inguinal hernia on the right. Phlegmon of the hernial sac
Lech-
1. isolation of the cavity (laparotomy with resection of the intestine within healthy tissues and the
establishment of drainage
2. opening of the hernial sac, installation of perforated drains
13. A 60-year-old patient P., on the 5th day after an extensive transmural myocardial infarction, developed
severe weakness, coffee-ground vomiting, and melena. Examined by the surgeon and the patient was
transferred from the cardiology department to the surgical one.
Objectively: the condition is serious. Severe pallor of the skin, covered with cold sweat.
Pulse 110 in 1 minute, rhythmic. BP 90 and 60 mmHg Abdomen - moderate pain in the
epigastrium.
Laboratory data: The number of erythrocytes is 2.2 x 10.12 \ l, the hemoglobin content is 86 g / l, the
hemotocrit index is 23%, the blood viscosity is 2.2 c.u. E. When the probe is inserted into the stomach,
contents such as “coffee grounds” enter, and then scarlet blood.
What additional research methods
necessary to clarify the diagnosis.
Determine the amount of blood loss.
Surgical tactics.
Answer.
Acute gastric ulcer. Gastrointestinal bleeding
Dsc = 1000* viscosity + 60* hematocrit - 6700m(6060g)

Treatment: transfusion. Therapy, operations (resection of the stomach with removal of a bleeding ulcer
14. Patient P., 40 years old, was brought to the clinic 8 hours after the onset of the disease with complaints
of pain in the epigastrium, shingles, nausea and repeated vomiting. From the anamnesis, it was established
that the patient had taken alcohol the day before.
Objectively: a state of moderate severity. Skin and mucous membranes of normal color. Pulse
96 in 1 minute, rhythmic. BP 120/80 mmHg The tongue is dry. The abdomen is not swollen,
participates in breathing. Moderate pain on palpation in the epigastrium. Shchetkin-Blumberg's
symptom is absent. Positive symptoms of Resurrection and Mayo-Robson.
What additional laboratory and
instrumental research methods are necessary
Create an infusion program for treatment
sick.
Which of the methods of extracorporeal detoxification
You could offer to treat the patient.
Answer.
Acute interstitial pancreatitis.
Examination - ultrasound, CT, X-ray.
Treatment - atropine, 5 fluorouracil, contrical, glucose, rheopolyglucin, heparin
15. Patient K., 23 years old, was admitted to the clinic on the 2nd day from the onset of the disease with
complaints of intense abdominal pain, more in the right half of it, general weakness, nausea and thirst. He
fell ill suddenly, when there were sharp pains in the epigastrium, nausea. Then they became less intense
and spread throughout the abdomen. From the anamnesis it is known that for several years the patient was
periodically disturbed by heartburn and hungry pains, which disappeared after eating.
Objectively: the state of moderate severity. Pulse 90 per minute, rhythmic. BP 120 and 80 mmHg Tongue
dry, covered with white coating. The abdomen is not swollen, participates in breathing to a limited extent.
Painful on palpation in the epigastrium and right half. Tension of the muscles of the abdominal wall in the
right half, a positive symptom of Shchetkin-Blumberg on the right. There is no dullness in sloping places of
the abdomen. Hepatic dullness is preserved. Peristalsis is rare.
Laboratory data: the number of leukocytes is 8.6x10.9 / l.

final diagnosis.
Surgical tactics.
Answer.
Yab12 pc. Donkey: perforated ulcer. Diffuse peritonitis.
Lech.
Transfusion therapy, surgery (excision of an anterior wall ulcer with piploroplasty and
vagotomy)
16. Patient N., 58 years old, was admitted to the clinic on the 3rd day from the moment of illness
with complaints of pain in the epigastrium, shingles, nausea, yellowness of the skin and sclera.
From the anamnesis it is known that 3 days ago she had pain in the epigastrium, girdle character,
nausea and vomiting. A day ago, yellowness of the sclera and skin appeared. It is also known that
6 months ago the patient underwent cholecystectomy for chronic calculous cholecystitis.
mmHg The tongue is dry. The abdomen is not swollen, participates in breathing to a limited extent. There is
a postoperative scar in the right hypochondrium. On palpation, the abdomen is soft and painful in the
epigastrium. There are no peritoneal symptoms. Dullness in sloping places of the abdomen is absent.
Peristalsis is heard. Urine dark, feces discolored.
final diagnosis.
Possible treatment options for the patient.
Answer.
Acute paccreatitis

Treatment - atropine, 5 fluorouracil, contrical, glucose, rheopolyglucin, heparin,
surgical drainage of the alnic bursa
17. Patient K., aged 56, was brought to the clinic with a diagnosis of "Acute abdomen". From the anamnesis,
it was established that he had been ill for 2 days, when pains appeared in the epigastrium, girdle character.
He did not seek medical help. Then the pain spread throughout the abdomen. There was nausea and
vomiting. The patient has a history of repeated attacks of acute pancreatitis.
Objectively: the condition is serious. Pulse 126 in 1 minute, rhythmic, weak filling. BP 90 and 60 mmHg Dry
tongue. The abdomen is somewhat swollen, participates in breathing to a limited extent. Palpation is painful in
all departments, more in the epigastrium. Tension of the muscles of the anterior abdominal wall and a positive
symptom of Shchetkin-Blumberg are noted. Percussion hepatic dullness is preserved, dullness in the sloping
parts of the abdomen. Peristalsis is sharply weakened.
use on a patient? Their informativeness.
Types of treatment.
Which method of extracorporeal detoxification
applicable to this patient.
Answer.
Acute destructive pancreatitis. Hemorrhagic pancreatic necrosis. (?) Diffuse

enzymatic peritonitis.
Treatment - atropine, 5 fluorouracil, contrical, glucose, rheopolyglucin, heparin,

surgical drainage of the alnic bursa
peritoneal dialysis.
18. Patient K., 45 years old, was admitted to the clinic 12 hours after the disease with complaints of
weakness, flickering of “flies” before the eyes, repeated vomiting, both of the “coffee grounds” type and of
scarlet blood. From the anamnesis it was established that in the morning, getting out of bed, he felt weak,
there was a flicker of “flies” before his eyes. Fell, lost consciousness, woke up, nausea appeared, and then
vomiting like “coffee grounds”. Further vomiting of scarlet blood. I have had viral hepatitis in the past.
Objectively: the condition is serious. Severe pallor of the skin, covered with cold sweat, somewhat
agitated. Pulse 124 in 1 minute, rhythmic, weak filling. BP 80 and 40 mmHg Dry tongue. The abdomen is
enlarged due to ascites. On palpation, the lower edge of the liver protrudes 4 cm from under the edge
of the costal arch. Percussion dullness in the sloping parts of the abdomen.
Laboratory data: erythrocyte count 2.8*1012\l., hemoglobin content 86 g/l, hemotocrit

rate 28%, viscosity 2.4 c.u.
Determine the deficiency of circulating blood and the magnitude
blood loss.
Determine the source of bleeding.
Surgical tactics.
Answer.
Cirrhosis of the liver. portal hypertension syndrome. Ascites.
Donkey: Bleeding from dilated veins of the esophagus. hemorrhagic shock 2. posthemorrhagic
anemia
Lech - Blackmer Probe. If not effective - transgastric ligation of the veins of the
esophagus. splenectomy with omentorenopexy and portocaval anastomoses
19. Patient K., 33 years old, was brought to the clinic 3 hours after the incident, with complaints of general
weakness, pain in the left hypochondrium, nausea and single vomiting.
Circumstances of injury: At a construction site, he fell from a height of 3 meters, hitting a metal
object with the left half of his abdomen.
Objectively: the condition is serious. Severe pallor of the skin. The patient cannot lie down, tries to
take a forced position. Pulse 126 beats per minute, rhythmic, weak filling. BP 80 and 40 mmHg Dry
tongue. The abdomen is correct in shape, participates in breathing to a limited extent. There is a skin
abrasion in the left hypochondrium. On palpation, the abdomen is soft and painful in the left
hypochondrium. Here is the tension of the muscles of the anterior abdominal wall. Percussion: dullness
in the sloping parts of the abdomen on the left. Peristalsis is heard.
Laboratory data: erythrocyte count 3.5*1012/l., hemoglobin content 102 g/l. hemotocrit
index 35%, blood viscosity 3.8 c.u.

to clarify the diagnosis?
Surgical tactics.
Answer.
Closed blunt trauma to the abdomen with damage to internal organs. Spleen rupture?
Donkey: Hemoperitoneum. trauma shock 2.
Examination - laparoscopy
Treatment - laparotomy. Splenectomy.
20. Patient S., 45 years old, was operated on for chronic cholecystitis, choledocholithiasis, obstructive jaundice.
Produced cholecystectomy, choledocholithotomy, drainage of the choledochus according to Pikovsky. Currently 15
days after surgery. Up to 600 ml of bile is constantly secreted through the drainage from the choledochus. Attempts
to squeeze the drainage are accompanied by the appearance of sharp pains and a feeling of heaviness in the right
hypochondrium.
mmHg The tongue is wet. The abdomen is not swollen, participates in breathing. In the right
hypochondrium there is a fresh postoperative scar and a drainage tube through which bile is separated.
needs to be done to determine the cause.
hypertension in the choledochus?
Surgical tactics.
Answer.
postcholecystectomy syndrome. Postoperative choledochal stricture.
Obsled-inform cholangiography, rhpg, ultrasound.
Treatment - repeated operation imposition of biliodigestive anastomoses
21. Patient K., 26 years old, was admitted to the clinic 3 days after the disease with complaints of
pain throughout the abdomen, nausea and vomiting. From the anamnesis it is known that 3 days
ago she had pain in the epigastrium, which after a few hours moved to the right iliac region. I had
loose stools three times. The patient did not seek medical attention. She took antibiotics on her
own. The day before, her condition worsened. There was a sharp increase in pain, which then
spread throughout the abdomen. There was nausea and vomiting.
Objectively: the patient's condition is grave, he groans from pain. The skin is pale. Pulse 126 beats
per minute rhythmic. BP 110 and 70 mmHg Dry tongue. The abdomen is swollen, participates in
breathing to a limited extent. Palpation: pain in all departments, more in the right iliac region. Tension of
the muscles of the anterior abdominal wall and a positive Shchetkin-Blumberg symptom. Percutere:
tympanic sound above the intestinal loops, dullness in the sloping parts of the abdomen. There is no
peristalsis. Gases do not leave. There is no chair. Diuresis is reduced to 500 ml. Body temperature 38.00C,
rectal 38.80C.
Laboratory data: the number of leukocytes 11.3 * 109 / l.
Determine the degree of intoxication.
Specify the order of stages in the treatment of the patient and
a set of activities at each stage.
Answer.
Acute appendicitis. Diffuse peritonitis.
St intoxication - medium.
Treatment of laparotomy, apenectomy, toilet of the cavity, drainage of the cavity with
subsequent lavage, correction of hydroionic disorders.
22. Patient I., 45 years old, was brought to the clinic 30 minutes after the injury with
complaints of pain in the right half of the chest, aggravated by breathing. Circumstances of
injury: while crossing the carriageway was hit by a car.
Objectively: the patient's condition is grave, the skin is pale. Pulse 116 per minute, rhythmic. BP 100
and 60 mmHg The right half of the chest lags behind during breathing, percussion sound with a box
tone, breathing from the right half of the chest is not carried out. On radiographs - a fracture of 5-7 ribs
on the right, mediastinal displacement to the left, collapse of the right lung. When puncturing the pleural
cavity on the right in the 2nd intercostal space received up to 1800 ml of air. Temporary improvement in
impaired breathing lasted 15 minutes.
What additional research methods are needed

to make the patient, clarifying the correctness of the measures taken.
surgeon tactics.
Answer.
Blunt trauma to the second half of the cell. Fracture of 5-7 ribs on the right. Tension
pneumothorax.
The treatment plan is novocaine blockade, puncture of 2 m / r. In case of failure - thoracotomy with suturing of the
hole.
23. Patient S., 23 years old, was delivered to the clinic 2 hours after the injury with complaints of pain
in the left side of the chest, shortness of breath. Beaten by unknown. The blows fell on the chest.
Objectively: the condition is serious. Pulse 118 in 1 minute, rhythmic. BP 110 and 70 mmHg The left
half of the chest lags behind in breathing. Palpation shows pain in the projection from 2 to 6 ribs and
crepitus of fragments. Percussion: there is a dullness of sound up to the 6th rib along the scapular line
on the left. Auscultatory: breathing is not audible in the lower sections.
What additional research methods are needed
apply to this patient.
What therapeutic measures should be taken to
improving respiratory function.
Answer.
Closed blunt trauma of the gr cells on the left. Fracture of 2-6 ribs on the left. . hemothorax.
Treatment plan - novocaine blockade, puncture at 2 m/r, after X-ray at 7 m/r along the posterior-axillary line.
In case of failure - thoracotomy, hemostasis.
24. Patient K., 13 years old, was brought to the clinic with complaints of general malaise,
constant pain in the right lower limb below the knee joint, inability to walk due to severe
pain. High body temperature.
Objectively: the patient's condition is severe. The skin is pale, dry. Pulse 124 beats per
minute, rhythmic. BP 90 and 60 mmHg Heart sounds are muffled. The right lower limb is
bent at the knee joint, passive and active extension is sharply painful, the lower leg is
enlarged in volume. Palpation: sharp pain along the anterior surface of the tibia in the upper
third. Body temperature 38.4.
Laboratory data: leukocytosis with a significant neutrophilic shift to the left. Accelerated ESR. On
the radiograph of the bones of the right leg, no pathological changes were found.
Survey plan.
Explain the absence of changes on the radiograph.

Treatment plan.
Answer.
Acute hematogenous osteomyelitis of the right tibia. local form
X-ray signs appear on the 10-14th day
Treat: a\b i\v or v\a, immunotherapy, detoxification therapy, bone drainage by applying
several burr holes, drainages, washing with antiseptics
25. Patient K., 26 years old, was brought to the clinic a day after the onset of the disease with complaints
of pain in the right iliac region, nausea and single vomiting. From the anamnesis it was established that a
day ago he had pains in the epigastrium, then they moved to the right iliac region. Examined by a
surgeon. Diagnosis: Acute appendicitis. Operated. The operation revealed a gangrenous appendix and a
significant amount of serous effusion in the right iliac fossa and small pelvis. An appendectomy was
performed, the abdominal cavity was drained of effusion through an incision in the right iliac region and
sutured tightly. On the 6th day after the operation, the patient's condition worsened. There were pains in
the lower abdomen and above the womb, dysuric phenomena, tenesmus, frequent loose stools, body
temperature began to rise in the evenings up to 38.0.
Objectively: The tongue is dry. On palpation of the abdomen, there is pain in the area of the
postoperative wound and above the womb. Moderate muscle tension. The Shchetkin-Blumberg
symptom is absent. On rectal examination - soreness of the anterior wall of the rectum, infiltrate will
be determined.
Laboratory data: leukocyte count 12.5*109/l, neutrophilic shift to the left.
Causes of complication after appendectomy.
surgeon tactics.
Answer
Douglas pouch abscess. Condition after appendectomy.
The reason is insufficient revision
Tactics - opening through the anterior wall of the rectum, drainage. Antibiotics,
detoxification.
26. Patient S., 54 years old, was delivered to the clinic 12 hours after the disease with complaints of
pain in the right iliac region, nausea and repeated vomiting. From the anamnesis established. that
the disease began with pain throughout the abdomen, which then localized in the right iliac
region. I suffered from nausea and repeated vomiting. Examined by a surgeon. Diagnosis: Acute
appendicitis. Operated. The operation revealed gangrenous
modified appendix with perforation in the apex. A significant amount of cloudy effusion in the right iliac fossa
and small pelvis. An appendectomy was performed, the abdominal cavity was drained of effusion through
the surgical wound and sutured tightly. On the 6th day of the postoperative period, deterioration in the
patient's condition was noted, which was expressed by the appearance of pain in the right hypochondrium
with irradiation to the right supraclavicular region and an increase in body temperature to 38.5.
Objectively: the patient's condition is moderate. Pulse 102 in 1 minute, rhythmic. BP 140 and 80 mmHg
When breathing, the patient breaks off a deep breath due to pain in the right hypochondrium.
Auscultatory: On the right, in the lower sections, breathing is sharply weakened. The tongue is dry. The abdomen is
not swollen. Painful on palpation in the right hypochondrium. Here is the tension of the muscles of the anterior
abdominal wall. Shchetkin-Blumberg's symptom is negative. Peristalsis is normal.
Laboratory data: the number of leukocytes 11.2*109/l, the shift of the leukocyte formula to the left.
Solution: What complication after appendectomy can be
speech.
needed to clarify the diagnosis
Causes of the complication
surgeon tactics.
Answer.
Acute subdiaphragmatic abscess on the right.
Prich-complications after appendectomy
Need to x-ray, ultrasound
Lech-opening, drainage. Antibiotics, detoxification.
27. Patient Sh., 46 years old, was delivered to the clinic 18 hours after the disease with complaints
of cramping abdominal pain, nausea, vomiting, flatulence and no stool. From the anamnesis it is
known that 18 hours ago there were cramping pains in the abdomen, which gradually intensified.
Then there were: nausea, there was repeated vomiting, gases stopped leaving, there was no stool.
In the past, she was operated on in a gynecological clinic.
Objectively: the patient's condition is moderate. Pulse 98 in 1 minute, rhythmic. BP 130 and 80 mmHg
The tongue is dry. The abdomen is somewhat swollen, asymmetrical. On palpation, pain in the
mesogastrium and muscle tension of the anterior abdominal wall is also determined here. Shchetkin-
Blumberg's symptom is negative. Splash noise. Auscultatory: increased peristalsis.

necessary to clarify the diagnosis?
Specify the sequence of stages of treatment of the patient and the complex
activities at every stage.
Answer
Acute adhesive small bowel obstruction
Need to x-ray
Lech-gastric lavage, then surgery (dissection of adhesions).
28. Patient P., aged 50, was admitted to the clinic on the 6th day after the injury with complaints of pain
around the wound of the right leg, general weakness, sweating, headache and fever up to 39. These
phenomena have been going on for 3 days, gradually progressing. The reason for the patient to seek
medical help was convulsions of masticatory muscles and difficulty opening the mouth.
Circumstances of injury: while working in the garden, she injured her right leg in the shin area with a
shovel.
Objectively: the patient's condition is severe, consciousness is preserved. The skin is moist. Pulse 120
beats per minute, rhythmic. When viewed in the upper third of the lower leg there is a superficial wound,
covered with a dry crust, without signs of suppuration. When trying to examine the patient's throat, she
cannot open her mouth due to convulsive contraction of the masticatory muscles.
What is the essence of complex treatment?
Answer
Acute general wound tetanus
Comprehensive treatment: PHO, wide drainage, rest, fight against convulsions, respiratory
disorders
Anti-tetanus serum: 100-150 thousand IU, course 200-300 thousand
Tetanus toxoid gamma globulin: from 10 thousand, then 5 thousand per day, course 20-50 thousand
Tetanus toxoid: intramuscularly three times with an interval of 5 days, 0.5 ml
29. Patient K., 46 years old, was delivered to the clinic on the 5th day after the disease with complaints of
pain in the right iliac region and an increase in body temperature up to 37.3. From the anamnesis it was
established that she fell ill acutely, epigastric pains appeared, which then were localized in the right iliac
region. Until now, she has not applied for medical help. She took antibiotics and no-shpu on her own.
The pain lessened, but did not completely disappear.
Objectively: the patient's condition is satisfactory. Pulse 88 in 1 minute, rhythmic. BP 130 and 70
mmHg The tongue is wet. The abdomen is of the correct form, is involved in breathing. On palpation, it is
soft and painful in the right iliac region, where the formation of a dense consistency is determined,
moderately mobile. There is no tension in the abdominal muscles. Shchetkin-Blumberg's symptom is
negative.
differential diagnosis.
final diagnosis.
Choice of treatment method
Answer
Acute appendicitis. Appendicular infiltrate
Diff jab, cholecystitis, b krone, acute adnexitis, ectopic pregnancy, nephrolithiasis
Treatment - bed rest, table No. 4, cold on the right iliac region, a \ b, UHF after the disappearance
of pain and temperature. With abscess formation - opening of the abscess using extraperitoneal
access. After 2-3 months appendectomy in a planned manner.
30. Patient K., 26 years old, sought medical help in the surgical room of the polyclinic with
complaints of a tumor-like formation on the back of the neck, severe pain in it, nausea,
vomiting, loss of appetite, headache and fever. From the anamnesis it was established that 2
days after shaving in the neck area on its back surface, he began to feel a slight itching and
tingling. Then a slightly painful infiltrate began to be palpated, and the symptoms described
above appeared.
Objectively: the patient's condition is moderate. Pulse 100 in 1 minute, rhythmic. On the
back of the neck, a painful infiltrate of 10 + 8 cm is determined, purple-red in color with
multiple purulent foci. Surrounding tissues are edematous. Body temperature 38.4.
surgeon's actions.
Answer.
Carbuncle on back of neck.
Treatment - treatment with alcohol, bandage, UHF, a\b, operation - dissection of the infiltrate to
the fascia with a cruciform incision with excision of necrotic tissues
31. Patient K., 62 years old, was admitted to the clinic with complaints of pain in the calf muscles,
intermittent claudication (he had to stop every 150 meters). From the anamnesis it is known that for the last
5 years he has been troubled by the above-described pains, numbness in the lower extremities, and
coldness of the feet.
Objectively: the condition is satisfactory. Pulse 86 in 1 minute, rhythmic. BP 140 and 90 mmHg
When examining both lower extremities, the skin is pale, hyperkeratosis, hairline is absent. The
muscles of the leg are atrophic. The pulse on the femoral arteries is preserved, on the popliteal
and arteries of the feet is absent. A rough systolic murmur is heard on the left femoral artery. The
muscles of the lower leg are soft, painless. Movement and sensation in the toes are not disturbed.
necessary to clarify the diagnosis?
Formulate a final diagnosis based on
classification accepted in the clinic and Fontaine -
Pokrovsky.
The choice of treatment method.
Answer.
General atherosclerosis of both lower extremities. Syndrome of circulatory subcompensation of

both lower limbs (department); persistent vascular insufficiency (111 - according to Pokrovsky)
Examination - angiography, thermography, rheovasography
Lech- endarterectomy
32. Patient M., 22 years old, went to the doctor of the trauma center with complaints of pain in the
right side, shortness of breath, painful cough. He was injured 18 hours ago, at home, in the
bathroom, he stumbled and hit the right half of his chest on the edge of the bathtub.
OBJECTIVELY. Satisfactory condition, clear consciousness, no cyanosis. Breathing is

shallow, abdominal. Palpation is determined by local pain and crepitus in the projection of
the V-VI ribs on the right in the midaxillary line, here is local swelling of the tissues.
Solution
Diagnosis
Survey
First aid measures

Treatment plan
Methods and methods of anesthesia
Duration of treatment
Terms of recovery
Complications
Answer.
Closed blunt trauma to the right half of the cage. Fracture of 5-6 ribs on the right.
Lechno-caine blockade, half-sitting position, UHF therapy from day 2, half-alcohol compress.
Duration of treatment - 3-4 weeks
Terms of labor recovery - 5 weeks
Donkey subcutaneous emphysema, pneumonia, pneumohemothorax
33. Patient N., 39 years old, was delivered by his comrades in his arms to the trauma center. Complaints of
severe pain in the chest, shortness of breath. At work, during loading operations in the workshop, he was
pressed against the wall by a heavy box.
OBJECTIVELY. The patient's condition is severe, his mind is confused (it is difficult to answer questions, not
always correctly), he groans. Paleness of the skin, cyanosis of the lips and mucous membranes. Pulse 110 in 1
min. Rhythmic, the boundaries of cardiac relative dullness are shifted to the right, heart sounds are muffled,
blood pressure is 90/50 mm. rt. Art. On percussion of the chest - a box sound on the left, on auscultation -
there is no breathing on the left, on the right - normal. Abdominal breathing. The abdomen is soft and
painless. On palpation of the chest - diffuse soreness along the anterior axillary line on the left. Swelling and
crepitus at the level of IV - VIII ribs.
Solution
Examination of the patient
Diagnosis
Complications
Relief measures
Treatment plan
Types of anesthesia
Answer
Blunt trauma gr Cl on the left. Donkey: Fracture of 4-8 ribs on the left. Tension pneumothorax. Injury shock 1 .
It is necessary to have an x-ray of the gr cells, a pleural puncture at 2 m / r on the left and drainage along the bullau.
Terms of treatment: 5-6 weeks
34. Patient A, 49 years old, fell down on the street and hit the fence with his left shoulder, felt sharp pains and a
crunch in the shoulder girdle, and when moving his arm, sharp pains appeared in the clavicle area, deformation and
shortening of the shoulder girdle. The patient was taken to the traumatological department of the hospital by
ambulance.
OBJECTIVELY. The condition is satisfactory. Deformity in the middle third of the left clavicle. Palpation of
this area is sharply painful, the sharp edge of the fragment protruding under the skin and pathological
mobility of the clavicle are determined. The skin over the protruding fragment is sharply tense.
Solution
Examination methods
Diagnosis
Treatment plan
Types of anesthesia
Types of immobilization
Possible Complications
Answer.
Fracture of the middle third of the clavicle. If without displacement of fragments, then the bowl rings or
an eight-shaped bandage for 4 weeks. If with a displacement, the reduction of fragments and the
imposition of a Kuzminsky tire. If not, then intramedullary osteosynthesis.
Labor - 5-6 weeks
35. Patient K., 32 years old, a worker, while working in a warehouse, was hit by the edge of a heavy box in the
area of the left shoulder. He felt a sharp pain, a shoulder deformity appeared. There was a short-term loss of
consciousness. He was delivered on a stretcher with transport immobilization with a Cramer splint to the
traumatology department of the city hospital.
OBJECTIVELY. The condition is moderate, the skin is pale, the questions are not always answered
correctly, groans. Pulse 110 per minute. Rhythmic. AD 90/60 mm. rt. Art. In the middle third
left shoulder extensive hematoma. Shoulder circumference increased by 3 cm compared with a healthy
limb. Angular deformity in the middle third of the shoulder, pathological mobility. Pulsation on the radial
artery is preserved, pain sensitivity on the hand is preserved, the fingers are somewhat swollen, cyanotic.
Solution
. Examination methods
. Diagnosis
. Types of anesthesia
. Transport immobilization
. Typical displacement of fragments in diaphyseal fractures of the humerus at different levels
. Methods and methods of conservative treatment
. Methods of surgical treatment
. The duration of treatment of the patient, the timing of fusion
. Possible Complications
Answer.
Closed fracture of the middle third of the left humerus. Injury shock 1
Abductor splint behind the olecranon.
Anesthesia - local in the hematoma 15-20 ml of 1-2% novocaine. If there is no displacement, then
the thoracobrachial bandage for 1.5 months. If displacement, then reposition + plaster cast or
skeletal traction or Ilizarov apparatus. Immobilization - Cramer's splint.
36. Patient Sh., aged 31. On the street, he fell on the right elbow joint, felt pain, a crunch in the lower
third of the shoulder. Appealed independently to the doctor of the trauma center.
OBJECTIVELY. The patient's condition is satisfactory. In the lower third of the right shoulder -
swelling of the soft tissues. On palpation - local pain in the lower third of the shoulder. There are
crepitus fragments and pathological mobility. Gunther's triangle is not changed, Marx's line is
broken. There are no changes in sensitivity and blood circulation on the periphery of the limb.
Solution
. Examination of the patient
. Diagnosis
. First aid measures
. Pain relief methods

. Methods of transport immobilization
. Methods of conservative and surgical treatment
. Periods of incapacity.
Closed supracondylar flexion fracture of the lower third of the diaphysis of the right humerus.
Treatment is local anesthesia. Cramer's splint, skeletal traction followed by the imposition of a
plaster splint, osteosynthesis.
Duration of treatment - 3-4 weeks.
Labor 4-4.5 weeks
37. Patient R., aged 52, fell from a height of 2.5 m at work. With support on a bent arm at the
elbow joint. He felt a sharp pain in the elbow joint. An hour later, the joint significantly
increased in volume, subcutaneous hemorrhage appeared. Couldn't do the job. He turned to
the doctor on duty at the trauma center 3 hours after the fall.
OBJECTIVELY. The left hand is hung on a belt. The elbow joint was enlarged by 3 cm.
Extensive bruising and subcutaneous hematoma were noted. Active movements are sharply
limited due to pain. On palpation, there is a distinct soreness in the region of the condyle of
the humerus. The isosceles triangle of Günther is broken. The fingers are cyanotic, the
pulsation on the radial artery is preserved, skin sensitivity is not changed.
Solution
Diagnosis
First aid
Transport immobilization
Types of anesthesia
Conservative and surgical treatment
Closed intra-articular fracture of the condyle of the humerus. Hemarthrosis of the left elbow
joint. subcutaneous hematoma.
Lech-skeletal traction, closed and open osteosynthesis.
The duration of treatment is 3-4 weeks.
38. Patient Z., 25 years old, at home, while descending from a ladder, he stumbled and fell, hitting
the floor with his left elbow joint. I felt severe pain in the joint, aggravated by trying
forearm movements. He turned to the doctor of the trauma center three hours after the
injury.
OBJECTIVELY. The left elbow joint is enlarged in size, movements in it are limited due to pain.
Active extension of the forearm is not possible. On palpation of the ulna in the region of the
olecranon, a diastasis of about 2 cm is determined.
Solution
Diagnosis
First aid, transport immobilization
Treatment of the patient
Periods of incapacity.
Closed fracture of the olecranon on the left. Treatment is local anesthesia. Cramer tire. Open osteosynthesis
(diastasis greater than 3 mm). Labor 4-6 weeks
39. Patient K., aged 45, was injured at work. During loading, the arm in the region of the middle
third of the forearm was pressed against the door of a railway carriage. He felt a sharp pain,
swelling, deformity, pathological mobility appeared at the site of the impact. I went to the trauma
center doctor.
OBJECTIVELY. The left forearm in the middle third is deformed, enlarged in volume. On palpation,
sharp pain and pathological mobility at the site of injury is determined. The rotational function of
the forearm is impaired, the muscle strength of the hand is sharply weakened. Axial load is
sharply painful.
Solution
Diagnosis
First aid and transport immobilization
Methods of conservative and surgical treatment
Terms of incapacity for work
Answer.
Closed fracture of the middle third of the left forearm. Median nerve injury?
Cramer's treatment, skeletal traction, osteosynthesis, Ilizarov apparatus.
Labor-10-12 weeks.
40. Patient S., aged 55, on the street during ice slipped and fell with support on the left hand.
He felt a sharp pain in the wrist joint, where a bayonet-like deformity appeared. The patient
went to the trauma center 1.5 hours after the injury.
OBJECTIVELY. There is a bayonet-like deformity and swelling in the area of the distal left
forearm. An attempt to make movements in the wrist joint causes pain. Axial load is
sharply painful.
Solution
Diagnosis
First aid
Transport and medical immobilization
Methods of treatment in a trauma center
Terms of immobilization and treatment
Answer.
Closed fracture of a ray of bone in a typical location.
Cramer's treatment, closed manual reposition. Gypsum splint for 3-4 weeks.
Duration of treatment 5-6 weeks
41. Patient K., aged 45, fell on his outstretched arm at work, felt a sharp pain and a crunch in
his forearm. He went to the doctor 2 hours after the injury with complaints of pain in the lower
third of the left forearm and in the wrist joint.
OBJECTIVELY. The left forearm is supported by a healthy hand. The fingers of the left hand are
moderately edematous, their sensitivity is preserved. The circumference of the left forearm in the lower
third is 2 cm larger than the right one. The hand is in the position of radial abduction, the protruding
head of the ulna is visible above the wrist joint. The axis of the limb is preserved in the region of the
middle third of the forearm. Active hand movements and rotation of the forearm are sharply painful and
limited. On palpation - local pain along the crest of the radius at the level of the lower and middle third of
the forearm. Crepitation of fragments and severe pain at the site of the head of the ulna. Loading along
the axis of the limb is painful.
Solution
Diagnosis

Timing of immobilization and duration of treatment
Answer.
Closed fracture of the ray of the bone with dislocation of the head of the ulna (Galeazzi).
Lech-osteosynthesis, gypsum splint.
Immobilization terms - 10-12 weeks
42. Patient L., 33 years old, fell on his outstretched right arm at work, felt a sharp pain in his
forearm. Went to the doctor an hour after the injury with complaints of pain in the right forearm
OBJECTIVELY. The right forearm is supported by a healthy hand. Moaning in pain. The deformity of the
forearm is clearly visible at an angle open to the rear and to the radial side, the limb in the upper third is
moderately edematous and shortened by 1.5 cm compared to the left. Active movements of the fingers
are preserved, but limited due to pain. Attempting to flex and rotate the forearm causes pain. Skin
sensitivity is not disturbed, pulsation on the radial artery is distinct. On palpation at the level of
deformation, diastasis is felt between the sharp edges of crepitating bone fragments. The load along the
axis of the forearm is sharply painful. When you try to bend your arm at the elbow joint, the angular
deformity increases sharply.
Solution
Diagnosis
Types of anesthesia
Indications for surgical treatment
Closed fracture of the ulna with dislocation of the head of the radius (Monteja).
Treatment - closed manual reposition and plaster splint or surgical treatment
Duration of treatment - 6-8 weeks. Labor 8-10 weeks.
43. Patient M., aged 44, went to the doctor of the trauma center with complaints of pain in the left
hand. A day ago, at work, I got hit with a hammer on my hand while repairing a pump.
OBJECTIVELY. In the region of the small muscular eminence of the left hand, there is a pronounced swelling
with diffuse subcutaneous hematoma on the back of the ulnar surface of the hand. With active movements
of the fingers, especially the fifth, the patient notes the appearance of acute pain at level V
metacarpal bone. On palpation - local pain in the middle third of the fifth metacarpal bone. The
deformation of the bone at the level of the middle third is determined, with deep pressure, crepitus
of bone fragments appears. The axial load on the V metacarpal bone is sharply painful.
Solution
Diagnosis
Types of anesthesia
Terms of immobilization and functional treatment
Answer
Closed fracture of the 5th metacarpal in the middle third on the left.
Therapeutic anesthesia, Cramer's splint, plaster splint up to one third of the forearm for 3-4 weeks, if
ineffective, closed reposition - osteosynthesis
Labor 4-6 weeks
44. Patient K., aged 22, was in a car as a passenger in the front seat. At the time of a car
accident, his left knee hit the front panel. Didn't lose consciousness. He was taken by
ambulance to the emergency department of the hospital with transport immobilization of the
left lower limb with a Cramer splint from the upper third of the thigh to the fingertips. The tire
is superimposed on the back surface of the left lower extremity.
OBJECTIVELY. The right knee joint is enlarged in volume, its contours are smoothed. Superficial abrasion
in the region of the patella. On palpation, a sharp soreness of the patella is determined, which consists
of 2 parts, with a distance of up to 1-2 cm between them. The limb cannot be raised and straightened.
An hour later, the right knee joint sharply increased in volume, a bruise appeared. The symptom of
balloting of the patella is positive. The load along the axis of the limb is painful. At a puncture of a joint
the blood with droplets of fat is received.
Solution
Diagnosis
Pain relief methods

Answer.
Closed fracture of the patella on the right. Hemarthrosis.
Lech- puncture of the joint stake 2% novocaine, gypsum splint, after the edema subsides with a divergence of fragments of
more than 5 mm - osteosynthesis
Duration - 4-6 weeks.
Labor - 1.5- 3 months
45. Patient Sh., 65 years old, slipped on the ice on the street and fell on his right side, the blow fell on the
region of the greater trochanter. He felt a sharp pain in the upper third of the right thigh. I didn’t lose
consciousness, I couldn’t get up on my own, because. the slightest movement of the limb caused acute
pain in the right hip joint.
OBJECTIVELY. The limb is rotated outward, there is a functional shortening of the right lower limb
by 3 cm, the greater trochanter is above the Roser-Nelaton line, passive movements in the right hip
joint are possible, but sharply painful. On palpation, there is a sharp pain under the inguinal
ligament, and there is also an increased pulsation of the femoral artery. The patient cannot lift the
extended limb.
Solution
Diagnosis
Transport and medical immobilization
Features of anesthesia
Operation methods
Terms of immobilization, treatment
Answer
Closed varus fracture of the femoral neck
Lechshina diterikhs, drugs. indications for surgery. Concern treatment - skeletal traction in the
position of abduction.
Oper lech- osteosynthesis with a three-blade nail Smith-Petersen.
Duration - 10-12 months

46. Patient F., aged 42, at work, while loading logs into the body of a car, fell down, while falling,
his leg fell between two logs and was pressed in the region of the middle third of the thigh. I felt a
sharp pain in the upper third. Unable to stand up on his own, he was taken to a traumatology
hospital by an ambulance doctor with transport immobilization with a Dieterichs splint.
OBJECTIVELY. Severe angular deformity of the left thigh in the upper third with an angle open
inwards. The circumference of the thigh at the level of deformation is increased by 5 cm
compared with a healthy limb. Swelling of soft tissues, pathological mobility in the upper third of
the thigh and crepitus of fragments. The femur is shortened by 3 cm, the distal limb is rotated
outwards. Cannot actively raise the straight leg.
Solution
First aid for trauma
Pain relief methods
Features of transport immobilization
Types of surgical interventions
Terms of immobilization and rehabilitation treatment
Answer.
Closed fracture of the diaphysis of the femur in the third with displacement of fragments.
Treatment - traction for 1.5-2 months, then coxite bandage for 3-3.5 months or intramedullary
osteosynthesis or Ilizarov apparatus.
Labor 3.5-6 months.
47. Patient S., aged 28, fell off the stairs at work and fell on his right leg with a sharp outward
deviation of the lower leg. He felt a sharp pain in his right knee joint. Could not load a limb
OBJECTIVELY. The right knee joint is enlarged by 3 cm in volume, movements in it are sharply
painful, pathological mobility in the joint and local pain on palpation of the lateral condyle of
the thigh are determined. Positive symptom of ballotation of the patella. When puncturing the
knee joint received blood in the amount of 120 ml. With drops of fat.
Solution

Diagnosis
Methods of treatment
Indications for conservative and surgical treatment
Terms of immobilization and disability
Answer.
Intra-articular fracture of the lateral condyle of the right hip bone. Hemarthrosis
Examination - x-ray, arthroscopy.
Treatment - 2 lateral Cramer splints, puncture of the knee joint, plaster cast, with displacement -
skeletal traction, osteosynthesis
Duration - 8-10 weeks
Labor - 3-4 months
48. Patient Ya., 35 years old, fell off a height of 2-3 m at work. He fell on straightened legs and felt
pain in the left knee joint. The joint quickly increased in volume, the slightest movement caused a
sharp pain. First aid was provided on the spot, he was taken to the medical center on his hands.
OBJECTIVELY. The left knee joint is enlarged in volume by 3 cm, the area of the femoral
condyles is expanded, the anatomical length of the limb is 2 cm less than healthy, there are no
active movements in the joint, passive ones are sharply painful, lateral pathological mobility in
the knee joint is determined, pain on palpation condyles of the thigh. The load along the axis of
the limb is sharply painful. Joint puncture yielded blood with droplets of fat.
Solution
Diagnosis
Conservative and surgical treatment, indications
Answer
Intra-articular fragmental fracture of both condyles of the left femur with rupture of the lateral ligaments
of the knee joint. Hemarthrosis
Examination - x-ray, arthroscopy

Lech-puncture of the knee joint, plaster cast, with displacement - skeletal traction,
osteosynthesis, ligament plastics.
Duration of treatment - 8-10 weeks, labor 3-4 months.
49. Patient S., 34 years old, was hit by a metal door on the left shin at work and felt a sharp
pain in the upper third. Here there was swelling, I could not step on my foot.
OBJECTIVELY. In the upper third of the lower leg there is a pronounced swelling, abrasion. Palpation of
the impact site is sharply painful, distinct crepitus. When trying active and passive movements,
pathological mobility in the upper third of the leg is determined. The load along the axis of the limb
causes acute pain.
Solution
Diagnosis
Types of anesthesia
Answer.
Closed fracture of the bones of the left tibia in the third third with displacement of the fragments.
Treatment: plaster cast to the gluteal fold, skeletal traction, Ilizarov apparatus.
Labor 4-5 months
50. Patient F., 19 years old, hit his head on the bottom while jumping into the water. He felt a
sharp pain in the cervical spine. The victim briefly lost consciousness. Delivered on a stretcher,
he cannot stand up on his own due to a sharp increase in pain in the cervical spine.
OBJECTIVELY. The head is tilted forward, the chin almost touches the sternum. Due to sharp pains, head
movements are limited. The spinous process of the VI cervical vertebra will stand, and in place of the V
cervical vertebra - retraction. Swallowing is difficult. Paralysis of the upper and lower limbs.
Solution

Diagnosis
First aid
Transport immobilization
Treatment of the victim, prognosis
Terms of treatment
Answer.
Complicated closed compression fracture of the 6th cervical vertebra, dislocation of the 5th cervical
vertebra. Spinal cord compression.
Lech-transport immobilization on a hard surface with a roller for reclination, traction

with a Glisson loop, in the presence of neurological symptoms - surgical reduction,
discectomy. Anterior osteosynthesis
Forecast - doubtful
Duration of treatment - 6-12 weeks.
51. Patient S., aged 45, jumped off a rack from a height of 2 at work
- 3 m. When falling, he landed on his feet and squatted down sharply, after which he felt severe
pain in the lumbar spine, radiating to his right leg. I could not get up on my own because of
the sharp increase in pain. Delivered on a rigid stretcher in the supine position with a reclining
roller under the lumbar spine.
OBJECTIVELY. The patient's condition is satisfactory, he complains of severe pain in the lumbar
spine. On examination, the protrusion of the spinous process of the third lumbar vertebra is
noted, in the lumbar region there is pathological muscle tension. Axial load causes severe
pain in the lumbar region. On palpation, local pain is noted in the area of the spinous
process of the third vertebra. He cannot stand on his feet because of severe pain.
Solution
Diagnosis
Types of anesthesia
Treatment of the patient
Terms of immobilization and treatment of the patient, prognosis.

Answer.
Closed compression fracture of the body of the 3rd lumbar vertebra.
Treatment - functional method - traction on the bed
Labor - 4-6 months.
52. Patient S., 54 years old, at work, when unloading reinforced concrete blocks from a car body, was
pressed by a block against a brick wall. He felt a sharp pain in the pelvic area, he could not stand up.
When trying to move, the patient experiences a sharp increase in pain.
OBJECTIVELY. The patient is lethargic, the skin is pale, the pulse is weak filling, blood pressure is
80./50 mm. rt. Art. The limbs are slightly bent at the knee joints and turned outward, the slightest
movement of the legs causes pain. With compression of the pelvis in the sagittal and frontal
planes - a sharp pain. The sticky heel sign is positive on both sides.
Decision Examination of the patient Diagnosis
Anesthesia
Treatment of the patient for
Answer.
Fracture of the pelvic bones with violation of the integrity of the pelvic ring. Grass shock 2. Lech- skeletal traction for
the trochanters and condyles of the thigh.
53. Patient T.P. 65 years old, turned to an orthopedist with complaints about the appearance of deformity and round
formation in the middle third of the right shoulder. He has been ill for about 10 years, but over the past year he has
noted an increase in the round formation by 2-3 times and the appearance of pain.
OBJECTIVELY. When viewed on the outer surface of the right shoulder, there is a rounded
formation measuring 12 by 8 cm, soldered to the skin. On palpation it is of bone density,
motionless, painful. The skin above it is not taken into a fold. Axillary lymph nodes are painful. On
the radiograph: in the middle third of the humerus - a bone cyst measuring 7 by 10 cm, with fuzzy
contours. The cortical layer of the bone above the cyst is significantly thinned, in some places it is
not defined. The structure of the cyst is cellular.
Solution .
Patient examination plan
Diagnosis
Conservative and surgical treatment, prognosis

Types and methods of operations
Answer.
Osteoblastoma in the middle third of the right shoulder.
Lech-excochleation of the cavity with simultaneous filling with bone grafts
54. Child K. Age - 3 weeks. Parents went to the doctor with complaints about the
presence of an additional skin fold on the inner surface of the right thigh.
OBJECTIVELY. On examination, there is an additional fold on the inner surface of the right thigh,
asymmetry of the gluteal folds, there is a restriction of abduction of the right thigh, a "click" symptom.
Child of normal development and nutrition. He sleeps well at night, appetite is not disturbed.
Solution.
Diagnosis
Patient treatment plan
Possibilities of conservative and surgical treatment
Forecast
Answer.
Dysplasia of the rights of the hip joint.
Treat - free swaddling, treat gymnastics, legs in the dilution position, followed by fixation
with stirrups, conservative treatment up to 8-10 months, later arthroplasty is possible
55. Child F., 7 years old, was admitted to the orthopedic department of the clinical hospital
with complaints of muscle weakness in the right lower limb, which appeared in early
childhood after a respiratory disease. Within 5-6 years, there was some restoration of muscle
tone, but weakness, muscle atrophy, and laxity of the knee joint persist.
OBJECTIVELY. There is a pronounced atrophy of the muscles of the right lower limb. The circumference of the
thigh and lower leg is less than on the healthy side by 6 cm. Muscle tone is sharply reduced, there is
underdevelopment of the right lower limb. When examining the right knee joint, looseness of the ligaments,
instability, displacement of the bones of the lower leg in the anteroposterior direction and in the lateral
directions up to subluxation of the lower leg are determined. When walking, the knee joint is unstable, the
patient is forced to use a cane or crutches.
Solution
Diagnosis
Survey plan
Conservative treatment and its possibilities
Operative treatment and its possibilities
Types of surgical interventions
Forecast
Answer.
Condition after poliomyelitis. Neuropathy.
Treatment massage, physiotherapy, electrical stimulation
56. Patient M., 44 years old, applied to the clinic of traumatology and orthopedics with complaints
of constant, aching pain in the left knee joint, aggravated after physical exertion. 3 years ago, she
suffered a knee joint injury when she fell on the street, hitting the ground with her knee joint.
Examination at the trauma center did not reveal any bone pathology, hemarthrosis was found, for
which a puncture of the knee joint and physiofunctional treatment were performed.
OBJECTIVELY. The knee joint is enlarged, edematous. The skin over the joint is not changed. Pain is
determined on palpation of the joint space along the inner surface, with movements in the joint, a
crunch is determined, pain in extreme positions and with axial load. On radiographs: sharpening of
the intercondylar eminence, narrowing of the joint space.
Solution
Diagnosis
Treatment plan
Forecast
To the left knee joint 2
Lech-physiotherapy, cuff traction
57. Wounded N. Discovered by a medical officer on the battlefield. He was wounded by a shell fragment in the left gluteal
region, where there is a wound measuring 10 by 8 cm. There is profuse bleeding from the wound. The condition is
severe, the patient is pale, the pulse is frequent. The medical instructor applied a tight bandage with wound tamponade.
After 4 hours from the moment of injury, the victim was taken to the WFP.
OBJECTIVELY. The condition is severe, the skin is pale, the pulse is 124 per 1 min. BP 80/50 mm. rt. Art. The bandage was
profusely soaked with blood.
Solution
Indicative diagnosis
What therapeutic measures should be carried out for this wounded man at the MPP, in the OMedB, in the
hospital.
What methods of temporary stop of bleeding should be carried out and at what stage?
Answer.
Shrapnel wound to the left gluteal region. gemm shock 2
Lech-on MPP - temporary stop of bleeding, omedb-general treatment (PHO, final stop of
bleeding)
In the hospital, special Treatment.
58. Soldier K. came to the checkpoint on his own, 4 hours ago he was wounded by a bullet in his left shoulder. There
was severe arterial bleeding. The comrade put a bandage on the wound, an impromptu tourniquet above it and
hung his hand on a scarf. After 2 hours from the moment of injury, the tourniquet was removed, the brachial artery
was pressed digitally for 3-4 minutes, then the tourniquet was again applied.
OBJECTIVELY. The general condition is satisfactory. Disturbed by severe pain in the left shoulder and numbness of
the arm. The bandage on the wound was profusely soaked with blood. The pulse on the radial artery of the left
forearm is not determined, on the right forearm - 82 per 1 min. Satisfactory filling. There is no pathological
mobility of the shoulder in the area of the wound.
Solution
Diagnosis
Triage of the wounded with similar injuries at the WFP
Assistance measures at WFP
Ways to temporarily and permanently stop bleeding
Answer.
Gunshot wound to the left shoulder with damage to the brachial artery. Priority sorting
on MPP. Help - antishock, tourniquet
59. Soldier V. was brought to the checkpoint. 3 hours ago he was wounded by a bullet in his left thigh. On the battlefield, the orderly
put a bandage on the wound from PPI and injected promedol from a syringe - a tube of AI.
OBJECTIVELY. The patient's condition is satisfactory. Pulse 84 in 1 min. The bandage on the thigh has fallen off.
There are two wounds in the middle third of the thigh: on the outer and inner surfaces with dimensions of 0.8 by
0.8 cm and 1 by 1 cm. There is no edema, hematoma and pathological mobility of the thigh in this place.
Solution
Diagnosis according to the accepted classification
Give a description of the first medical aid to this wounded man, carried out on the battlefield.
In which division of WFP and what assistance should be provided to him
What type of treatment for a gunshot wound of the thigh will you choose in the future, and at what stage of the
medical evacuation will you carry it out.
Possible complications (early and late).
Answer.
Gunshot wound to the left thigh
Treatment - temporary stop of bleeding (pressure bandage)
60. Soldier D was brought to the checkpoint. During the explosion of an aerial bomb, he was hit in the stomach with a hard
object. About 4 hours have passed since the injury. Complains of pain in the abdomen, thirst.
OBJECTIVELY. The general condition is severe. There are no external damages. Dry tongue. Pulse 100 in 1
min., Satisfactory filling. The abdomen is tense, painful, Shchetkin-Blumberg's symptom is positive. The
boundaries of hepatic dullness are narrowed, there is no dullness of percussion sound in sloping areas of the
abdomen.
Solution
Indicative diagnosis
What assistance and in what functional unit should it be provided to the wounded
In what turn, in what position and by what transport should the wounded be evacuated
Answer.
Closed blunt abdominal trauma with damage to hollow organs, internal bleeding.
damage to hollow organs, diffuse peritonitis
Lech-operation in omedb in the first place

61. Soldier P. was delivered to the OMedB 2 hours after being wounded by a bullet in the left half of the chest.
From under the broken bandage, a wound measuring 1 by 1 cm is visible on the anterior surface of the chest,
located in the region of the IV intercostal space along the parasternal line.
OBJECTIVELY. The condition of the wounded is extremely serious, slowed down. There is no bleeding from the
wound. The pulse on the peripheral arteries is not determined, on the common carotid artery it is very weak, it
cannot be counted. With percussion, cardiac dullness is sharply expanded to the right and left. Heart sounds are
almost not auscultated. Breathing is frequent, superficial, Neck veins are swollen.
Solution
Diagnose the underlying injury and its complications Determine the urgency of treating this
injured person
and the nature of that assistance.
Terms of hospitalization in the OMedB and further evacuation
Answer.
Penetrating gunshot wound to the gr cells on the left. Heart injury. Cardiac tamponade.
Lech-in omedb in the first place
62. Soldier B was delivered to the checkpoint 1.5 hours after being wounded. He was wounded by a fragment of a grenade
in the region of the middle third of the right shoulder. A tourniquet was applied above the wound. The clothes are
profusely soaked in blood. The limb is immobilized with a transport scarf.
OBJECTIVELY. The condition is serious, pale, during the control of the tourniquet - arterial
bleeding appears from the wound. Arterial pressure - 75/30 mm. rt. Art. Pulse threadlike,
weak filling. Breathing is superficial. Bone damage is not defined.
Solution
Make a diagnosis
Determine the sequence of manipulations carried out on the MPP
Indications for blood transfusion at the MPP
Features of blood transfusion on MPP
Determine the need, the sequence of evacuation of the wounded to the OMedB.
Answer
blind shrapnel wound of the right shoulder with damage to the brachial artery. Hemorrhagic shock 3.
On MPP - anti-shock measures, temporary stop of bleeding
In omedb-operative treatment.
63. A wounded man was brought to the checkpoint. A torn wound of the right gluteal region
measuring 5 by 4 cm is visible from under the bandage that has gone astray. There is no
bleeding from the wound.
OBJECTIVELY. The condition of the victim is relatively satisfactory, breathing is free, blood pressure
is 100/60 mm. rt. Art., pulse 98 in 1 min., superficial. There is no transport immobilization at the
extremity. A lacerated wound, contaminated with earth, 5 by 4 cm in size, is visible from under the
loose bandage.
Solution
Make a diagnosis
List the manipulations that need to be carried out on the MPP
Treatment of a patient in OMedB
The sequence of surgical intervention, its purpose and features
Answer.
blind shrapnel wound to the right gluteal region. trauma shock 1.
On MPP - anti-shock measures, time to stop bleeding.
In omedb-opera treatment. Prevention of tetanus.
64. Wounded K. was delivered to the checkpoint 3 hours after being wounded. During the explosion of a
mine, a fragment hit the region of the middle third of the right shin. The limb is immobilized with one Cramer
splint applied from the fingertips to the knee joint. An aseptic bandage was applied to the wound.
OBJECTIVELY. The condition of the victim is satisfactory. Breathing free, BP 120/70 mm. rt. Art. Pulse 66 in
1 min. On the extremity - Cramer's transport tire, there is pathological mobility in the region of the
middle third of the right leg. The bandage was moderately soaked with blood.
Solution
Make a diagnosis
List all first aid measures that need to be performed for this wounded person
List all the activities that need to be carried out at the WFP.
List all the activities that need to be carried out in the OMedB.
Answer.
Blind shrapnel wound in the middle third of the right leg.
On MPP - antishock, temporary stop of bleeding

In omedb-operat to lay down
65. Wounded S. was delivered to the checkpoint 4 hours after the injury. During the attack, get a
bullet wound to the right half of the chest. An aseptic bandage was applied to the chest.
OBJECTIVELY. The condition of the wounded is relatively satisfactory. Breathing is superficial, BP

90/40 mm. rt. Art. Pulse 110 in 1 min. weak filling. The bandage fell off. On examination
- In the region of the right half of the chest, there is a puncture bullet wound in the 5th intercostal
space along the anterior axillary line, from the wound - a foamy bloody discharge. Breathing on the
injured side is not audible.
Solution
Make a diagnosis
Assess the correctness of first aid
MPP, in OMedB.
List possible complications of injury
Determine indications for surgery
Answer.
Blind bullet wound gr cells on the right. Open pneumohemothorax.
On MPP - antishock, temporary stop of bleeding, bandaging
In omedb - vagosympathetic blockade, opera treatment.
66. Patient S., aged 45, was admitted to the clinic with complaints of pain, swelling and cyanosis of the
skin of the right upper limb, aggravated by lowering the arm down. He fell ill 12 days before
admission, when, after intense physical exertion, pain appeared in his right arm, swelling of the hand
and forearm, which then spread to the shoulder.
Objectively: the condition is satisfactory. The right upper limb is edematous, cyanotic, especially in the
distal sections. There is an abundance of venous collaterals in the area of the shoulder joint and subclavian
fossa. The veins in the cubital fossa are dilated and tense. The difference in the perimeters of both limbs in
the middle third of the shoulder is 3 cm, forearm - 2 cm. The muscle strength of the right upper limb is
preserved, the function is limited.

allow you to clarify the diagnosis?

surgeon's actions.
Answer.
Acute thrombosis of the subclavian vein (with paget-shrettara-kristelli)
Phlebography
Lech-disaggregants, anticoagulants, antispasmodics. Operthrombectomy
67. Patient K., 29 years old, had an urgent normal delivery. In the postoperative period, the body temperature
was constantly high, which did not decrease under the influence of antibiotics. The cause of the temperature
has not been clarified. On the 13th day after childbirth, pain suddenly appeared in the region of the right
shoulder blade, then a dry cough began to disturb. There was no hemorrhage. The patient was transferred to
the therapeutic department with a diagnosis of exudative pleurisy. On the 17th day (after delivery) there were
pains in the left lower limb, edema, cyanosis and numbness. Transferred to the surgical department.
Objectively: the state of moderate severity. Body temperature 39 degrees C. Pulse 120 in 1 minute, rhythmic.
In the lungs, weakened breathing and dullness of percussion sound in the posterior lower sections on the
right. The left lower limb is enlarged in volume, the pattern of saphenous veins in the upper third of the thigh
and in the inguinal region is well expressed. Minor flexion contracture of the hip. Sharp pain along the vessels
of the left lower limb and in the muscles of the lower leg. The perimeter of the left thigh is 4 cm, the left leg is
5 cm larger than the perimeter of the corresponding sections of the right lower limb.
What additional research methods are needed to clarify the diagnosis?
surgeon's actions.
Answer
Iliofemoral phlebothrombosis. Tela
Phlebography
Lechthrombectomy from the femoral-popliteal segment, elastic bandage, disaggregants,

anticoagulants, antispasmodics
68 Patient L., aged 51, was admitted to the clinic with complaints of pain in the right lower limb and
its edema. 7 days before admission, he developed pain and redness in the region of the inner
surface of the right leg, which gradually spread to the anterointernal surface of the right thigh and
inguinal region. Outpatient treatment was not successful. Soon, the growing edema of the right
lower limb joined the indicated, in connection with which the patient was hospitalized.
Objectively: General condition is satisfactory. There is no tachycardia. Vesicular breathing in the
lungs. The right lower limb is edematous, cyanotic. On palpation, there is a sharp pain along the
great saphenous vein of the thigh, the latter is sealed. The difference in the perimeters of the
right and left lower extremities: hips by 5 cm, shins by 3 cm.
What additional research methods are needed to clarify the diagnosis?
surgeon's actions.
Answer.
Ascending thrombophlebitis of the femoral-popliteal vein on the right. Thrombophlebitis of the femoral vein on the
right.
Lechthrombectomy from the femoral-popliteal segment, elastic bandage, disaggregants,

69. Patient A., aged 17, was admitted to the clinic with complaints of poor discharge from a small fistula in the
coccyx area. From the anamnesis it was established that since childhood he was worried about such
phenomena, but he did not go to the doctors. One year ago there was a big abscess. After its opening in the
clinic, a purulent fistula remained. Subsequently, abscesses began to appear in the patient in the region of the
sacrum and open on their own. Objectively: no pathological changes in the internal organs were found. The
skin in the area of the lower third of the sacrum, coccyx and intergluteal folds is compacted, cicatricially
changed. There are 3 pinholes along the midline, 4-5 cm from the edge of the anus, and a purulent fistula to
the right of the midline.
2. What additional research methods are needed to clarify

diagnosis?
3. Tactics.
Answer: coccygeal move.
Treat: excision within healthy tissues, physiotherapy.
70. Patient M., aged 53, was admitted to the clinic with complaints of a fistula in the perianal region.
The disease started 6 months ago. back from a subcutaneous abscess in this area, which was opened in
the clinic. Subsequently formed a fistula of the rectum. When examining in the perianal region, 2-3 cm
away from the edge of the anus at 4 o'clock, there is an external opening, palpation reveals a cord
going from the external fistulous opening to the posterior semicircle of the anal canal, an infiltrate is
determined to the left of the latter. On digital examination of the rectum in the posterior crypt, an
internal opening with a diameter of 0.2 cm is determined, the tissues around are soft.

2. What additional research methods are needed to clarify
diagnosis?
3. Tactics.
Answer: chronic paraproctitis.
Treatment: conservative (warm baths after defecation, washing the fistula with antiseptics,
introducing antibiotics into the fistula, microclysters with sea buckthorn oil or collargol). If the
surgical treatment is not effective:
71. Patient S., 41 years old, suffered from thrombophlebitis of the great saphenous vein of the thigh. Was treated
for 2 months. Acute phenomena subsided, but edema of the right lower limb appeared. After 5 months,
shortness of breath and pain in the region of the heart suddenly appeared, followed by pain in the left inguinal-
iliac region, left thigh and lower leg. The edema of the entire left lower limb rapidly increased. The patient was
admitted to the clinic.
Objectively: the state of moderate severity. In the lungs, moist rales on the right. The heart sounds
are muffled, the accent of the second tone is over the pulmonary artery. On the ECG - signs of moderate
overload of the right heart. CVP - 100 mm of water. On the anterointernal surface of the right thigh along the
great saphenous vein, there is induration, the skin is hyperemic. The left lower limb is sharply edematous,
tense, the edema extends to the left lower quadrant of the anterior abdominal wall, the left labia. The
inguinal fold is smoothed, the limb is cyanotic, the venous pattern in the region of the left thigh is increased,
the pulsation of the femoral artery cannot be determined due to a sharp edema on the left.
What additional research methods will help clarify the diagnosis?
surgeon's actions.
Tela. Thrombophlebitis of the femoral-popliteal vein on the right. Left iliofemoral thrombosis.
Phlebography Lechthrombectomy from the femoral-popliteal segment, elastic bandage,

antiplatelet agents, anticoagulants, antispasmodics
72. Patient P., aged 28, was admitted to the clinic with complaints of constant pain in the lower extremities. From the
anamnesis it is known that he has been ill for 3 years, when these complaints appeared. Can walk 150m without
stopping.
Objectively: the state of moderate severity. The skin of both feet is pale, the fingers of the
right foot are cyanotic, on the plantar side of the 1st finger there is a deep ulcer with uneven
edges. Pulsation in the distal arteries of the right lower limb is not determined, the left one is
significantly reduced.
What additional research methods will help clarify the diagnosis.

Methods of complex treatment of the patient.
Answer.
Obliterating endoarteritis of the vessels of the lower extremity. St decompensation to / o (stage of development of
complications according to Pokrovsky).
Rheovasography, thermography, angiography
Complex treatment
1. elimination of the impact of adverse factors
2. elimination of vasospasm (antispasmodics, ganglionic blockers)
3. pain relief
4. normalization of coagulation (anticoagulants, heparin, reopoligyukin)
5. desensitizing therapy.
Operation - lumbar sympathectomy.
73. Patient V., aged 38, was admitted to the clinic with complaints of constant pain in the left
lower limb.
From the anamnesis revealed: Ill for 6 years. Pain began in the right lower limb. Not-
despite the ongoing conservative treatment, the disease progressed. Gangrene of the foot developed
and the patient underwent amputation of the right leg at the level of the upper third. Soon there were
pains in the left lower extremity. Treatment in hospitals and at the resort did not bring success. 2 months
before the admission, the pain in the left limb became permanent. A trophic ulcer appeared on the back
of the foot, he slept after taking large doses of narcotic drugs with his leg lowered to the floor.
Objectively: the state of moderate severity. The left lower limb is pale, cold, slight swelling and
congestive hyperemia of the foot. There is a trophic ulcer with a diameter of 4 cm on the dorsum of the
foot. A distinct pulsation is determined on the femoral artery, sharply reduced on the popliteal artery,
and absent on the arteries of the feet.
Make a plan for examining the patient.
Methods of complex treatment of the patient.
Answer.
Obliterating endarteritis of the vessels of the left lower limb.
Stage of decompensation to / o (stage of development of complications according to Pokrovsky).
Examination - angiography, thermography, rheovasography

Lech: most likely amputation.
74. Patient P., 30 years old, was admitted to the clinic a day after the moment of illness with complaints
of severe pain in the right hypochondrium, vomiting, severe icterus of the sclera and skin.
From the anamnesis it is known: A day ago, there was pain in the right hypochondrium,
nausea, then icterus of the sclera and skin appeared. Sick for 4 years. Fourth attack of pain. Three
previous attacks were also accompanied by vomiting, high fever and jaundice.
Objectively: the state of moderate severity. Pulse 116 in 1 minute, rhythmic. Dry tongue. The
abdomen is correct in shape, participates in breathing to a limited extent. On palpation, there is sharp pain
and muscle tension in the right hypochondrium and epigastrium.
Laboratory data: leukocyte count 12.4 x 109/l, bilirubin 160.7 µmol/l.
What additional research methods will help to differentiate the nature of jaundice and clarify
the diagnosis?
Stages of complex treatment of the patient.
Answer.
Zhkb, o calculous cholecystitis, choledocholithiasis. Donkey: obstructive jaundice. local

peritonitis
Ultrasound, oral cholecystography, rchpg.
Treatment - NPVS, a\b, cholecystectomy (from the neck, with separate ligation of the cystic duct and
cystic arterias)
75. Patient K., 25 years old, was admitted to the clinic 2 weeks after childbirth with complaints
of pain in the right mammary gland, chills and fever up to 38 degrees.
Objectively: the state of moderate severity. Pulse 92 per minute, rhythmic. The right
mammary gland is enlarged in comparison with the left. The skin is moderately hyperemic. It is
painful on palpation, the infiltrate is determined by the size of 4 by 5 cm, which is located mostly
under the areola. Axillary lymph nodes are enlarged on the right.
Surgical tactics.
Answer.
Postpartum mastitis of the nipple region.
Lech - elevated position of the mammary gland, suction of milk with a breast pump, a\b,
near-areolar opening of the abscess, UHF
76. Patient M., aged 71, was admitted to the clinic 3 days after the disease with complaints of pain
in the right iliac region. From the anamnesis it is known that he fell ill acutely when pains appeared
throughout the abdomen, then they were localized in the right iliac region. Prior to admission to
the clinic, he did not seek medical help. 4 years ago suffered an ischemic stroke.
Objectively: the condition is relatively satisfactory. Pulse 88 in 1 minute, rhythmic. BP 140

and 90 mm Hg The tongue is wet. The abdomen is not swollen, participates in breathing. On
palpation, it is soft and painful in the right iliac region. There are no peritoneal symptoms.
Peristalsis is heard. Temperature 37.2.
Laboratory data: The number of leukocytes is 6.2 x 109/l.
To clarify the diagnosis, the patient underwent laparoscopy. Found: There is no effusion in
the abdominal cavity. Hyperemia of the dome of the caecum and the base of the appendix.
Throughout the appendix is not visible. Due to the fact that it is not possible to exclude the
diagnosis of acute appendicitis, it was decided to operate the patient. Oblique incision in the right
iliac region. The abdominal cavity was opened. There is no effusion. In the right iliac region, a
conglomerate is determined, consisting of loops of the blind and ileal intestines. The appendix is
located inside this conglomerate.
Next steps for the surgeon
What recommendations will be given to the patient after discharge from the hospital.
Answer
O. appendicitis. appendicular infiltrate.
Lech-bed rest, table 4, cold on the right iliac region, a\b, UHF after the
disappearance of pain. After 2-3 months, a planned appendectomy.
77. Patient P., 55 years old, was delivered to the clinic in 25 minutes. after what happened
Circumstances of the injury: unknown persons stabbed him twice. Lost consciousness.
Objectively: the condition is extremely serious. Consciousness is confused. Severe pallor of the
skin. Pulse 100 in 1 min., rhythmic, BP 90 and 60 mm Hg. In the left half of the chest in the area of the
nipple there was a stab wound measuring 2 x 1 cm, moderately bleeding. The second wound of the same
size at the base of the xiphoid process. With percussion of the left half of the chest, dullness is
determined, starting from the 6th rib.
Auscultatory: breathing is weakened on the left. Heart sounds are muffled.
The tongue is wet. Abdomen of the correct form, not swollen. On palpation, the tension of the anterior
abdominal wall in the epigastrium.
Chest X-ray revealed: heart contractions are sluggish, there is fluid in the left sinus.
Designate a complex of resuscitation measures.
surgeon's actions.
Order of execution of operational aids.
Answer.
Penetrating stab wound to the left half of the cell. Injury to the left ventricle of the heart.
Hemipericardium. Hemothorax on the left. Penetrating stab wound of the abdominal
cavity.
Treatment - open thoracotomy, suturing of the wound of the heart, laparotomy, revision of the abdominal cavity
78. Patient K., 5 years old, was brought to the clinic 18 hours after the onset of the disease with
complaints of abdominal pain, vomiting of intestinal contents, frequent loose stools mixed with blood
and mucus. From the anamnesis it was established that he fell ill suddenly, when cramping pains in
the abdomen appeared at first, then vomiting of food joined, and later on intestinal contents.
Objectively: the condition is serious. Pulse 120 in 1 minute, rhythmic. BP 110 and 70 mm
Hg Dry tongue. Belly swollen. On palpation, soft and painful in the right half. In the right iliac
region, an infiltrate of a test-like consistency is determined. Peristalsis is enhanced. When
examining the rectum - traces of blood on the finger.
What additional methods of examination can help in clarification of the diagnosis?
Surgical tactics.
Answer.
Ileal intussusception
Plain radiography
Treatment - First, it is possible to use conservative methods (retrograde distention of the large
intestine), if not effective - surgery (desinvagination, or resection of intestinal loops)
79. Patient S., aged 60, was admitted to the clinic with complaints of shortness of breath, cough,
weakness and subfebrile temperature.
Objectively: the condition is serious. Somewhat excited. Pulse 120 in 1 minute, rhythmic. BP 120 and
70 mm Hg Moderate cyanosis of the lips. The number of breaths is 24 in 1 minute. The left half of the chest
lags behind the right in breathing. Vesicular breathing on the right, on the left it is auscultated only in the
upper sections. Percussion on the left marked dullness
percussion sound up to 4 ribs. X-ray shows hydrothorax on the left. Produced pleural puncture
on the left in the 8th intercostal space and received 1500 ml of hemorrhagic effusion.
Plan for further examination of the patient.
Surgical tactics.
Answer.
Pleural mesothelioma
Treatment is pleuropulmonectomy or pleurectomy. Radiation therapy is possible.
80. Patient M., 32 years old, was delivered to the clinic 2 hours after the incident in a
critical condition. It is not possible to collect anamnesis. From the words of the ambulance
doctors, it was possible to find out that an unknown person stabbed the victim in the left
half of the chest.
Objectively: the condition is extremely serious. Severe pallor of the skin and mucous
membranes. Pulse 128 in 1 minute, rhythmic, weak filling. BP 60 and 30 mm Hg In the left half of the
chest in the 6th intercostal space, along the anterior axillary line, there is a stab wound measuring 2 by
1 cm, through which air is sucked. Auscultatory breathing in the left half of the chest is weakened. The
tongue is dry. The abdomen is not swollen. On palpation, soft and painful in the left hypochondrium.
Percussion in the left half of the abdomen dullness.
Laboratory data: The number of erythrocytes in the blood is 2.1x10.12 / l, the content of
hemoglobin is 46 g / l.
Actions of the resuscitator.
surgeon's actions.
Answer
Penetrating stab wound of the chest and abdomen on the left. Spleen injury.
Pneumothorax on the left, hemoperitoneum.
Treatment - general anesthesia, intubation, anti-shock therapy, splenectomy, novocaine

blockade, puncture at 2 m/r, after X-ray at 7 m/r
81. Patient A., 35 years old, was brought to the clinic in a state of severe alcohol intoxication
4 hours after the incident. According to the ambulance doctors, the victim was riding a
motorcycle and was hit by a truck.
Objectively: the state of moderate severity. Pulse 88 in 1 minute, rhythmic. BP 110 and 50 mm Hg The
tongue is dry. The belly of the correct form, participates in the act of breathing. On palpation soft and
painless, except for the suprapubic region, where there is soreness and some tension in the
muscles of the anterior abdominal wall. There is no independent urination. Axial loads on the
pelvic bones are painful. During catheterization of the bladder received 150 ml of urine mixed
with blood. Zeldovich's test is positive. X-ray revealed a fracture of both pubic and ischial
bones.
What additional methods of examination will help clarify the diagnosis?
surgeon's actions.
Answer.
Closed blunt abdominal trauma. Fracture of the pelvic bones with violation of the integrity of the pelvic ring.
Retroperitoneal rupture of the bladder
X-ray, laparoscopy
Lech-lumbotomy, revision of the retroperitoneal space, skeletal traction for the trochanters and condyles of
the thigh.
82. Patient S., 60 years old, was brought to the clinic with complaints of intense wetting of the dressing on the stump of
the thigh with scarlet blood. From the anamnesis it is known that a month ago he underwent an amputation of the right
lower limb at the level of the middle third of the thigh. The postoperative period was complicated by suppuration of the
wound. Treatment was carried out. The wound began to clear of necrotic tissue, granulations appeared, and suddenly
the dressings were soaked with scarlet blood.
Objectively: the condition is relatively satisfactory. Pulse 92 in 1 minute. BP 140 and 80 mm Hg When
removing the bandage from the stump, a pulsating stream of blood was found from the depth of the
granulating wound.
How would you describe the bleeding present?
surgeon's actions.
Answer
Condition after amputation of the limb at the level of the middle third of the thigh. Suppuration of the surgical
wound. Arrosive bleeding from the right femoral artery
Lech- Repeated amputation at the level of the upper third of the thigh.
83. Patient V., 35 years old, was admitted to the clinic with complaints of malaise, weakness,
headache, chills, fever, burning pain, sensation of heat and skin hyperemia in the right leg. From
the anamnesis it was established that 4 days ago, during work, he received an abrasion
right shin. He did not seek medical help. On the eve of the symptoms listed above.
Objectively: the state of moderate severity. Pulse 90 per minute, rhythmic. When viewed in the
middle third of the lower leg, there is limited intense redness and swelling of the skin. Palpation
moderate pain in the area of hyperemia, local skin temperature increased, no fluctuations. Body
temperature 39 degrees.
Blood test: leukocytosis with neutrophilic shift to the left.
Make a differential diagnosis.
Formulate the final diagnosis taking into account the classification.
surgeon tactics.
Answer
Abscess of the right leg
Lech-Conservative treatment: antibiotics, vitamins, half-alcohol compresses, UHF. If not

effective - opening, draining
84. Patient T., 30 years old, was admitted to the clinic with complaints of throbbing pain in the 5th finger
of the right hand, swelling of the hand and distal part of the forearm, fever. From the anamnesis it is
known that within a week he was treated on an outpatient basis for subcutaneous panaritium of the 5th
finger of the right hand. Despite ongoing conservative therapy, the patient's condition worsened, the
symptoms listed above appeared.
Objectively: the state of moderate severity. Pulse 100 in 1 minute. On examination, the fingers of the
right hand are bent. There is swelling of the hand and lower third of the forearm. Active and passive
movements of the 5th finger are painful. Temperature 38.4 degrees.
What research methods will help in clarifying the diagnosis?
Surgical tactics.
Answer
Tendovaginitis of the 5th finger, right hand, u-shaped phlegmon of the hand.
Lech-linear lateral incisions, drainage of the tendon sheaths
85. Patient N., 36 years old, was brought to the clinic after a railway injury with an extensive
scalp wound of the right thigh. Performed primary surgical treatment of the wound.
However, on the 2nd day after the operation, the patient's condition deteriorated sharply - severe arching
pains appeared in the wound area, the temperature rose.
Objectively: the patient's condition is severe. He is agitated, marked pallor of the skin. Pulse 124
in 1 minute, rhythmic. BP 100 and 60 mm Hg On examination, the skin around the wound is bluish,
pronounced edema, crepitus is determined. Through drainage from the wound, scanty hemorrhagic
exudate with an unpleasant odor. Temperature 39 degrees.
What research methods will help clarify the diagnosis?
What comprehensive measures should be taken when this infection is detected?
What is the essence of complex treatment of the patient?
Answer.
Condition after pho scalp wound of the right thigh, gas gangrene of the right thigh,
rapidly progressive form.
Treatment - necrotomy, necrectomy, antigangrenous serum 150 thousand IV, and 150 thousand IV,
infusion therapy, barotherapy
86. Patient K., 46 years old, was admitted to the clinic with complaints of moderate pain, itching and moisture in
the perianal area. From the anamnesis it is known that a month ago the patient was operated on for acute
subcutaneous paraproctitis.
Objectively: the condition is satisfactory. Pulse 80 in 1 minute, rhythmic. When viewed in the
perianal region, a fistulous opening with a diameter of 3 mm. When pressed, pus is released from it
with an admixture of intestinal contents.
Research methods to clarify the diagnosis.
Surgical tactics.
Answer
Chr. Paraproctitis. External fistula of the rectum
Nado-sigmoidoscopy
Lech-opening drainage of the abscess, excision of the fistulous tract, elimination of the internal opening
of the fistula
87. Patient K., 40 years old, was admitted to the clinic with complaints of weakness, dizziness,
tinnitus, palpitations that occur after eating. From the anamnesis it was established that 4 months
ago he underwent surgery: gastric resection due to ulcer bleeding. Soon after
surgery, he developed the symptoms described above. This state usually lasts about 30
minutes.
Objectively: the condition is relatively satisfactory. Pulse 84 in 1 minute. BP 130 and 70 mm Hg

The tongue is wet. The belly of the correct form, participates in the act of breathing. There is a
postoperative scar on the anterior abdominal wall in the midline. On palpation, the abdomen is soft and
painless. X-ray shows accelerated evacuation of barium suspension from the stomach stump.
Solution: What post-resection complication are we talking about?
What methods of research allow to clarify the diagnosis?
surgeon's actions.
Answer.
dumping syndrome
Examination - hemodynamic parameters, X-ray
Treatment - therapeutic nutrition, novocaine, anestezin, substitution therapy before meals

(gastric juice, hydrochloric acid, with pepsin, gastrojejunoduodenoplasty)
88. Patient V., 43 years old, was admitted to the clinic with complaints of recurrent epigastric pain,
aggravated after eating, belching with an unpleasant odor, vomiting with an admixture of bile and
weight loss. From the anamnesis it was established that a year ago he underwent surgery:
resection of the stomach according to B-2 for a duodenal ulcer. In the immediate postoperative
period, he felt relatively satisfactory, then the symptoms described above appeared.
Objectively: the pulse is 100 in 1 minute is rhythmic. BP 120 and 70 mm Hg The tongue is wet. The
abdomen is of the correct form, is involved in breathing. There is a postoperative scar on the anterior
abdominal wall in the midline. On palpation, it is soft and slightly painful in the epigastrium.
Solution: What post-resection complication are we talking about.
Additional research methods to clarify the diagnosis.
surgeon's actions.
Answer.
Adductor loop syndrome
x-ray
Lech-u-shaped gastrojejunal anastomosis

89. Patient Sh., aged 38, was admitted to the clinic with complaints of severe weakness,
fatigue, lethargy, drowsiness, pain in the extremities, and dysmenorrhea. From the
anamnesis it was established that 6 months ago she was operated on for diffuse toxic goiter.
She underwent surgery: subtotal resection of the thyroid gland.
Objectively: the state of moderate severity. General lethargy, dryness of the skin,
hair loss is noted. Pulse 68 per minute, rhythmic. The basic exchange is sharply reduced.
Methods for determining the main exchange.
Doctor tactics
Answer.
Condition after subtotal resection of the thyroid gland. Secondary hypothyroidism
Jill formula = pulse + pulse pressure - 111
Iodine, hormones, biopsy
Lech-thyroxine
90. Patient K., aged 40, was admitted to the clinic with complaints of increased nervousness, severe
irritability, insomnia, increased sweating, muscle weakness, weight loss, decreased performance, an
increase in the anterior surface of the neck, palpitations, bulging eyes.
From the anamnesis it was established: a year ago, after a nervous shock, she began to notice
increased nervousness, sharp excitability. Then insomnia, increased sweating joined, soon she
noticed bulging eyes, an increase in the front surface of the neck, increased heartbeat, she lost 15
kg in weight.
Objectively: the state of moderate severity. The skin is moist. Pulse 126 1 min., extrasystole. BP 140
and 50 mm Hg. Art. Heart sounds are muffled. Systolic murmur at apex. When examining the neck
area, an increase in its anterior surface was noted. On palpation diffuse enlargement of both lobes
of the thyroid gland. Puffy eyes. Positive symptoms of Graefe, Möbius and Stelwag. The main
exchange is increased.
Specify the methods for determining the main exchange.
Specify the stages of complex treatment of the patient.
A set of activities at each stage.
Answer: diffuse toxic goiter. Thyrotoxicosis, visceropathic stage 3 degree thyroid enlargement
Osl: thyrotoxic heart, ophthalmopathy
Jill formula = pulse + pulse pressure - 111
Iodine, hormones, biopsy
Lechmercasolil, subtotal subfascial resection of the thyroid gland
91. Patient K., 23 years old, went to the clinic to the surgeon 2 days after inflicting a stab wound in
the interphalangeal region from the dorsal surface of the 2nd finger, complaining of severe
throbbing pain in it, aggravated by movement.
Objectively: the patient's condition is satisfactory. On examination, attention is drawn to the edema
and hyperemia of tissues in the area of the interphalangeal joint of the 2nd finger, the dorsal
interphalangeal grooves are smoothed. The inflamed joint took on a fusiform shape. Flexion-extensor
movements of the finger cause a sharp increase in pain in the affected joint. The temperature has
risen.
surgeon's actions.
Answer.
Articular panaritium 2 fingers
Treatment - linear lateral incisions + antibiotics and detoxification
92. Patient K., aged 40, was admitted to the clinic with complaints of pain, a feeling of heaviness in the
epigastrium, nausea, vomiting on the eve of food eaten and belching rotten.
From the anamnesis it was established that 2 months ago he was operated on for a
perforated duodenal ulcer. The perforated ulcer was sutured. A month after discharge from
the hospital, these symptoms appeared.
Objectively: the state of moderate severity. Lost 5 kg in weight. Pulse 100 in 1 minute, rhythmic. BP 110 and 70
mm Hg The belly of the correct form, participates in the act of breathing. Postoperative scar along the midline.
Painfulness of the abdomen on palpation is determined, there is splashing noise.
What additional laboratory and instrumental research methods

needs to be done to the patient. The importance of these studies in the complex treatment of the patient.
Stages of complex treatment of the patient and the essence of each of them.
Answer.
Yab 12pcs. Condition after suturing a perforated ulcer. Stenosis of the outlet of the stomach. St
subcompensation
Medical nutrition, antacids, sedatives, surgical treatment (stem vagotomy + drainage
operation)
93. Patient Sh., 48 years old, was admitted to the clinic with complaints of persistent pain in the epigastrium, spontaneous vomiting
of food at the height of pain.
From the anamnesis it is known that the patient has been suffering from duodenal ulcer for 15 years. In the
spring and autumn in recent years, there has been an exacerbation of the disease.
Objectively: the condition is satisfactory. Pulse 80 in 1 minute, rhythmic. The tongue is wet. The
abdomen is of the correct form, is involved in breathing. On palpation, it is soft and moderately
painful in the epigastrium. X-ray revealed cicatricial and ulcerative deformity of the bulb 12 -
duodenal ulcer. Peristalsis is slightly increased. Initial evacuation delayed. With
fibrogastroduodenoscopy: deformation of the pyloric canal, its slight narrowing, the pylorus is not
fully disclosed.
Solution: Formulate the diagnosis taking into account the existing classification.
What additional research methods determine the method of treatment in this patient?
sick?
Surgical tactics.
Answer
Yab 12pcs. Stenosis of the outlet of the stomach. St compensation
Lech - conservative antiulcer treatment (medical nutrition, antacids, sedatives), surgical

treatment (stem vagotomy).
94. Patient S., aged 50, was admitted to the clinic with complaints of dull pain in the epigastrium, aggravated after
eating, and vomiting of food.
From the anamnesis it was established that the patient had been suffering from duodenal ulcer for 20
years. Exacerbation of the disease was observed in the autumn-spring period. In recent years, it has lost
its seasonality.
Objectively: the patient's condition is relatively satisfactory. Pulse 90 in 1 minute is rhythmic. The tongue
is wet. The abdomen is of the correct form, is involved in breathing. On palpation, it is soft and slightly
painful in the epigastrium. The sound of splashing in the stomach is determined. X-ray data: The
stomach is expanded. Peristalsis is increased, the pyloric canal is narrowed. Evacuation slow.
Fibrogastroduodenoscopy data: deformation of the pyloric canal, narrowing of the lumen to 1 cm.
Solution: Formulate the diagnosis taking into account the existing classification.
What laboratory tests should be performed for this patient?
Stages of complex treatment of the patient.

A set of measures at the first stage.
Answer.
Yab 12pcs. Stenosis of the outlet of the stomach. St subcompensation
Treatment - therapeutic nutrition, antacids, sedatives, surgical treatment (stem vagotomy)
95. Patient P., aged 44, was admitted to the clinic with complaints of pain aggravated after eating, a feeling of
heaviness, vomiting of stagnant contents, weight loss.
From the anamnesis it is known that the patient has been suffering from duodenal ulcer for 20 years.
Objectively: the state of moderate severity. Pulse 110 in 1 minute, rhythmic. Dry tongue. The belly of
the correct form is involved in breathing. On palpation, slightly painful in the epigastrium. Noise
splashing in the stomach. I have lost 10 kg in weight over the last year. Diuresis up to 500 ml. On x-ray,
the stomach is distended and hypotonic. The evacuation is sharply slowed down, the initial one is
missing. Barium suspension is stored in the stomach for a day.
Solution: Formulate the diagnosis according to the classification.
What additional methods of research should be carried out by the patient.
Specify the sequence of stages in the treatment of the patient. A set of activities at each stage.
Specify the scope of surgical care.
Answer
Yab 12pcs. Stenosis of the outlet of the stomach. St decompensation
Treatment - therapeutic nutrition, antacids, sedatives, surgical treatment (stem vagotomy)
96. Patient S., 35 years old, was admitted to the clinic with complaints about the presence of a dense formation on the skin of the
middle third of the right thigh.
From the anamnesis, it was established that she had a pigmented formation of this localization since
childhood. The patient has fair skin. She traveled south every year. Loved to sunbathe. After that, she
noted an increase in pigment formation in size. However, she did not go to the doctor. During pregnancy a
year ago, the tumor began to grow rapidly, and there was bleeding from it. Has addressed to the doctor.
Objectively: the patient's condition is satisfactory. On the skin of the anterior surface of the middle third
of the right thigh there is a dark-colored tumor measuring 2 X 4 cm, bleeding on contact. There is a
dense lymph node in the right inguinal region.
Solution: What is the disease?
Analyze tactics at the prehospital stage.
Specify risk factors.

surgeon tactics.
Answer
Melanoma of the anterior surface of the middle third of the right thigh. 2b stage
Treatment - chemotherapy, and chir treatment
97. Patient P., 23 years old, was admitted to the clinic with complaints about the presence of a tumor-like formation in the
left mammary gland.
From the anamnesis it was established that she accidentally discovered this formation in herself. She went to the
surgeon at the clinic, from where she was sent to the hospital.
Objectively: the condition is satisfactory. On examination, both mammary glands are of the same size. On
palpation in the upper outer quadrant of the left mammary gland, a dense, mobile, with clear boundaries
node with a diameter of 1.5 cm is determined. There is no discharge from the nipple.
Survey plan.
Surgical tactics.
Answer.
Fibroadenoma of the left breast
Mammogram
Lech-sectoral resection
98. Patient K., 50 years old, was in the clinic because of ileofemoral phlebothrombosis.
Suddenly, in a relatively satisfactory condition, she developed weakness, shortness of
breath, chest pain, cough and blood-streaked sputum.
Objectively: the patient's condition is severe. Cyanosis of the face and upper body. Pulse 110 in 1
minute. HELL = 80/40 mm Hg. Art. On auscultation, rales are heard over the lung fields. On the
ECG - overload of the right heart.
Survey plan.
Choice of treatment method.
Answer
Iliofemoral phlebothrombosis. Tela with the formation of pulmonary infarction. Infarction

pneumonia. Acute cor pulmonale. Shock.
Phlebography
Lechthrombectomy from the femoral-popliteal segment, elastic bandage. Disaggregants,
99. A 56-year-old patient was brought to the clinic 2 hours after the onset of illness with complaints of severe
pain in the right lower leg, a feeling of numbness and coldness in it. From the anamnesis it was established
that the complaints listed above arose acutely. The patient suffers from rheumatism, mitral defect.
Objectively: the condition is serious. Pulse 92 in 1 minute, arrhythmic, BP = 140/80 mm Hg. Art. On
examination, the right lower extremity is pale, the foot is cool to the touch, pain sensitivity of the lower leg and
foot is reduced. Pulsation on the femoral, popliteal and arteries of the feet is not determined. Active
movements in the toes of the right foot are preserved, but "viscous".
What additional methods of examination are necessary for the patient.
Treatment.
Thromembolism of the right popliteal artery. Acute violation of the c / o in the right n / extremity 2 tbsp.
Phlebography
Lechthrombectomy, elastic bandage, disaggregants, anticoagulants, antispasmodics
100. A 72-year-old patient was brought to the clinic in a critical condition 4 hours after the onset of
illness with complaints of weakness, pain in the left side of the abdomen and lumbar region.
From the anamnesis, it was established that the patient suddenly felt severe weakness, and the
symptoms listed above appeared.
Objectively: the patient's condition is extremely serious, the skin is pale, covered with cold
sweat. Pulse 126 in 1 minute, weak filling. BP = 70/40 mm Hg. Art. Heart sounds are muffled.
Dry tongue. Belly of the correct form. On palpation, it is soft and painful in the left half, where
a pulsating formation measuring 10 X 8 cm is palpated. A systolic murmur is heard over this
formation.
Survey plan.
What complex of resuscitation measures is shown to the patient.
Surgical tactics.
Answer
Dissecting aortic aneurysm with incipient rupture
Examination - X-ray, angiography
Lech-resection with prosthetics

101. Patient T., aged 58, was admitted to the clinic with complaints of frequent pain in the
mesogastrium after eating, a feeling of heaviness, discomfort, bloating and flatulence.
From the anamnesis, it was found that the above symptoms have been bothering the patient for 8
years. Repeatedly asked for medical help. Treatment was carried out, which each time turned out
to be ineffective.
Objectively: the condition is relatively satisfactory. Pulse 88 in 1 minute, rhythmic. BP = 150/90 mm

Hg. Art. The tongue is wet. The abdomen is of the correct form, is involved in breathing. On
palpation, it is soft and slightly painful in the mesogastrium. Tension of the muscles of the anterior
abdominal wall and peritoneal symptoms are absent. Peristalsis is normal. A coarse systolic
murmur is heard above the umbilicus on the left. X-ray examination of the gastrointestinal tract,
gastroduodenoscopy, colonoscopy, computed tomography of the liver and pancreas revealed no
pathology.
The choice of treatment method.
A-c abdominal aorta
Examination - X-ray - angiography, thermography, rheovasography
Lech- endarterectomy
102. Patient S., 44 years old, was injected with 2 ml of 2% lidocaine solution for the purpose of pain relief
during tooth extraction, after which a sharp deterioration in the patient's condition was noted. Loss of
consciousness, pallor of the skin, cold clammy sweat, rare shallow breathing were noted. The pulse on the
peripheral arteries is not determined. A weak pulsation was noted in the large vessels. Pulse up to 140 in 1
minute. BP = 70/40 mm Hg. Art.
Solution: Formulate a presumptive diagnosis. What the doctor should have found out
from the patient before anesthesia
What resuscitation measures are shown to the patient.
Answer
Acute allergic reaction. Anaphylactic shock.
Treatment - adrenaline, calcium chloride, atropine, antihistamines
103. A 50-year-old patient K., who was operated on for a chronic stomach ulcer, gradually
developed cyanosis of the skin during intubation anesthesia. Pupil dilation was noted.
They stopped responding to light. Cardiac activity is saved. The operating surgeons
noticed the darkening of the blood in the wound.
Solution: What complication arose in the patient during anesthesia.

What complex of resuscitation measures is necessary for the patient. actions of surgeons.
Answer
Asphyxia of central origin.
Lech-anticholinergics
104. Patient K., 33 years old, came to the clinic with a surgeon complaining of bleeding from the
anus during defecation and general malaise. The diagnosis was made: hemorrhoids and the patient
was treated on an outpatient basis, prescribing suppositories, baths, laxatives. After 3 months, the
patient was consulted by a neurologist due to pain in the lumbar region. Lumbosacral sciatica was
diagnosed and thermal applications of ozocerite were prescribed. The patient's condition worsened
and he was sent for a consultation to the proctology department. At the first examination, the
proctologist made a digital examination of the rectum and in its lower section found a bumpy,
almost immobile formation, bleeding on contact.
Solution: What mistakes were made by doctors at the prehospital stage?
What additional methods of research is necessary for the patient.
Formulate a diagnosis.
Surgical tactics.
Answer
Cancer of the lower ampulla of the rectum t4 n0 m1
Lech- resection of the rectum (abdomino-perineal extirpation)
105. Patient N., 26 years old, was brought to the clinic with complaints of severe weakness, dizziness,
regular bleeding with scarlet blood during defecation and, sometimes, regardless of the stool.
From the anamnesis it was established that she suffers from persistent constipation, for which she has never
been treated. During the last 3 years, the above symptoms have occurred.
Objectively: the condition is serious. Severe pallor of the skin. Pulse 96 in 1 minute. Rhythmic.
BP = 100/70 mm Hg. Art. With a digital examination of the rectum at points projected at 3, 7
and 11 o'clock on the dial, internal hemorrhoids bleeding on palpation. Blood test:
erythrocytes - 2.1 X 10.12\l, hemoglobin content 48 g/l.
Make a differential diagnosis. What additional research methods should be used in the
differential diagnosis.
Surgical tactics.
Hemorrhoids 1 tbsp
Treatment - elimination of constipation, ascending shower, sclerosing therapy, operation - excision of nodes with the
help of a fenestrated clamp (Miligan-Morgan method)
106. Patient L., aged 55, was brought to the clinic in the first hour after the incident with complaints of stab
wounds and shortness of breath. Circumstances of injury: unknown persons stabbed him in the left half of
the chest and in the region of the xiphoid process of the sternum. Upon admission, the patient's condition
was severe, acrocyanosis. Pulse 100 in 1 min., rhythmic, A/D 100/60 mm. rt. Art. In the region of the left
nipple there is a bleeding wound 2*1 cm in size, the second wound is at the base of the xiphoid process of
the sternum. Heart sounds are muffled. Breathing on the right is auscultated in all lung fields, on the left it is
weakened. Percussion on the left is determined by dullness, starting from the VI rib. The abdomen is of the
correct form, is involved in breathing. On palpation - soreness and tension of the abdominal muscles in the
right hypochondrium, dullness of percussion sound on the right. Peristalsis is heard.
Solution: 1. Formulate a diagnosis
2. What research methods are needed to clarify the diagnosis
3. Tactics.
4. The sequence of implementation of the operational manual.
Answer: Penetrating wound of the chest and abdomen. Osl: left-sided

hemopneumothorax. Hemoperitoneum. Hemorrhagic shock 1 tbsp.
Radiography of organs gr Cl and br cavity, laparoscopy.
Pleural puncture to remove air and blood, laparotomy and stop bleeding.
107. Patient B., 31 years old, was taken to the anti-shock ward in an unconscious state. The
circumstances and timing of the injury are unknown. The skin is pale, wet, cold. The pupils are
moderately dilated, the reaction to light and the corneal reflex are absent. The pulse is determined
only on the carotid arteries. A/D is not defined. Heart sounds are very muffled. Breathing is
shallow, rapid, weakened on both sides. When examining the chest on the left in the VI intercostal
space along the mid-clavicular line, an incised wound measuring 2.5 * 1 cm, a similar wound on the
right at the same level along the posterior axillary line.
Solution: 1. Formulate a diagnosis
2. What research methods are needed to clarify the diagnosis.
3. The procedure for providing assistance to the patient, including resuscitation.
Answer: through penetrating wound of the chest with damage to both lungs and mediastinal
organs. Osl: Bilateral hemopneumothorax. Hemopericardium. Cardiac tamponade.
Hemorrhagic shock 3 tbsp.
Pleural puncture to remove air and blood, laparotomy and stop bleeding. Pericardial puncture.
108. Patient O., 28 years old, was taken to the clinic 1 hour after the incident. Unknown persons
stabbed him in the left half of the chest. On admission, the patient was in a serious condition. The
skin and mucous membranes are pale, covered with cold sweat. Pulse 110 in 1 min., Rhythmic,
weak filling and tension. A/D 90/60 mm. rt. Art. When examining the chest in the 7th intercostal
space along the anterior axillary line, there is a stab wound measuring 3 * 1 cm, moderately
bleeding. The left half of the chest lags behind the right when breathing, dullness of percussion
sound is determined, breathing on the left is sharply weakened. The abdomen is painless on
palpation.
Diagnosis: a penetrating stab wound to the chest on the left with a lung injury.
Hemothorax.
Chest X-ray showed hemopneumothorax on the left. The patient was operated on. A left thoracotomy
was performed. During the revision, it was found that in the pleural cavity about 1.5 liters. liquid blood. In
the lower lobe of the left lung, there is a wound 4*1 cm in size, moderately bleeding. The wound of the lung
is sutured. The bleeding has been stopped. Further revision revealed a wound in the diaphragm.
Solution: 1. Your next steps.
2. If a diaphragm injury is detected, will you use blood from

pleural cavity for reinfusion.
3. Formulate the final diagnosis.
penetrating stab wound of the chest and abdomen on the left with a lung injury and damage to
the diaphragm. Hemothorax. Hemopneumoperitoneum?
109. Patient S., aged 71, was admitted to the clinic with complaints about the presence in both inguinal
regions of rounded formations that appear in the vertical position and disappear in the horizontal
position of the body. From the anamnesis it was established that for the last 3 years he had difficulty
urinating. Urine is excreted in a thin, sluggish stream. Frequent urge to urinate. Nighttime diuresis
prevails over daytime. A year ago, the patient noticed the appearance of tumor-like formations in both
inguinal regions. Objectively:
The abdomen is of the correct form, is involved in breathing. In both inguinal regions, a
rounded formation, soft-elastic consistency, painless, 5 * 5 cm in size, retracting into the
abdominal cavity. The external openings of the inguinal canal pass two transverse
fingers. Solution: Formulate a diagnosis.
What comorbidity does the patient have? What additional

research methods must be carried out by the patient, which will be important when choosing
tactics.
surgeon tactics.
Bilateral inguinal hernia. SoP: BPH
Cons of a urologist (overflow of the bladder with urine can be one of the main causes of hernia
formation.
110. Patient Sh., 23 years old, was delivered to the clinic by ambulance 6 hours after a
traffic accident. When crossing the carriageway, he was hit by a car.
Objectively: the patient's condition is severe. The skin is pale. Complains of pain in the right half of the
chest, right hypochondrium and lumbar region on the right. Pulse 120 per minute, rhythmic. BP 90-60
mm Hg. Art. Palpation of the chest revealed crepitus of bone fragments in the projection of 7-8 ribs on
the right along the anterior axillary line. There is no subcutaneous emphysema. Breathing is auscultated
in all lung fields in the same way both on the right and on the left. The tongue is dry. The abdomen is
not swollen. On palpation, it is soft and painful in the right hypochondrium. Moderate muscle tension in
this area. There is swelling in the lumbar region on the right, sharp pain on palpation. Percussion
dullness of percussion sound in the right lateral canal.
In the analysis of urine macrohematuria. Blood test: erythrocytes
3.0*10 12/l; Hb-100 g/l.
Solution: Your diagnosis.
Additional research methods.
surgeon tactics.
Blunt trauma to the chest on the right. Fracture of 7-8 ribs on the right. Right kidney injury. Hematuria.
Hemoperitoneum? Hemorrhagic shock 2 tbsp.
Radiography of the chest and abdominal organs, intravenous pyelography.
Surgical treatment depending on the results of the examination.
111. Patient K., 38 years old, was taken to the anti-shock ward. The circumstances and time of the injury
are unknown.
Objectively: the patient's condition is severe. Not contact. Coma 11. Pulse 112 per minute, rhythmic. AD
100 and 60 mm. Hg When examining the chest, no bone damage was detected. Breathing is heard in all
lung fields. The abdomen is of the correct form, somewhat swollen in the lower sections. Palpation
above the womb is determined by a rounded dense formation. Percussion above it is a dull sound, and
in other departments it is tympanic. There is no dullness in the sloping parts of the abdomen. There is
urethrorrhagia and hematoma in the perineum. There is no urination. An x-ray of the pelvic bones
revealed a fracture of the ischial bones.
Research methods confirming the diagnosis.
surgeon tactics.
Blunt trauma to the abdomen with fracture of the ischial bones and damage to the urethra.
Hematoma of the perineum. Acute retention of urine.
Urethrography.
Puncture of the bladder, dissection of the perineum, removal of blood clots,

hemostasis, stitching of the urethra.
112. Patient B., 78 years old, was hospitalized 6 times in the cardiology department with a
diagnosis of myocardial infarction based on complaints of severe pain behind the sternum, not
relieved by nitroglycerin, morphine and antispasmodics. The pains were disturbing for several
hours, accompanied by vomiting and a decrease in blood pressure .. They arose after taking a
plentiful meal. Strict bed rest, prescribed at that moment, worsened the patient's condition,
therefore, despite the prohibitions of doctors, he sat up in bed on his own, which brought him
relief. Repeated ECG did not reveal fresh focal or cicatricial changes in the myocardium. Upon
careful questioning of the patient, it was possible to find out that he periodically had regurgitation,
heartburn, salivation and loud belching of air.
Additional research methods, confirming the diagnosis.
Physician tactics.
Answer.
Diaphragmatic hernia. Herb. Hernia of the esophageal opening of the diaphragm. Reflux - esophagitis.
Esophagogastroscopy. X-ray of the esophagus. Intraventricular pH-metry
Lech-concer + chir
113. Patient S., 14 years old, aspirated a sunflower seed
Two months ago. After 3 days it was removed through a bronchoscope, but the patient still had a
cough, especially in the morning, purulent sputum began to appear in a small amount. At the
slightest cooling, the temperature rose to 37.5-38 C for 1-2 days.
When examining the patient, lagging of the left half of the chest during breathing was noted. During
percussion - shortening of the percussion sound under the left shoulder blade. Auscultatory - weakened
breathing in the lower sections of the left lung behind. Blood test without features. On the radiograph: the
lung fields are transparent, but the left lung field is narrowed, the diaphragm is elevated, and the mediastinal
shadow is shifted to the left.
What additional research can
confirm it?
How to treat the patient?

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Translated from Russian to English - www.onlinedoctranslator.

In the study of blood leukocytosis, ESR 45 mm/h.

Solution: Formulate a diagnosis.

Management in the postoperative period.

Acute thrombosis of the branches of the superior mesenteric artery.

Donkey: Acute small bowel obstruction. Peritonitis.

Solution: 1. Formulate a presumptive diagnosis.

2. Additional research methods.

Radiography of the organs of the cavity, rectoscopy.

Abdominal-anal resection (because the op is located at a distance of 8-9 cm).

Solution: 1. Formulate a preliminary diagnosis.

2. What additional research needs to be done to clarify

Blunt abdominal trauma. Peritonitis. Intra-abdominal bleeding. Kidney injury?

Solution: 1. Formulate a preliminary diagnosis.

2. What additional research needs to be done to clarify

Esophagogastroscopy. X-ray of the esophagus. Intraventricular pH-metry

Solution: Formulate a preliminary diagnosis.

Determine the deficiency of circulating blood.

Determine the source of bleeding.

Formulate the final diagnosis.

Yab 12 PC, exacerbation. Gastrointestinal bleeding.

Osl: posthemorrhagic anemia 3-4 tbsp.

DC = 1000* V+ 60* hematocrit (%) - 6700m(6060g) (Barovsky)

Complaints of weakness, pain in the left lumbar region.

Solution: Formulate a preliminary diagnosis.

Determine the set of necessary additional

laboratory and instrumental methods

Ultrasound, laparoscopy, removal of the left kidney and stop bleeding

Solution: Formulate a diagnosis.

What complex of additional laboratory and

instrumental methods of research is necessary

to clarify the diagnosis.

Zhkb, acute destructive cholecystitis, local peritonitis.

Examination: ultrasound, rhpg, oral cholecystography

Solution: Formulate a preliminary diagnosis.

Specify the necessary complex of laboratory and

instrumental research methods that allow

clarify the diagnosis.

Determine the degree of intoxication.

Specify the sequence of stages in the treatment of the patient.

A set of activities at each stage.

Acute obstructive colonic obstruction. Tumor of the sigmoid colon.

Solution: Formulate a preliminary diagnosis.

What laboratory and instrumental methods

investigations to clarify the diagnosis.

Choice of method of treatment of the patient.

Examination - X-ray, FGDs

Solution: Formulate a preliminary diagnosis.

Specify Additional Methods

research to clarify the diagnosis.

perforated ulcer. Diffuse peritonitis.

Examination - X-ray, FGDs

Ulcer suturing, cavity toilet, drainage

Solution: Formulate a diagnosis.

What additional methods

investigations to clarify the diagnosis.

Indicate the sequence of stages of treatment of the patient and

a set of activities at each stage.

perforated ulcer. Diffuse peritonitis.

Examination - X-ray, FGDs