· state vascular system skin - the presence, localization and severity of the venous pattern (if necessary, use the symptoms of a tourniquet or pinch).
Skin appendages:
· Hair: uniform growth, paying attention to excess growth (limbs, back), appearance hair (shiny, dull, etc.);
· Nails, paying attention to their appearance: they should have a smooth surface and an even edge, pink color, fit tightly to the nail bed. The periungual fold should not be hyperemic or painful.
Mucous membranes lips, mouth, conjunctiva of the eyes: color (pale, red), moisture, dryness, integrity (erosions, ulcers), presence of rashes, hemorrhages, thrush.
Subcutaneous fat layer:
· degree of development (atrophied, poorly developed, well, excessively, excessively);
· correct distribution (uniform, uneven in individual areas of the body and limbs);
soft tissue turgor;
presence of edema
· Child 2 years old. Subcutaneous fatty tissue moderately developed, correctly distributed. The thickness of the subcutaneous fat layer on the face is 2 cm, on the abdomen 1 cm, under the collarbone 1.5 cm, under the shoulder blade 1 cm, on the inner surface of the thighs 3 cm. Tissue turgor is elastic. ( norm ).
· Child 7 years old. Subcutaneous fat is underdeveloped, unevenly distributed, and absent on the abdomen. Thickness of skin folds: above the biceps 0.5 cm, above the triceps 1 cm, above the spine ilium 1.5 cm, 1 cm under the shoulder blade. Tissue turgor on the thigh is reduced. ( dystrophy stage I ).
The lymph nodes: localization, quantity, (single, multiple), size (indicated in cm), shape, consistency, mobility, relationship of nodes to the surrounding tissue and to each other, pain or sensitivity on palpation.
Examples of conclusion wording:
· submandibular, anterior cervical, axillary and inguinal lymph nodes, single in size up to 0.3 cm, soft elastic consistency, not welded to each other or to the skin, mobile, painless ( norm )
· single occipital and cubital, multiple anterior and posterior cervical, axillary and inguinal are palpated The lymph nodes, up to 3-5 mm in size, dense, not fused to each other or to the skin, mobile, painless. ( micropolyadenia ).
Endocrine glands: thyroid gland, testicles (presence of hypoplasia, cryptorchidism, monorchidism). Secondary sexual characteristics.
Muscular system: degree of development (weak, normal, average, good), the presence of atrophies (individual muscles or muscle groups), paralysis and paresis, the presence of seizures (their characteristics are tonic, clonic, tonic-clonic, tetanic). Muscle tone. Muscle strength.
Examples of conclusion wording:
· muscle tone is sufficient, passive and active movements are performed in full, muscle strength is good. – ( norm )
· general muscle weakness (myasthenia gravis), muscle pain (myalgia), focal compactions on palpation (calcifications in the muscles). Atrophic changes not in the muscular system. Passive movements in full, limitation of active movements due to muscle weakness. (pathology muscular system- dermatomyositis)
Skeletal system:
· head– shape of the skull (round, tower-shaped, with a flattened occiput, with the presence of frontal or parietal tubercles); symmetry, condition of the upper and lower jaw, features of occlusion (orthognathic, straight, prognathic), dental development.
· chest cell: shape, symmetry, presence of deformations (heart hump, Harrison's groove (recession along the line of attachment of the diaphragm), rachitic rosary). The epigastric angle is assessed.
· spine: symmetry of the location of the shoulder blades, iliac crests, volume and symmetry of the back muscles, the presence of physiological curves and their severity, the presence of lateral curves of the spine (scoliosis).
· gait
· limbs: symmetry, length, the presence of curvatures (valgus - X-shaped, varus - O-shaped, the presence of “bracelets”), equal number and the same depth of the gluteal folds (in the prone position on the stomach).
Examples of conclusion wording:
· Skeletal changes are determined - flattening of the occiput, the presence of a “rosary” and Harrison’s groove, varus deformity of the legs. ( consequences of rickets ).
· There is a symmetrical lesion knee joints in the form of defiguration, hyperthermia, pain, limited mobility - the angle of flexion on the right is 120 0, on the left 110 0, extension is not limited. Symptom of patellar ballotation in both knee joints. ( Arthritis ).
Respiratory system:
Nasal breathing (free or difficult), swelling of the wings of the nose. Type of breathing (thoracic, abdominal, mixed). Depth and rhythm of breathing (shallow, deep, rhythmic, arrhythmic). The number of breaths per minute, the presence of shortness of breath, its type (inspiratory, expiratory, mixed). Symmetry of participation in breathing chest, participation of auxiliary muscles, retraction or bulging of intercostal spaces. The supraclavicular spaces bulge or retract. The shoulder blades fit tightly to the body or lag behind.
Palpation determines the resistance of the chest, voice tremors(strengthened, weakened, equally in symmetrical areas).
When percussing the chest, the nature of the percussion sound is determined (clear, pulmonary, dull, tympanic, boxed).
Auscultation determines the nature of breathing (puerile, vesicular, hard, bronchial, increased, weakened) and the presence of wheezing, indicating their location, quantity (single, scattered, multiple), caliber and sonority (dry, buzzing, whistling, wet coarse, medium - and fine bubbles).
Examples of conclusion wording:
Child 8 years old. No complaints. Nasal breathing is free, there is no discharge. The voice is clear and loud. No cough. The shape of the chest is conical, symmetrical, both halves evenly participate in the act of breathing. The supraclavicular and subclavian fossae are expressed equally on both sides. Breathing is deep, the rhythm is correct, the type is mixed. Respiration rate 20 per minute. The chest is moderately rigid, voice tremor is the same in symmetrical areas of the chest. Upon percussion, a clear pulmonary sound is detected over the symmetrical parts of the lungs. Auscultation reveals vesicular breathing, no wheezing. Bronchophony is not changed. (norm).
The cardiovascular system:
External examination: presence of visible pulsation ( carotid arteries, swelling and pulsation of the neck veins, pulsation of the abdominal aorta, capillary pulse).
The degree of development of subcutaneous fat is determined by palpation (palpation) and consists of measuring the thickness of the skin fold formed when the skin is grasped with the thumb and forefinger.
In the area of the lower third of the shoulder along the back surface;
On the anterior abdominal wall at the level of the navel along the edge of the rectus abdominis muscles;
At the level of the angles of the shoulder blades;
At the level of the costal arches;
On the front of the thigh.
With a skin fold thickness of 1-2 cm, the development of the subcutaneous fat layer is considered normal, less than 1 cm - reduced, more than 2 cm - increased.
Attention is also paid to the nature of the distribution of the subcutaneous fat layer. Normally, it is distributed evenly (the thickness of the skin fold is almost the same in different parts of the body). If the subcutaneous fat layer is unevenly distributed, it is necessary to indicate the areas of increased fat deposition.
9. Edema: varieties according to origin and mechanism of development. Characteristics of cardiac and renal edema. Methods for detecting edema.
Edema is an excessive accumulation of fluid in body tissues and serous cavities, manifested by an increase in tissue volume or a decrease in the capacity of serous cavities and a disorder in the function of edematous tissues and organs.
Swelling can be local (local) or general (widespread).
There are several degrees of edema:
1. Hidden edema: not detected by examination and palpation, but detected by weighing the patient, monitoring his diuresis and the McClure-Aldrich test.
2. Pastosity: when pressing with a finger on the inner surface of the leg, a small pit remains, which is detected mainly by touch.
3. Obvious (pronounced) swelling: the defiguration of joints and tissues is clearly visible and when pressed with a finger, a clearly visible hole remains.
4. Massive, widespread edema (anasarca): accumulation of fluid not only in the subcutaneous fatty tissue of the torso and limbs, but also in the serous cavities (hydrothorax, ascites, hydropericardium).
The main reasons for the development of edematous syndrome:
1) increase in venous (hydrostatic) pressure - hydrodynamic edema;
2) decrease in oncotic (colloid-osmotic) pressure - hypoproteinemic edema;
3) disturbance of electrolyte metabolism;
4) damage to the capillary wall;
5) impaired lymphatic drainage;
6) drug-induced edema (minerolocorticoids, sex hormones, non-steroidal anti-inflammatory drugs);
7) endocrine edema (hypothyroidism).
Edema of cardiac origin. U In a patient with heart failure, edema is always localized symmetrically. First, swelling of the feet and ankles forms, which can completely disappear after a night's rest. Swelling increases towards the end of the day. As heart failure progresses, the legs and then the thighs swell. In bedridden patients, swelling of the lumbosacral region appears. The skin over the swelling is tense, cold, and cyanotic. The swelling is dense; when pressed with a finger, a hole remains. As heart failure progresses, ascites and hydrothorox may appear. Trophic changes in the skin in the shin area are often detected in the form of increased pigmentation, depletion, cracking, and the appearance of ulcers.
The subcutaneous fat layer is assessed based on the following data.
Inspection. Upon examination, the degree of development and correct distribution of the subcutaneous fat layer are determined. Be sure to emphasize gender differences, since in boys and girls the subcutaneous fat layer is distributed differently: in boys - evenly, in girls from 5 to 7 years old and especially during puberty, fat accumulates in the hips, abdomen, buttocks, chest in front .
Palpation. Objectively, the thickness of the subcutaneous fat layer for children in the first 3 years of life is determined as follows:
on face-in area cheeks (norm 2 - 2.5 cm);
on the stomach - at the level of the navel outward from it (the norm is 1 - 2 cm);
on the body - under the collarbone and under the scapula (norm 1 - 2 cm);
on the limbs - along the posterior surface of the shoulder (norm 1 - 2 cm) and on the inner surface of the thighs (norm 3 - 4 cm).
For children over 5-7 years old, the thickness of the subcutaneous fat layer is determined by four skin folds (Fig. 39).
above the biceps (normal 0.5-1 cm);
above the triceps (normal 1 cm);
above the axis of the ilium (normal 1-2 cm);
above the shoulder blade - a horizontal fold (norm 1.5 cm).
When palpating the skin fold, you should pay attention to the consistency of the subcutaneous fat layer. It can be flabby, dense and elastic.
Soft tissue turgor due to the condition of subcutaneous fat and muscles; it is determined by the feeling of resistance to the examiner’s fingers when squeezing the folds of skin and underlying tissues on 
the inner surface of the shoulder or thigh.
When palpating, pay attention to the presence swelling. Edema is observed both in the skin and in subcutaneous fat. They can be general (generalized) and local (localized). The formation of edema may be associated with an increase in the amount of extracellular and extravascular fluid.
To determine the presence of edema or pastiness on lower limbs, you need to press index finger right hand on the shin above tibia. With edema, a hole is formed that disappears gradually. Often, deep indentations of the skin from diapers, elastic bands of clothes, belts, belts, and tight shoes indicate the pastiness of tissues. U healthy child there are no such phenomena.
In addition to obvious edema, there are hidden ones, which can be suspected when diuresis decreases, a large daily increase in body weight and is determined using the McClure-Aldrich test. To carry out this test, 0.2 ml of isotonic sodium chloride solution is injected intradermally and the time of resorption of the resulting blister is noted.
Subcutaneous fatty tissue (subcutaneous base, subcutaneous tissue, hypodermis) is loose connective tissue with fatty deposits, connecting the skin with the underlying tissues. It has elasticity and tensile strength, its thickness
uneven in different parts of the body, the most significant body fat on the stomach, buttocks, and in women also on the chest. The subcutaneous fat layer in women is almost 2 times thicker than in men (m:f = 1:1.89). In men, the amount of fat is about 11% of body weight, in women - about 24%. Subcutaneous fatty tissue is richly supplied with blood vessels and lymphatic vessels, the nerves in it form broadly looped plexuses.
Subcutaneous fatty tissue is involved in the formation of the external shape of the body, skin turgor, promotes skin mobility, and participates in the formation of skin folds and furrows. It functions as a shock absorber under external mechanical influences, serves as the body's energy depot, participates in fat metabolism, and acts as a thermal insulator.
When clinically assessing the development of subcutaneous fat tissue, the terms “nutrition” and “fatness” are used. Nutrition is divided into normal, increased or excessive (obesity), decreased (weight loss, emaciation) and exhaustion (cachexia). Nutrition is assessed visually, but it is judged more objectively by palpation examination of the thickness of the fat layer, body weight and its relationship with proper weight, and the percentage of fat in the body. For these purposes, special formulas and nomograms are used.
The severity of the subcutaneous fat layer significantly depends on the type of constitution: hypersthenics are prone to increased nutrition, asthenics - to low nutrition. That is why, when determining the proper body weight, it is necessary to take into account the correction for the type of constitution.
At the age of 50 and over, the amount of fat increases, especially in women.
A healthy person can have varying degrees fatness, which depends on the type of constitution, hereditary predisposition, lifestyle [diet, physical activity, nature of work, habits (smoking, drinking alcohol)]. Older age, excess eating, drinking alcohol, especially beer, and a sedentary lifestyle contribute to excess fat accumulation - obesity. Poor nutrition, addiction to certain diets, fasting, exhausting physical labor, psycho-emotional overload, habitual intoxication (smoking, alcohol, drugs) can lead to weight loss and exhaustion.
Obesity and weight loss are observed in some diseases of the nervous and endocrine systems. Weight loss of varying degrees
occurs in many somatic, infectious and oncological diseases. Excessive fat deposition and its sharp decrease can be generalized and local, limited, focal. Local changes, depending on the cause, can be symmetrical or unilateral.
Initially, nutrition is assessed visually, taking into account gender, constitution type and age.
With normal nutrition there is:
- the correct ratio of height and body weight, the correct ratio of its individual parts - the upper and lower half of the body, the size of the chest and abdomen, the width of the shoulders and pelvis, the volume of the hips;
- there are moderate fat deposits on the face and neck, there are no folds on the chin and back of the head;
- the muscles of the trunk and limbs are well developed and clearly contoured;
- bony protrusions - collarbones, shoulder blades, spinous processes of the spine, iliac bones, kneecaps protrude moderately;
- the chest is well developed, its anterior wall is at the level of the anterior wall of the abdomen;
- the stomach is of moderate size, the waist is clearly visible, there are no fat folds on the stomach and waist;
- moderate fat deposits on the buttocks and thighs.
With excess nutrition, the face becomes rounded, wide, swollen with fat with a pronounced chin, fine wrinkles disappear, large folds appear on the forehead, chin, back of the head,
on the stomach, in the waist area. In obesity, muscle contours disappear, natural recesses (supraclavicular, subclavian fossae, etc.) are smoothed out, bone protrusions “sink” into adipose tissue.
A decrease in nutrition is manifested by a decrease in body size, a decrease or disappearance of the fat layer, and a decrease in muscle volume. Facial features become sharper, cheeks and eyes become sunken, zygomatic arches are outlined, supraclavicular and subclavian fossae deepen, clavicles, shoulder blades, spinous processes, pelvic bones are clearly contoured, intercostal spaces and ribs, interspinous spaces on the hands are clearly outlined. Extreme exhaustion is called cachexia.
Palpation examination of the subcutaneous fat layer is carried out to determine the degree of its development in various parts of the body, to identify fatty and non-fatty formations in its thickness and in other tissues, to identify pain and swelling.
Palpation is carried out with a sliding movement of the palmar surface of the fingers in places of greatest accumulation of fat and especially where there is an unusual configuration of the surface of the skin and its folds. Such areas are additionally felt by covering them with two or three fingers from all sides, while paying attention to consistency, mobility and pain.
U healthy person the subcutaneous fat layer is elastic, resilient, painless, easily removable, its surface is smooth. With careful palpation, it is not difficult to determine its finely lobed structure, especially on the stomach, internal surfaces of the upper and lower extremities.
The thickness of the subcutaneous fat layer is determined by grasping the skin-fat fold with two or three fingers in certain places (Fig. 36).
By the thickness of the skin-fat fold in different places, one can judge the severity and nature of the distribution of adipose tissue, and in case of obesity, the type of obesity. With normal nutrition, the thickness of the skin-fat fold fluctuates within 1-2 cm. An increase to 3 cm or more indicates excess nutrition, a decrease of less than 1 cm indicates malnutrition. The thickness of the skin-fat fold can be measured with a special caliper, but in practical medicine there are none (Fig. 37).
There are cases of complete disappearance of the subcutaneous fat layer with a healthy muscle condition, which may be due to congenital generalized lipodystrophy. Existence
Rice. 36. Places for studying the thickness of the skin-fat fold.
- - on the stomach at the edge of the costal arch and at the level of the navel along the midclavicular line; 2 - on the front chest wall along the midclavicular line at the level of the 2nd intercostal space or 3rd ribs; 3 - at the angle of the blade; 4 - on the shoulder above the triceps; 5 - above the iliac crest or on the buttock; 6 - on the outer or front surface of the thigh.
Rice. 37. Measuring the thickness of the skin-fat fold with a caliper compass. 
There is a special variant of lipodystrophy - the disappearance of the subcutaneous fat layer against the background of excessive muscle development - hypermuscular lipodystrophy, its genesis is unclear. These features must be taken into account when assessing body weight and calculating the percentage of body fat.
A local increase in the fat layer or limited accumulation of fat masses is observed with lipomatosis, lipoma, Dercum's disease, after subcutaneous injections.
Limited thickening of the fat layer occurs with inflammation in the subcutaneous fat tissue - panniculitis. This is accompanied by pain, redness, and increased local temperature.
Local reduction or disappearance of the fat layer is possible on the face, upper half of the body, legs, and thighs. Its genesis is unclear. Focal disappearance of the subcutaneous fat layer occurs at the sites of repeated injections. This is often observed in places where insulin is systematically administered - on the shoulders and hips.
Knowing your body mass index (BMI), you can use a formula to calculate the percentage of body fat, which is important for identifying obesity and for monitoring during treatment.
Formula for men - (1.218 x body mass index) - 10.13
Formula for women - (1.48 x body mass index) - 7.0
When calculating body mass index and body fat percentage, it is necessary to exclude the presence of edema, especially hidden edema.
The degree of development of subcutaneous fat is determined by palpation (palpation) and consists of measuring the thickness of the skin fold formed when the skin is grasped with the thumb and forefinger.
In the area of the lower third of the shoulder along the back surface;
On the anterior abdominal wall at the level of the navel along the edge of the rectus abdominis muscles;
At the level of the angles of the shoulder blades;
At the level of the costal arches;
On the front of the thigh.
With a skin fold thickness of 1-2 cm, the development of the subcutaneous fat layer is considered normal, less than 1 cm - reduced, more than 2 cm - increased.
Attention is also paid to the nature of the distribution of the subcutaneous fat layer. Normally, it is distributed evenly (the thickness of the skin fold is almost the same in different parts of the body). If the subcutaneous fat layer is unevenly distributed, it is necessary to indicate the areas of increased fat deposition.
9. Edema: varieties according to origin and mechanism of development. Characteristics of cardiac and renal edema. Methods for detecting edema.
Edema is an excessive accumulation of fluid in body tissues and serous cavities, manifested by an increase in tissue volume or a decrease in the capacity of serous cavities and a disorder in the function of edematous tissues and organs.
Swelling can be local (local) or general (widespread).
There are several degrees of edema:
Hidden edema: not detected by examination and palpation, but detected by weighing the patient, monitoring his diuresis and the McClure-Aldrich test.
Pastiness: when pressing with a finger on the inner surface of the leg, a small pit remains, which is detected mainly by touch.
Explicit (pronounced) swelling: the defiguration of joints and tissues is clearly visible and when pressed with a finger, a clearly visible hole remains.
Massive, widespread edema (anasarca): accumulation of fluid not only in the subcutaneous fatty tissue of the torso and limbs, but also in the serous cavities (hydrothorax, ascites, hydropericardium).
The main reasons for the development of edematous syndrome:
1) increase in venous (hydrostatic) pressure - hydrodynamic edema;
2) decrease in oncotic (colloid-osmotic) pressure - hypoproteinemic edema;
3) disturbance of electrolyte metabolism;
4) damage to the capillary wall;
5) impaired lymphatic drainage;
6) drug-induced edema (minerolocorticoids, sex hormones, non-steroidal anti-inflammatory drugs);
7) endocrine edema (hypothyroidism).
Edema of cardiac origin. U In a patient with heart failure, edema is always localized symmetrically. First, swelling of the feet and ankles forms, which can completely disappear after a night's rest. Swelling increases towards the end of the day. As heart failure progresses, the legs and then the thighs swell. In bedridden patients, swelling of the lumbosacral region appears. The skin over the swelling is tense, cold, and cyanotic. The swelling is dense; when pressed with a finger, a hole remains. As heart failure progresses, ascites and hydrothorox may appear. Trophic changes in the skin in the shin area are often detected in the form of increased pigmentation, depletion, cracking, and the appearance of ulcers.
Edema of renal origin.
Renal edema is of two types:
1) nephritic edema - forms quickly and is localized mainly on the face, less often on the upper and lower extremities; First of all, tissues rich in blood vessels and loose fiber swell;
2) nephrotic edema is one of the manifestations of nephrotic syndrome, which is characterized by hypoproteinemia, dysproteinemia, hypoalbuminemia, hyperlipidemia, massive proteinuria (more than 3 g/day); nephrotic edema develops gradually, first the face swells after a night's rest, then the legs, lower back, and anterior abdominal wall, ascites, hydrothorax, and anasarca may occur.
Renal edema is pale, soft, pasty, sometimes shiny, and easily movable.
Methods for detecting edema:
1) inspection;
2) palpation;
3) daily determination of body weight, measurement of diuresis and comparison with the volume of fluid consumed;
4) test for hydrophilicity of McClure-Aldrich tissues.
Technique and normal parameters of the test for tissue hydrophilicity: 0.2 ml of physiological NaCl solution is injected intradermally into the area of the inner surface of the forearm. With a pronounced tendency to edema, the blister resolves within 30-40 minutes instead of 60-90 minutes normally.
