CLINICAL MANIFESTATIONS AND PATIENT EXAMINATION AND MANAGEMENT

The clinical manifestations of suppurative-inflammatory diseases are comprised of local and general symptoms. The local features of inflammation reflect the stage of development, the character and localization of the inflammatory process. Hence foci of superficial inflammation (suppurative inflammatory skin diseases, subcutaneous fat, the breasts, muscles etc.) or foci located deep but with the involvement of skin in the inflammatory process are characterized by the classical signs of inflammation - redness (rubor), caused by peristatic hyperemia, edema, swelling (tumor), pain (dolor), increase in local temperature (calor) and organ function disorder (functio laesa).The spread and manifestation of the inflammatory process determine the extent of the local clinical presentation. The inflammatory process of the internal organs has their own specific local clinical signs that differ from organ to organ, for example in purulent pleurisy, peritonitis.

During the process of clinical examination of patients with suppurative-inflammatory disease the stage of the disease process can be identified: when a firm tender mass is palpated in the presence of other signs of inflammation, it is an indication of some inflammatory process in the soft tissue and glandular organ, skin and subcutaneous layer, breast or in the abdominal cavity that is still in its infiltrative phase. Palpation of a soft infiltrate, positive fluctuation sign indicate that the infiltrative phase has moved into the suppurative (purulent) phase. The local clinical signs of progressive suppuration are: zones or stripes of redness in the skin (lymphangitis), firm tender strings of induration along the superficial veins (thrombophlebitis), the appearance of firm tender indurations at the sites of the regional lymph nodes (lymphadenitis). There is always a correlation between the extent of the local presentation and the intensity of general clinical signs of intoxication: a progression of the inflammatory process is accompanied by the progress of both local and general signs of inflammation and intoxication.

The body's response to the inflammatory process is shown clinically as follows: a rise in body temperature, chills, agitation or alternatively weakness, and in extreme cases mental confusion, sometimes unconsciousness, headaches, general malaise, fatigue, a rapid pulse, extreme deviations in the blood picture, signs of liver and kidney function disorder, a reduction in the blood pressure and congestion in the pulmonary blood circulation. The above symptoms can either be pronounced or latent depending on the character, type, extent, location and spread of the inflammation as well as the organism's response to it.

In surgical infections the body temperature can rise to 40 °C and over, there occur recurrent chills and headache, the level of hemoglobin tends to decrease sharply as do the erythrocytes, leucocytes increase - in severe cases up to 25, 0-30, 0x10⁹/l. Plasma globulins increase while albumins decrease, there is loss of appetite and intestinal disorders, constipation, protein and cylinders appear in the urine. Intoxication that results leads to a distortion of the hemopoesis as a result of which the patient becomes anemic accompanied by marked changes in the white blood components: immature blood cells appear in the peripheral circulation, a shift of the leukocyte formula to the left is observed (a decrease in the mature and stab forms of neutrophils). A sharp increase in the erythrocyte sedimentation rate (ESR) occurs during the inflammatory process. It is notable that once it appeared at the onset of inflammation it tends to persist for a long time even after the inflammation is over. Sometimes the spleen and liver can enlarge, with yellowish sclera.

In hyperergic (excessive) reactions of the individual to the surgical infection, all the above-mentioned manifestations are further enhanced; in average or minimum reactions these signs can be either moderate or even latent. Yet any local inflammatory process is associated with general manifestations, which in the case of suppurative infections have features that are similar to sepsis and some other infectious diseases (typhoid, brucellosis, paratyphoid, tuberculosis etc.). Such patients therefore need to be thoroughly investigated, one of the most important aims being to establish the primary focus of infection, and the point of entry for the pyogenic microorganisms. When the general condition of a patient with a local infection is severe, one should bear in mind not only the possibility of an infectious disease but also try to establish by repeated blood cultures the presence or absence of bacteremia. The detection of bacteria in the blood in the absence of clinical improvement after surgical treatment of the focus of infection argues the presence of sepsis and not just the body's general response to the local suppurative process.

The main difference between sepsis and the organism's general reaction to the suppurative process is that in the case of the body's reaction all the symptoms sharply decline or disappear following incision of the locus of infection and proper drainage of its contents; whereas in the case of sepsis the symptoms change almost not at all. Determination of the extent of the patient's reaction to the local suppurative infection is essential for the correct assessment of the patient's general condition, the character of the inflammatory process and the prognosis of possible complications.

The clinical signs of endogenic intoxication are a function of its severity: the more pronounced the extent of intoxication, the more vividly it manifests itself. In mild intoxications the skin is pale, and in severe cases the skin is sallow; there is acrocyanosis, and the face is hyperemic. Pulse rate is fast -up to 100-110 beats per min, in severe conditions more than 130 per minute, blood pressure falls. The patient becomes dyspnoeic - breathing rate reaches 25-30 per min, and in severe intoxication more than 30 in a min. A change in the functions of the CNS is a vital feature of intoxication; from light euphoria at the beginning to depression or psychosis in the case of toxemia, in extreme cases of intoxication the patient can develop intoxication delirium. Assessment of diuresis plays a vital role in determining the severity of intoxication: there is a reduced output of urine in severe intoxications and in extreme cases acute renal failure can occur with associated oliguria and sometimes anuria.

The most important laboratory tests, which provide a clue to intoxication, are those that permit to assess the following: the increase of blood urea, necrotic, polypeptides, circulatory immune complexes, proteolytic activity of blood serum. Severe intoxication is also associated with anemia, a shift of the leukocyte formula to the left, the appearance of toxic granules in the blood cells and the development of hypoand disproteinemia.

Special methods of investigations are used to confirm the diagnosis of suppurative-inflammatory disease - puncture, roentgenography, endoscopic methods, clinical laboratory and biochemical analysis of blood, urine and exudates.

Microbiological analysis has the potential not only to isolate the causative agent, its pathogenic properties but also to determine the microorganism's sensitivity to the antibacterial preparations. An important role in the comprehensive treatment of suppurative-inflammatory disease is assigned to the assessment of the patient's immune status, in order to select the appropriate and tailored immune therapy.

The adequate and timely surgical treatment of trauma and acute surgical disease in combination with rational antibiotic therapy have contributed to reduced incidence of suppurative infections and led to a change in the classical outcome of suppurative infections.

These days when antibiotic therapy is widely used before the patient is admitted to the hospital, sometimes not even prescribed by a doctor, surgeons often have to deal with patients with advanced and critical forms of suppurative processes (purulent appendicitis, gall bladder empyema, peritonitis, purulent pleurisy, mastitis, phlegmon etc.) who present without high body temperature, with moderate leucocytosis, minimal changes in ESR and minimal intoxications.

The foregoing changes in the clinical pattern of suppurative processes especially in cases of hidden locus of infection in the abdominal cavity can make an accurate diagnosis more difficult. It is only through complex examination of patients with suppurative-inflammatory conditions that a correct diagnosis of the disease can be made and its nature and extent ascertained.

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