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Файл:Pathophysiology of breathing and cardiovascular pathology. Educational and methodological manual
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Topic 3. Pathophysiology of external respiration
Questions:
1. Highlight and justify syndromes, identify the presenter.
2. Please provide physical data that support the assumption of
the cause of pain in the patient.
3. Assign additional examinations. Specify the leading diag-
nostic method.
4. Formulate a preliminary diagnosis and specify diagnostic
criteria.
5. Specify MLP:
I. Alveolar ventilation disorder. Broncho-pulmonary, obstructive.
II. Diffusion disorder.
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. According to the complaints, the following syndromes were
identified: asthenic, pain, fever. Lead — pain in the right half of
the chest, which may be associated with pleural damage.
2. Lesion of the pleura, confirms the presence of noise (noise
of friction of the prevra), which is heard on inhalation and exhalation and is preserved during a sample with imitation of breathing.
3. The patient showed radiography of the lungs in the direct
and lateral projection, spirometry, CBC, consultation with a
phthisiatrician (to exclude the tuberculosis etiology of the pleura
lesion).
4. Dry right-sided pleurisy is the most likely diagnosis, since
the characteristic of the pain syndrome reflects the lesion of the
pleura, which is confirmed by the data of auscultation.
5. I. Alveolar ventilation disorder. Broncho-pulmonary form,
restrictive.
Clinical case №
4
Patient N., 67 years old, complained of coughing with yellow-
green sputum, fever to 38.7
°C, shortness of breath during exercise,
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Pathophysiology of breathing and cardiovascular pathology
pain in the right half of the chest that occurs with cough and deep
inhalation, sweating, general weakness and headache. I fell ill
acutely 3 days ago, after hypothermia. When contacting the polyclinic at the place of residence, the doctor prescribed the antibiotic
gentamicin at 80 mg intramuscularly (IM) 2 times a day, mucaltin
3 tablets per day, paracetamol. There was no significant positive
dynamics during treatment.
History: Former serviceman, currently working as a watchman. Smokes for 22 years, 1.5—2 packs of cigarettes per day. Periodically (several times a year), after hypothermia, he notes the
appearance of cough with the departure of yellow-green sputum,
over the past 2 years, shortness of breath has appeared with moderate physical activity.
Objectively: the condition is satisfactory, the skin is without
features, hyperemia of the facial skin is noted. Body temperature —
°C. Peripheral lymph nodes are not enlarged. respiratory rate
37.6
(RR) at rest — 22 per minute. The chest is emphysematous, during
examination — the lag of the right half of the chest during breathing. Percutorally, against the background of boxed sound, a blunting section is marked on the right below the corner of the blade, in
the same area — an increase in voice jitter. During auscultation
scattered dry whirring wheezing is heard, to the right below the
blade angle — crepitation zone. The tones of the heart are muted,
there are no noises. HR — 107 per minute, BP — 120/70 mm Hg.
Laboratory and instrumental data:
Complete blood count: RBC — 4.3
9
× 10
12.7
66
%, Lymphocytes — 23 %, Monocytes — 5 %, ER — 32 mm/h.
, Neutrophils band — 6 %, Neutrophils segmented —
12
× 10
, WBC —
General analysis of sputum: the character is mucopurulent,
white blood cells densely cover the field of vision; eosinophils,
Curchmann spirals, Charcot — Leiden crystals, BC — absent;
gram-positive diplococci are determined.
Chest X-ray in two projections: the area of infiltration of
pulmonary tissue in the lower lobe of the right lung, emphysema of
the lungs, enhancement of the pulmonary pattern due to the interstitial component are determined.
72
Topic 3. Pathophysiology of external respiration
Questions:
1. Highlight and justify the leading syndrome.
2. What is the preliminary diagnosis and what are the diagnos-
tic criteria?
3. What additional methods of examination are appropriate?
4. Formulate a clinical diagnosis and specify diagnostic criteria.
5. Specify MLP:
I. Alveolar ventilation disorder.
II. Diffusion disorder.
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. Pulmonary compaction syndrome.
2. At the first stage of the diagnostic search, the analysis of the
patient's complaints allows us to suspect an acute inflammatory
disease of the respiratory tract, most likely pneumonia.
3. External Respiratory Function (ERF) to assess bronchial patency.
4. Community-acquired pneumococcal right-sided lower lobe
pneumonia, moderate course.
5. I. Alveolar ventilation disorder. Bronchopulmonary, restrictive.
II. Diffusion disorder.
VI. Combination of pathogenetic factors.
Clinical case №
5
Patient I., 45 years old, was admitted to the admission department with complaints of cough with a small amount of viscous,
difficult to separate sputum, for shortness of breath during physical
activity.
Medical history: cough has been worrying for the past 7 years,
intensifying mainly after frequent SARS, antibiotics with a positive
73
Pathophysiology of breathing and cardiovascular pathology
effect were prescribed. Over the past 2 years, he began to note
shortness of breath with moderate physical activity. The patient
smokes from the age of 17 years, 1 pack of cigarettes per day. By
profession, a locksmith, work is associated with frequent hypothermia. Condition deteriorated within the last 3 days, cough increased with a small amount of mucopurulent sputum, subfebrile
body temperature appeared.
Objective: Moderate condition. Body temperature 37.5
°C.
Over the lungs with percussion — a box sound, with auscultation —
hard breathing, scattered dry buzzing and whistling wheezing. Respiratory rate (RR) — 22 per min. Pulse — 80 per min. BP —
130/80 mm Hg.
Laboratory and instrumental data:
Complete blood count: RBC — 4.5
9
× 10
12.9
%, ESR — 23 mm/h.
7
, Neutrophils 70 %, Lymphocytes — 23 %, Monocytes —
12
× 10
, WBC —
General analysis of sputum: white blood cells — 60—80 in
view, macrophages — plentiful, Curschmann spirals, Charcot —
Leyden crystals and eosinophils — not found, bacterial cells (BC)
and atypical cells were not found. Chest X-ray: there are no fresh
focal and infiltrative changes, pulmonary fields of increased transparency, bronchial walls are compacted, roots are dilated.
External Respiratory Function (ERF): Vital Capacity (VC) —
%, FEV1 — 64 %, Cardiac output (CO) 25—53 %, CO 50—49 %,
57
CO 75—58
%, CO 25—56 %, CO 50—54 %, CO 75—62 %.
68
%; after berotek inhalation: VC — 60 %, FEV1 —
Questions:
1. Highlight and justify syndromes, identify the presenter.
2. Describe the mechanism of complaints.
3. Formulate a preliminary diagnosis and specify diagnostic
criteria.
4. Formulate a clinical diagnosis and specify diagnostic criteria.
5. Specify MLP:
I. Alveolar ventilation disorder.
II. Diffusion disorder.
74
Topic 3. Pathophysiology of external respiration
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. Pulmonary airiness syndrome (emphysema syndrome), bronchial obstruction syndrome, respiratory failure syndrome. Leading
syndrome — bronchial obstruction.
2. These complaints are associated with bronchospasm, mucus
hypersecretion and inflammatory edema of the bronchial mucosa.
3. Preliminary diagnosis: chronic obstructive pulmonary disease. Diagnosis can be made based on complaints, history, objective data.
4. Clinical diagnosis: Obstructive pulmonary disease, moderate
course, in the exacerbation phase. Respiratory failure of the II century. The diagnosis can be made on the basis of complaints, history, objective data, data from additional examination methods.
5.
I. Alveolar ventilation disorder.
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
VI. Combination of pathogenetic factors.
Clinical case №
6
Patient L., 38 years old, was admitted to the clinic with complaints of an attack-like cough with intractable viscous sputum mucosa (single spitting), suffocation attacks with difficulty exhaling,
which occur daily during the day and at night, shortness of breath
with minor physical exertion, nasal congestion.
Medical history: The patient's sister suffers from polypous
rhinosinusitis, the patient's mother has a food allergy in the form of
urticaria. The patient works as a knitter at a textile enterprise, has
constant contact with wool. Over the past years, he has noted fre-
75
Pathophysiology of breathing and cardiovascular pathology
quent ARVI — 2—3 times a year. History of allergic reactions to
ampicillin — nasal congestion, lacrimation; citrus fruits and strawberries are urticaria. For many years, almost constant nasal congestion has worried, polypous rhinosinusitis was diagnosed 2 years
ago, a nasal polypectomy was carried out. The condition worsened
in the spring when an euphyllinum-induced choking attack first
developed. The last deterioration after ARVI, the frequency of suffocation attacks in the daytime sharply increased, night attacks appeared.
Objectively: the condition is relatively satisfactory, the heart
rate is 22 per minute, eczematous plaques are on the skin of the
hands. Nasal breathing is dramatically difficult. With percussion of
the lungs — a boxed sound, with auscultation, a large number of
dry whistling and buzzing wheezes are heard over the entire surface of the lungs. HR 96 per min BP 110/70 mm Hg.
Laboratory and instrumental data:
Complete blood count: RBC — 4.5
12.9
63
9
× 10
, Eosinophils — 7 %, Neutrophils — 3 %, Neutrophils —
%, Lymphocytes — 20 %, Monocytes —7 %, ESR — 10 mm/h.
12
× 10
, WBC —
General analysis of sputum: viscous consistency, mucous
character, white blood cells 1—5 in view; eosinophils 20—40—60
in view; there are no red blood cells; Curschmann spirals — 1—3
in the preparation, Charcot — Leyden crystals — 5—7 in the preparation; atypical cells, elastic fibers, BC were not found.
ERF: Vital Capacity (VC) — 84
output (CO) 25—66
%, CO 50—42 %, CO 75—38 %; After inhala-
tion, 400 μg of salbutamol: FEV1 — 84
50—59
%, CO 75—58 %.
%, FEV1 — 55 %, Cardiac
%, CO 25—68 %, CO
Chest X-ray: no focal and infiltrative changes were detected, a
flattening of the diaphragm dome, an increase in the airiness of the
lung tissue, and thickening of the bronchial walls were determined.
Questions:
1. Highlight and justify syndromes, identify the presenter.
2. Describe the mechanism of complaints.
76
Topic 3. Pathophysiology of external respiration
3. Determine the type of respiratory impairment.
4. Formulate a preliminary diagnosis and specify diagnostic
criteria.
5. Formulate a clinical diagnosis and specify diagnostic criteria.
6. Specify MLP:
I. Alveolar ventilation disorder.
II. Diffusion disorder.
III. perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. Pulmonary airiness syndrome (emphysema syndrome), bronchial obstruction syndrome, respiratory failure syndrome. Leading
syndrome — bronchial obstruction.
2. These complaints are associated with bronchospasm, mucus
hypersecretion and inflammatory edema of the bronchial mucosa.
3. Obstructive type of impaired respiratory function.
4. Preliminary diagnosis: Bronchial asthma. Diagnosis can be
made based on complaints, history, objective data.
5. Bronchial asthma, severe course, in the exacerbation phase.
Pulmonary emphysema. Respiratory failure of stage II.
6.
I. Alveolar ventilation disorder.
III. Perfusion disorder. Blood bypass.
VI. Combination of pathogenetic factors.
Clinical case №
7
Patient V., 33 years old, went to the reception department with
complaints of an increase in body temperature to 38.5
°C, shortness
of breath of a mixed nature during physical exertion, dry cough,
intense pain in the right half of the chest, worsening during breathing and coughing.
77
Pathophysiology of breathing and cardiovascular pathology
History: I fell ill an acute week ago, when my body tempera-
ture suddenly rose to 39.0
°C, headache appeared, dry cough. Self-
administered antipyretics without significant effect. On the third
day of the disease, a runny nose appeared, slight pain when swallowing. After 5 days of the disease, the temperature dropped to
38.5
°C, pain appeared in the right half of the chest during breath-
ing and coughing.
Objective: moderate condition. There is a slight lag in the right
half of the chest during breathing. Severe breathing in the lungs,
intense "scraping" noise on inhalation and exhalation is heard over the
lower parts of the right lung. RR 20 per minute BP 110/70 mm Hg.
Heart rate 120 bpm, the rhythm is correct.
Laboratory and instrumental data:
Complete blood count: RBC — 4.2
13.9
phils segment — 28
9
× 10
, Eosinophils — 1 %, Neutrophils band — 3 %, Neutro-
%, Lymphocytes — 61 %, Monocytes — 8 %,
12
× 10
, WBC —
ESR — 28 mm/h.
Chest X-ray: no fresh focal and infiltrative changes were detected.
Questions:
1. Highlight and justify syndromes, identify the presenter.
2. Describe the mechanism of complaints.
3. Formulate a preliminary diagnosis.
4. Give justification for the preliminary diagnosis.
5. Specify MLP:
I. Alveolar ventilation disorder. Bronchial, restrictive type.
II. Diffusion disorder.
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. Pleural lesion syndrome, inflammatory syndrome, leading —
pleural lesion syndrome.
78
Topic 3. Pathophysiology of external respiration
2. The symptom of pain is associated with the development of
pleural inflammation and with irritation when breathing nerve receptors of pleural leaves.
3. Acute right-sided dry pleurisy of viral etiology.
4. Inflammatory syndrome (fever, signs of intoxication) and
signs of respiratory damage (cough, chest pain associated with
cough and breathing), acute onset, pain syndrome clearly associated with breathing, pleural friction noise during auscultation, lag of
half of the chest during breathing may indicate the development of
dry pleurisy, viral etiology is evidenced by high levels of lymphocytes in the CBC, the absence of fresh foci and infiltrative foci on
the radiograph.
5.
I. Alveolar ventilation disorder. Restrictive type.
III. perfusion disorder. Blood bypass.
VI. Combination of pathogenetic factors.
Clinical case №
8
Sick D., 27 years old, a painter by profession, entered the admission department with complaints of a sharp difficulty in breathing, mainly exhalation, cough with a viscous vitreous sputum department, more often in the early morning hours.
History: The patient's sister suffers from allergic dermatitis.
The patient's son (3 years old) suffers from exudative diathesis.
The patient smokes 1 pack of cigarettes a day for 10 years. A history of allergic reaction in the form of Quincke's edema to lidocaine,
food allergy — urticaria when eating citrus fruits. The deterioration
of the condition during the week when a cough with difficult to
separate viscous sputum appeared after ARVI, the patient independently began to take amoxicillin. On the 2nd day of the drug
administration at night, a choking attack was developed, which was
stopped by the emergency medical care team with intravenous administration of prednisolone and euphyllinum. Since that time, is
worried about a sharp difficulty in breathing, mainly exhalation, an
attack-like cough remains.
79
Pathophysiology of breathing and cardiovascular pathology
Objective: moderate condition. Remote whistling wheezing.
The chest is barrel-shaped. RR 24 in min. Percutaneous sound over
pulmonary fields boxed. In the lungs, breathing is sharply weakened, a large number of dry whistling wheezes are heard over the
entire surface of the lungs. Heart tones rhythmic, heart rate 100 per
minute, BP 120/80 mm Hg,
Laboratory and instrumental data:
Complete blood count:
RBC — 4.5
P/YA. Neutrophils band — 2
Lymphocytes — 17
12
× 10
, WBC — 8.6 × 109, Eosinophils — 11 %,
%, Neutrophils segment — 62 %,
%, Monocytes — 8 %, ESR — 10 mm/h.
General analysis of sputum: mucous character, viscous consistency, lake. 5—10 in view, eosinophils 50—60 in the preparation. Curschmann spirals, Charcot — Leyden crystals — single in
the preparation. Elastic fibers, atypical cells, BC were not found.
X-ray examination of the lungs: no fresh focal and infiltrative
changes were detected. There is a flattening of the diaphragm dome,
an increase in the airiness of the lung tissue.
ERF: Vital Capacity (VC) — 87
output (CO) 25—68
%, CO 50—54 %, CO 75—24 %; FEV1/ For-
ced Vital Capacity (FVC) — 82
%, FEV1 — 53 %, Cardiac
%.
Questions:
1. Highlight and justify syndromes, identify the presenter.
2. Determine the type of respiratory impairment.
3. Perform a diagnostic search.
4. Formulate a clinical diagnosis and specify diagnostic criteria.
5. Specify MLP:
I. Alveolar ventilation disorder.
II. Diffusion disorder.
III. Perfusion disorder. Blood bypass.
IV. Disorders of ventilation-perfusion ratio.
V. Dysregulation of respiration.
VI. Combination of pathogenetic factors.
Answer:
1. Pulmonary airiness syndrome (emphysema syndrome), bronchial obstruction syndrome, respiratory failure syndrome. Leading
syndrome — bronchial obstruction.
80
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