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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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Basic (mandatory) diagnostic examinations carried out at the out-
patient level:
y Biochemical blood tests (creatinine, total protein, albumin, ALT,
AST, total and direct bilirubin, total cholesterol);
y determination of the glomerular ltration rate;
y determination of anti-double-stranded DNA, C3-C4
complement components;
y Cardiolipin antigen for microprecipitation reaction;
y Chest X-ray or uorography;
y ECG
Additional diagnostic examinations carried out on an outpa-
tient basis:
y Echocardiography (with heart damage);
y Coagulation tests (prothrombin index, brinogen, ethanol test);
y Ultrasound of the abdominal organs, ultrasound of the kidneys;
y Determination of the level of potassium, sodium, determination of
total alpha-amylase in serum;
y ELISA (determination of antigen and antibodies to hepatitis B and
C viruses);
y ELISA (determination of total antibodies to human
immunodeciency virus);
y X-ray densitometry of the spine and proximal femur (central or
axial DEXA densitometry);
y determination of lupus anticoagulant (LA1 / LA2) in blood plasma;
y etermination of antibodies to β2-glycoprotein I in blood serum by
ELISA method.
3. What is the patient’s management?
Non-drug treatment:
y Educational program: knowledge and skills of self-control of
the disease;
y Exclusion of psycho-emotional stress, stress management skills;
y Reduction of exposure to the sun, protective equipment from
ultraviolet rays;
y Active screening and treatment of concomitant, including
infectious, diseases;
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y During an exacerbation of the disease and when taking cytotoxic
drugs - eective contraception for safe oral contraceptives. Oral
contraceptives with a high estrogen content should not be taken as
they may worsen SLE;
y For the prevention of osteoporosis - smoking cessation, eating
foods high in calcium and vitamin D; physical exercises;
y or the prevention of atherosclerosis, diabetes: a diet low in fat and
cholesterol, smoking cessation, body weight control, exercise;
y Anticipate the risk of thrombosis and the need for
anticoagulant therapy.
Medication. The choice of treatment for SLE is based on an indi-
vidual approach;
y depends on clinical manifestations, involvement of organs and
systems, the severity of the disease;
y all patients with SLE should receive antimalarial drugs, unless they
are contraindicated;
y glucocorticosteroids and cytotoxic / Immunosuppressive drugs
(methotrexate, azathioprine, cyclophosphamide, mycophenolate
mofetil) are used to treat more severe manifestations with
signicant organ involvement.
Standard therapy. Antimalarial drugs - chloroquine and hydroxy-
chloroquine, in combination with NSAIDs - are the drugs of choice
for moderate SLE. The most eective for constitutional symptoms
(fatigue, fever), for complaints of musculoskeletal, skin manifesta-
tions, moderate pleurisy complaints. Reduces SLE activity by> 50%
in both pregnant and non-pregnant patients, leading to> 50% reduc-
tion in mortality.
It is necessary to see an ophthalmologist before starting treat-
ment, and then every 6-12 months of treatment. Dosage: hydroxychlo-
roquine - 200 mg orally 2 times a day, for 3 months and then 200 mg
daily. The maintenance dose should not exceed 6 mg / kg / day. Stop
taking the drug if central scotoma is found at any stage of the dis-
ease. NSAIDs - in standard therapeutic doses, are generally eective
for relieving the minimal symptoms of SLE - arthralgia, complaints
of musculoskeletal pain, fever, headache, moderate complaints with
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serositis. In patients with antiphospholipid syndrome (APS), caution
is required when using COX-2 inhibitors (nimesulide, celecoxib, etc.),
since they can contribute to the development of thrombosis in patients
with a tendency to hypercoagulability.
4. Medical and labor expertise. Dispensary observation.
Temporary disability criteria: acute and subacute course of dif-
fuse connective tissue disease, active phase in the chronic course of
the disease, complications. The duration depends on the nature of the
course, the degree of activity, the severity of visceral lesions, insuf-
ciency of the functions of internal organs and systems, the eec-
tiveness of treatment, on average 2-3 months, including: SLE, acute
course II-III degree of activity 60-90 days, subacute the course of the
I – III degree of activity is 45–55 days, the chronic course of the I – II
degree of activity is 35–50 days; Systemic scleroderma, acute course
II – III degree of activity 55–75 days, subacute course I – III degree
of activity 30–40 days, chronic course (exacerbation) I – III degree of
activity 30–45 days.
Contraindicated types and working conditions: work associated
with signicant physical stress, the prescribed pace, forced position
of the body, during the night shift; mental work with pronounced
psycho-emotional stress; work associated with exposure to insolation,
cooling, vibration, temperature uctuations in the workplace, dust and
gas pollution, toxic chemical agents (arsenic, acid, alkali, etc.), radia-
tion, allergens.
Permanent disability
III group of disability is dened by patients with diuse connec-
tive tissue diseases with a limitation of the ability to self-service, move-
ment, labor activity, I degree. due to moderate dysfunctions of internal
organs, joints, nervous system, persisting against the background of
supportive therapy in the case of a chronic, slowly progressive course
of diseases of this group in persons working in contraindicated types
and conditions of physical and mental labor and who need to be trans-
ferred to work on another, available professions of lower qualica-
tions or a signicant decrease in the volume of work performed.
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Disability group II is dened by patients with diuse connective
tissue diseases with limited ability to self-service, movement, and
work activity of the II degree due to the generalization of the process,
pronounced dysfunctions of internal organs, joints, nervous system
in cases of acute and subacute, as well as chronic progressive course
with frequent relapses, medium or high activity of the process and
insucient eectiveness of conservative therapy. Patients in periods
of relative remission in some cases can perform work at home or in
specially created working conditions.
Disability group I is dened by patients with diuse connective
tissue diseases with limited ability to self-service, movement, work
activity of the III degree due to the generalization of the process and
pronounced disorders of the kidneys, cardiovascular system, joints,
digestive and respiratory systems, central and peripheral nervous sys-
tems. Patients in such cases require constant outside care.
Clinical case No. 5
1. What is the preliminary diagnosis?
Hemorrhagic vasculitis with skin-hemorrhagic, articular, renal
and abdominal syndrome. Complication: gastrointestinal bleeding.
2. What additional tests would you recommend to the patient,
and what are the expected results?
The following examinations are considered the main methods for
diagnosing hemorrhagic vasculitis:
y Coagulation tests: bleeding time, blood coagulation rate,
platelet count.
y Identication of circulating immune complexes (CICs).
y Determination of immunoglobulins of classes A (increased) and
G (decreased).
y Biochemical analysis (protein fractions, CRP, antistreptolysin O).
y General (detailed) blood test with the calculation of the absolute
values of the indicators of the leukocyte formula.
y ECG
y Fibro gastroduodenoscopy,
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y Consultation with an ophthalmologist and neurologist.
3. What is the patient’s management?
Treatment of hemorrhagic vasculitis is carried out in a compre-
hensive manner, taking into account the patient’s age, the degree of the
disease and other characteristics of the patient’s body.
Hypoallergenic diet;
Enterosorbents - prevent the absorption of harmful substances
into the intestinal walls;
Antiplatelet agents- prevents the formation of blood clots, im-
proves blood circulation through small vessels;
Antihistamines - prevent the development of allergies;
Infusion therapy - intravenous administration of drugs to cleanse
the body of harmful substances;
Broad-spectrum antibacterial therapy;
Glucocorticosteroids - synthetic analogs of the hormones of the
human adrenal cortex;
Non-steroidal anti-inammatory drugs - have analgesic, anti-
pyretic, anti-inammatory properties;
Membrane stabilizing drugs - vitamins that restore the cell mem-
brane, allow them to be provided with useful substances;
Cytostatic drugs - suppress the growth of tumor-like processes,
activate the immune system;
Plasmapheresis is a procedure to remove harmful substances from
the blood. It is carried out using special devices;
Symptomatic treatment - aimed at eliminating the symptoms
caused by hemorrhagic vasculitis;
Antacids - reduce the acidity of gastric juice, reduce the risk of
damage to the gastric mucosa by glucocorticoid drugs;
Antispasmodics - reduce pain that occurs as a result of muscle
spasms in the periarticular tissues.
4. Medical and labor expertise. Dispensary observation.
Disability criteria: recurrent forms with visceral complications,
if the duration of the disease is more than 6 months. Examination of
temporary disability. During the period of exacerbation, patients are
disabled until complete relief of articular and abdominal syndromes,
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in the absence of fresh hemorrhagic rashes - within 7-10 days. Average
terms of temporary disability: with skin form - 21 days, with skin and
articular - 28 days, with abdominal - 40 days.
Medical and social expertise. Indications for referral to the medi-
cal and social expert commission: skin-articular form of hemorrhagic
vasculitis, causing dysfunction of the joints of the 2-3rd degree; ab-
dominal form of hemorrhagic vasculitis with frequent exacerbations.
Dispensary observation. Frequency of examinations by special-
ists: pediatrician - once every 1-2 months, hematologist - once every
2 months, dentist and otolaryngologist - once every 6 months.
When examining a family doctor need to pay attention to the pres-
ence of a hemorrhagic rash, pain in the joints, abdomen, condition of
internal organs, sinuses, tonsils, teeth, discoloration of stools (black),
urine (hematuria). Additional studies: general blood test - 2 times
a year, general urine analysis - at least 1 time per quarter and after each
acute respiratory disease, feces analysis for eggs of worms, protozoa,
and occult blood; coagulation tests - as indicated. Duration of observa-
tion is 5 years. If there are no exacerbations, the child is removed from
the register. Preventive vaccinations: contraindicated within 2 months.
Clinical case No. 6
1. What is the preliminary diagnosis?
Secondary infective endocarditis in the presence of congenital
heart disease: ventricular septal defect. Insuciency of the aortic
valve of the 2nd degree. Chronic heart failure III (NYHA).
2. What additional tests would you recommend to the patient,
and what are the expected results?
General blood analysis, general urine analysis, ECG, blood test
for sterility, blood culture and antibiotic sensitivity, chest X-ray, ultra-
sound of internal organs.
3. What is the patient’s management?
Successful treatment of infective endocarditis is based on the
eradication of microbes with antimicrobial drugs. Surgery contributes
to the removal of infected material and drainage of abscesses. The
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intrinsic defenses have little eect, which explains the greater eec-
tiveness of bactericidal modes in comparison with bacteriostatic ones,
both in experiments in animals and in humans.
Antibiotic therapy caused by streptococci:
Standard treatment: 4 weeks. Penicillin G or Amoxicillin or Cef-
triaxone 12-18 million IU per day IV in 4-6 injections, or infusion of
100-200 mg / kg / day IV in 4-6 injections 2 g / day IV or IV m once
a day.
Standard treatment: 2 weeks. Penicillin G or Amoxicillin or Cef-
triaxone + Gentamicin, or Vancomycin 12-18 million units / day IV in
4-6 injections, or infusion of 100-200 mg / kg / day IV in 4-6 injec-
tions 2 g / day IV or IM once a day 3 mg / kg / day IV or IM in one
administration 4-5 mg / kg / day IV in one administration.
Surgery. The two main goals of surgery are complete removal of
infected tissue and reconstruction of cardiac morphology, including
repair or replacement of diseased valves.
4. Medical and labor expertise. Dispensary observation.
Temporary disability. Acute infective endocarditis - 60–80 days.
Subacute infective endocarditis - 90–120 days, in case of compli-
cations - registration of disability through a medical and social ex-
pert commission.
Permanent disability. Usually, the ratios of the functional class of
HF and disability groups are as follows: With HF FC I according to
NYHA, disability is usually not established.
With HF FC II according to NYHA, it is usually the 3rd group
of disability.
With HF FC III according to NYHA - usually the 2nd group of
disability.
With HF FC IV according to NYHA - 1st disability group.
Dispensary observation of patients with infective endocarditis is
ideal - 1, 3, 6 and 12 months after discharge. Within six months after
discharge from the hospital, monthly monitoring of the condition is
recommended - the presence of infection (including blood cultures
when indicated), the functional state of the valves and clinical and
instrumental manifestations of heart failure (with the progression of
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symptoms - consultation of a cardiac surgeon), monitoring of the side
eects of antibiotic therapy. In the future, the condition is monitored
once every 6 months. It is imperative to teach the patient about pre-
ventive measures, since patients who have undergone infective endo-
carditis are at a high risk of recurrence of the disease.
Rehabilitation of patients is aimed at restoring the optimal func-
tional ability of the body, mobilizing compensatory mechanisms,
eliminating the consequences of surgical intervention, preventing re-
invasion of infection, and it is also recommended to conduct a course
of antibiotic therapy (6–8 weeks). The period of rehabilitation, with
the possibility of resuming work, is at least 2 months.
Clinical case No. 7
1. What is the preliminary diagnosis? Chronic rheumatic heart
disease: moderate carditis, mitral valve insuciency, arrhythmias like
ventricular premature beats. Chronic heart failure FC III (NYHA)
2. What additional tests would you recommend to the patient,
and what are the expected results?
Laboratory research.
y General blood analyses: increased ESR and positive CRP;
y bacteriological examination: detection in a smear from the pharynx,
beta hemolytic streptococcus of group A (can be both with active
infection and with carriage);
y serological test: increased or (more importantly) increasing in
dynamics titers of antistreptolysin-O.
Instrumental research.
1. ECG: clarication of the nature of heart rhythm and conduction
disorders (with concomitant myocarditis), Holter ECG monitoring.
2. Chest X-ray
3. What is the patient’s management?
1st stage - inpatient treatment.
2nd stage - follow-up treatment in a local cardio-rheumatolo-
gy sanatorium.
3rd stage - dispensary observation in the polyclinic.
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List of essential medicines:
Antibiotic therapy
1. Amoxicillin / clavulanic acid 625 mg tablets.
2. Cefuroxime 250 mg tablets.
3. Cexime 400 mg capsules.
4. Lincomycin 250 mg tablets.
5. Azithromycin 500 mg tablets.
Non-steroidal anti-inammatory drugs (diclofenac 2.5% 3 ml, di-
clofenac 50 mg tablets, aceclofenac, nimesulide).
Glucocorticoids: Prednisolone.
List of additional medicines.
Diuretic therapy:
1. Furosemide 40 mg tablets.
2. Torasemide 5 mg, 10 mg tablets
3. Indapamide 2.5 mg capsules.
4. Hypothiazide 100 mg tablets.
5. Spironolactone 25 mg, 50 mg tablets.
Antihypertensive drugs:
1. Amlodipine 5 mg, 10 mg tablets.
2. Metoprolol 50 mg tablets.
3. Cardiac glycosides: Digoxin 25 mg tablets.
Antibiotic therapy: Benzyl penicillin is used for 10 days in adults
and adolescents, 500 thousand - 1 million IU 4 times a day IM, in
children 100 thousand - 150 thousand IU 4 times a day IM for 10
days. In the future, they switch to the use of prolonged-release benzyl
penicillin in the secondary prophylaxis regimen. In case of intolerance
to benzyl penicillin, macrolides are used.
Anti-inammatory therapy: Glucocorticoids are used for acute
rheumatic fever with severe carditis and / or polyserositis. Predniso-
lone is prescribed for adults and adolescents at a dose of 20 mg / day,
for children - 0.7-0.8 mg / kg in 1 dose in the morning after meals until
a therapeutic eect is achieved (on average, within 2 weeks). Then the
dose is gradually reduced (by 2.5 mg every 5-7 days) until complete
cancellation. The total duration of the course is 1.5–2 months.
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4. Medical and labor expertise. Dispensary observation.
Temporary disability
Temporary disability: rheumatic fever - 3 months or more, de-
pending on the degree of activity, the severity of carditis and other
manifestations, the nature of the course, complications. In rheumat-
ic heart diseases, temporary disability is established for the treat-
ment of heart failure, rhythm disturbances for a period of 3 weeks to
1.5 months, surgical correction - mitral commissurotomy, prosthetics
of heart valves - 4 months or more.
Contraindicated types and working conditions: work associated
with signicant physical and psycho-emotional stress, exposure to
unfavorable microclimatic conditions, the prescribed pace, staying at
a height, driving vehicles, business trips.
Permanent disability
Disability criteria: rheumatic fever, taking into account the activ-
ity, the nature of the course, the severity of carditis, damage to other
organs and systems; the stage of the defect, the severity of pulmo-
nary hypertension, the stage of heart failure, heart rhythm disturbanc-
es, complications.
III group of disability is dened by patients with a prolonged or
subacute course of rheumatic fever of I degree of activity, the pres-
ence of II-III degree of mitral or aortic valve defect, in which there is
passive pulmonary hypertension and heart failure of II FC according
to NYHA, secondary coronary syndrome FC II, corresponding to the
severity of angina pectoris, mild or moderate cardiac arrhythmias; re-
duction of the ejection fraction to 45%, regurgitation of the II degree,
according to echocardiography. The recognized invalids of the III
group may be recommended to work with mild physical and moderate
psycho-emotional stress in favorable working conditions.
II group of disability is dened in patients with rheumatic fever
with high activity of a protracted or continuously recurrent course, se-
vere damage to the myocardium, central nervous system; the presence
of III-IV stages of mitral or aortic valve defect with the development
of active pulmonary hypertension and heart failure FC III according to
NYHA, secondary coronary syndrome corresponding to the severity
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