Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
.pdf
11
breath with little physical exertion, pain in the right half of the chest of
a nagging nature, increasing with coughing and deep breathing, gen-
eral weakness, loss of appetite.
It is known from the anamnesis: a week ago he fell ill with a viral
infection after swimming in a mountain river. Despite outpatient treat-
ment with ibufen and ingavirin, the condition did not improve. Last
night, a new rise in temperature was noted and the complaints listed
above appeared.
On objective examination: general condition of moderate sever-
ity. Satisfactory nutrition. The skin of the body is of ordinary color,
clean, high humidity. Mild diuse cyanosis of the face. Subcutaneous
fat has a homogeneous consistency, there is no peripheral edema. Hair
and nails are not changed. The thyroid gland is not visually deter-
mined, with palpation of a soft consistency, painless. Peripheral lymph
nodes are not enlarged. The muscular system is developed satisfacto-
rily. The joints are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation, the heart tones a little bit dull, rhythm
is regular, no murmurs. BP 120/75 mm Hg. HR - 96 bpm. Shortness
of breath at rest. The examination of the respiratory system revealed
an increase in vocal tremor and dulling of percussion sound in a 6 cm
2
area of the corner of the right shoulder blade. The breathing here is
hard, dry whistling and moist small-bubbly sonorous wheezes are
heard. The abdomen is soft, painless. Liver at the edge of the cos-
tal arch.
Complete Blood Count: RBC – 4,5х10
12
/L, Нb –125 g/L, MCH –
30 pg/cell, WBC – 12,0х10
9
/L, neutrophils bands – 8%, neutrophils
segments – 52%, lymphocytes – 32%, monocytes – 8%, eosinophil –
1%, PLT – 240,0х10
9
/L, ESR – 30 mm/h.
t.me/medicina_free
12
Sputum analysis: yellowish, mucopurulent, viscous, odorless, at
epithelium - 2-3 in n/a, ciliated epithelium - 4-6 in n/a, alveolar —
5-7 in n/a, leukocytes — 80-100 in n/ a, atypical cells and CB were not
detected, Gr +coccal ora. Bacteriological analysis of sputum - pneu-
mococcal ora sensitive to benzylpenicillin, cephalosporins, erythro-
mycin, lincomycin was sown.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 4
Patient N, 55 years old, SMM manager, went to the polyclinic to
the family doctor with complaints of cough with sputum, the presence
of blood veins, pain in the right side when inhaling, increased sweat-
ing, weakness, an increase in body temperature to 37.7°C. It is known
from the anamnesis that the patient suered focal pulmonary tuber-
culosis 12 years ago, was observed by a phthisiologist for 2 years,
then was removed from the register. Heredity is not burdened. Since
childhood, have often been ill with viral infections more than 4 times
a year.
On objective examination. The general condition is satisfactory.
Consciousness is clear. The position is active. Satisfactory nutrition.
The skin is of normal color, clean, normal humidity. Subcutaneous fat
has a homogeneous consistency, there is no peripheral edema. Hair
and nails are not changed. The thyroid gland is not visually deter-
mined, with palpation of a soft consistency, painless. Peripheral lymph
nodes are not enlarged. The muscular system is developed satisfacto-
rily. The joints are not externally changed.
t.me/medicina_free
13
The cardiovascular system. Apical beat is located in the V inter-
costal space 1.5 cm inward from the left mid-clavicular line. With per-
cussion, the boundaries of relative cardiac dullness are within normal
limits. During auscultation, the heart tones are clear, rhythm is regular,
no murmurs. BP 125/75 mm Hg.
The respiratory system. On examination, normal shape of the
chest, symmetrical. With comparative percussion over the entire sur-
face of the lungs, the pulmonary sound is determined, the boundaries
of the lungs are within the normal range. BR - 24 in 1 min. During
auscultation, hard breathing is heard in both lungs, single dry wheezes
and small bubbly wheezes in the interscapular space after coughing.
On palpation, the abdomen is soft, painless. The percussive
boundaries of the liver are within normal limits. The gallbladder is
not palpable, palpation in its projection is painless. Stool and diuresis
are normal.
MBT was not detected in sputum by bacterioscopy.
Complete Blood Count: RBC – 4,8х10
12
/L, Нb –142 g/L, MCH –
27 pg/cell, WBC – 9,2 х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 78%, lymphocytes – 12%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 25 mm/h.
X-ray picture: presence of polymorphic foci in both lungs
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 5
Patient N, 27 years old, cosmetologist, turned to the family doc-
tor at the polyclinic. It is known from the anamnesis: two weeks ago,
after working in the garden appear weakness, sweating, subfebrile
t.me/medicina_free
14
temperature, shortness of breath, chest pain on the left appeared. She
was treated with the diagnosis: “Acute respiratory viral infection”
without eect. Shortness of breath increased, body temperature in-
creased to 390C. At the same time, the patient notes that the chest
pains on the left have decreased.
On objective examination. The general condition is satisfactory.
Consciousness is clear. The position is active. The skin is of normal
color, clean, normal humidity. Subcutaneous fat has a homogeneous
consistency, there is no peripheral edema. Hair and nails are not
changed. The thyroid gland is not visually determined, with palpa-
tion of a soft consistency, painless. Peripheral lymph nodes are not
enlarged. The muscular system is developed satisfactorily. The joints
are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation, the heart tones are clear, rhythm is
regular, no murmurs. BP 120/70 mm Hg.
The respiratory system. The left half of the chest lags behind in
the act of breathing. Dullness is determined to the left below the IV
rib during lung percussion. Breathing in this area is not listened to.
BR - 25 in 1 min.
On palpation, the abdomen is soft, painless. Percussion boundar-
ies of the liver are normal. The gallbladder is not palpable, palpation in
its projection is painless. Defecation and diuresis are normal.
Complete Blood Count: RBC – 4,2х10
12
/L, Нb –140 g/L, MCH –
27 pg/cell, WBC – 12,0х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 80%, lymphocytes – 20%, monocytes – 6%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 38 mm/h.
MBT was not detected in sputum.
Questions:
1. What is the preliminary diagnosis?
t.me/medicina_free
15
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 6
Patient N, 65 years old, a private entrepreneur, turned to the fam-
ily doctor at the polyclinic with complaints of fever up to 38°C, weak-
ness, sore throat. The doctor diagnosed “Acute respiratory viral infec-
tion”, prescribed treatment with antiviral, antihistamines, as well as
rinsing the throat with chamomile decoction, calendula tincture. Three
weeks later, the patient re-applied to the polyclinic, since after a viral
infection, he has a subfebrile temperature, weakness, loss of strength,
cough with scant sputum, shortness of breath at rest.
On objective examination. The general condition is satisfactory.
Consciousness is clear. The position is active. Reduced nutrition. The
skin is of normal color, clean, normal humidity. Subcutaneous fat has
a homogeneous consistency. Hair and nails are not changed. The thy-
roid gland is not visually determined, with palpation of a soft consis-
tency, painless. Peripheral lymph nodes are not enlarged. The mus-
cular system is developed satisfactorily. The joints are not externally
changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation, the heart tones are clear, rhythm is
regular, no murmurs. BP 110/70 mm Hg.
The respiratory system. With auscultation of the lungs, weakened
breathing is heard on the right in the upper part of the lung. BR - 25
in 1 min.
On palpation, the abdomen is soft, painless. The percussive
boundaries of the liver are within normal limits. The gallbladder is
not palpable, palpation in its projection is painless. Defecation and
diuresis are normal.
t.me/medicina_free
16
Complete Blood Count: RBC – 4,1х10
12
/L, Нb –112 g/L, MCH –
27 pg/cell, WBC – 3,8х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 40 mm/h.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 7
Patient N, 57 years old, a policeman, turned to a family doctor
with complaints of increased expiratory dyspnea with minor physical
exertion (washing, dressing), accompanied by whistling in the chest;
paroxysmal cough with an increase in sputum up to 20 ml per day in
the morning, an increase in temperature to 37.8 ° C.
It is known from the anamnesis: dry cough for the last 20 years.
Over the past 10 years, he have been noticing expiratory shortness
of breath with accelerated walking, climbing to the 2nd oor. Over
the past year, shortness of breath has sharply intensied and began
to bother with normal exercise, conversation, thick, scanty sputum of
yellow-green color appeared. Exacerbations 2 times over the past year.
Deterioration within 2 weeks: the temperature rose to 37.8 ° C, cough
intensied, purulent sputum appeared, its volume increased, expira-
tory dyspnea intensied. He took Ampicillin 250 mg 3 times a day at
home, Berodual 2 breaths 4 times a day without improvement. Than
he turned to the emergency room of the city hospital.
Anamnesis of life: smokes for 30 years for 1.5 packs a day, con-
sumes 200 ml of vodka 1 time a month. Works as a foreman at a con-
struction site. Relatives have no respiratory diseases. There is no al-
lergic predisposition in anamnesis.
t.me/medicina_free
17
On objective examination: the skin is moist, diuse cyanosis. The
temperature is 37.5 °C. Height - 172 cm, weight - 60 kg. The thorax
is enlarged in anteroposterior size, smoothness of the supra- and sub-
clavian pits, the epigastric angle is obtuse. Percussion sound is boxed.
The mobility of the lower pulmonary margin along the middle axillary
line is 2.5 cm. During auscultation – weakened vesicular breathing,
scattered dry wheezing on both sides. BR – 24 per minute. The heart
tones are muted, the rhythm is correct. HR - 100 beats per minute.
BP is 120/72 mm Hg. The abdomen is soft, painless. The size of the
liver according to Kurlov is 10 ×9 × 8 cm. There is no swelling. Ac-
cording to the modied questionnaire of the British Medical Research
Council for assessing the severity of the condition mMRS question-
naire - 4 points.
Complete Blood Count: RBC – 4,4х10
12
/L, Нb –165 g/L, Ht
- 50%, WBC – 8,4 х10
9
/L, neutrophils bands – 8%, neutrophils seg-
ments – 62%, lymphocytes – 25%, monocytes – 4%, eosinophil – 1%,
PLT – 214,0х10
9
/L, ESR – 28 mm/h.
The general analysis of sputum is viscous, green in color. Leuko-
cytes - 100 in the eld of vision, red blood cells – no.
According to pulse oximetry, oxygen saturation is 88%.
Spirometry-FEV1 – 29%, VLC- 52%, FEV1/FVC index - 57%.
When tested with Salbutamol 4 doses, the increase in FEV1 is 2.12%.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
t.me/medicina_free
18
Clinical case No. 8
Patient N, 43 years old, a human resources specialist, turned to
a family doctor with complaints of daily attacks of suocation, espe-
cially dicult exhalation, general weakness, malaise. After the attack,
a small amount of viscous vitreous sputum departs.
It is known from the anamnesis that she has been ill for 3 years,
these complaints occur annually in June, in July all symptoms disap-
pear. He associates his illness with the loss of a loved one. There are
two children of 7 and 13 years old who also have attacks of suoca-
tion. The mother and grandmother also had attacks of suocation. The
patient has an allergy to red foods and some medications.
On objective examination: the condition of moderate severity.
The patient is sitting with her hands resting on the edge of the chair.
The skin is clean, with a cyanotic tint. The chest is barrel-shaped, the
supra- and subclavian areas are smoothed, the intercostal spaces are
expanded, there is swelling of the cervical veins, the participation
of auxiliary muscles, intercostal retraction. Breathing is loud, with
a whistle and noise and with an elongated exhalation, 26 times per
minute. With percussion, a box sound is noted, the lower border of the
lungs along the mid-axillary line is determined at the level of the 9th
rib, the excursion of the lungs along this line is 2 cm. Against the back-
ground of weakened vesicular respiration with an elongated exhala-
tion, dry whistling wheezes are heard. Heart tones are rhythmic, clear,
92 in min., blood pressure 110/70 mm Hg. No abdominal pathology
was detected. The peak exhalation rate at peak owmetry is 70% of
the proper one.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
t.me/medicina_free
19
Clinical case No. 9
Patient N, 57 years old, a molecular nutritionist, went to the poly-
clinic at her place of residence with complaints of headache, high fe-
ver, sharp stabbing pain in the right half of the chest, aggravated by
coughing, shortness of breath, cough with rusty sputum. The disease
began acutely, after hypothermia: swam in an outdoor pool in October.
Ill for the fourth day, was treated with folk methods.
On objective examination: the temperature is 39.4 °C. The gen-
eral condition is serious. The face is hyperemic, herpetic rashes are
detected on the lips. Subcutaneous fat has a homogeneous consisten-
cy. Hair and nails are not changed. The thyroid gland is not visually
determined, with palpation of a soft consistency, painless. Peripheral
lymph nodes are not enlarged. The muscular system is developed sat-
isfactorily. The joints are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation, the heart tones are clear, rhythmic,
noises are heard. Pulse 110 per min., rhythmic. BP 110/70 mm Hg.
The respiratory system. BR - 28 in min. On examination, the right
half of the chest lags behind when breathing, when palpation, the vo-
cal tremor on the right is increased, when percussion is detected on the
right above the lower lobe, sound bluntness is determined, when aus-
cultation is on the right above the lower lobe, breathing is weakened,
vesicular, crepitation is determined.
On palpation, the abdomen is soft, painless. The percussive
boundaries of the liver are within normal limits. The gallbladder is
not palpable, palpation in its projection is painless. Defecation and
diuresis are normal.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
t.me/medicina_free
20
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 10
Patient N, 37 years old, psychologist, went to the polyclinic to
the family doctor with complaints of weakness, malaise, shortness
of breath, cough with the release of abundant mucopurulent sputum
without odor, especially in the morning, up to 300 ml is released per
day. Sometimes hemoptysis is noted.
It is known from the anamnesis that in childhood the patient had
frequent exacerbations of bronchopulmonary infections, which, as
a rule, happened in wet, cold weather. The patient’s body temperature
increased, the amount of sputum increased; sometimes, at the begin-
ning of an exacerbation, an increase in sputum is preceded by a delay
in its release. At the age of 6, the patient underwent inpatient treat-
ment in a hospital with a diagnosis of Acute bronchitis, severe course,
at the age of 12 he underwent inpatient treatment with a diagnosis of
Chronic bronchitis, at the age of 15 and 24 he also underwent inpatient
treatment for bronchopulmonary infection. From the age of 17, the
patient smokes 1 pack a day.
On objective examination: the temperature is 37.4 °C. The gen-
eral condition is satisfactory. The skin is pale, cyanosis of the lips,
subcutaneous fat is insuciently developed, the nail phalanges of the
toes and hands are in the form of “drumsticks”, nails are in the form
of “watch glasses”. Hair and nails are not changed. The thyroid gland
is not visually determined, with palpation of a soft consistency, pain-
less. Peripheral lymph nodes are not enlarged. The muscular system is
developed satisfactorily. The joints are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. The heart tones are muted. Pulse - 95 per minute, rhythmic.
BP - 130/60 mm Hg. BR - 22 in min. With percussion over the lower
t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана