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
321
aminoglycosides (kanamycin, amikacin, streptomycin),
ethambutol,
pyrazinamide.
Second-line drugs are prescribed when the patient has a poor tol-
erance of rst-line drugs or resistance to them is revealed.
These drugs are highly toxic and ineective. These include:
uoroquinolones,
PASA,
cycloserine,
protionamide,
ethionamide,
capreomycin et al.
Anti-tuberculosis drugs are prescribed taking into account the
weight of the patient, the side eect of the antibacterial drug, the con-
comitant pathology of the patient. There are 3 or more drugs in the
treatment regimen. Of these, two drugs – rifampicin and isoniazid are
the main ones.
Treatment of tuberculosis is signicantly complicated in the case
of late detection of the disease, when the aected organ is signicantly
destroyed and terrible complications have appeared, and the patient
himself is exhausted and anemic.
The problem of drug resistance
With irregular intake of anti-tuberculosis drugs, MBT resis-
tance develops. Stable forms are transmitted from a sick person to
a healthy one.
The arsenal of drugs for the treatment of drug-resistant tubercu-
losis around the world is very small. The growth of resistant forms
of the disease is outpacing the search for new medicines. Resistance
to the two main drugs (isoniazid and rifampicin) is called multidrug
resistance and is the No. 1 problem worldwide.
Surgical treatment
It is used when the tuberculosis process cannot be stopped by con-
servative methods of treatment. The volume of surgical intervention
depends on the degree of destruction of organ tissues. The following
types of surgical interventions are distinguished:
t.me/medicina_free
322
resection - removal of a part of an organ;
cavernectomy is the removal of a pathological destroyed area - the
cavern. It is considered an organ-preserving type of surgical treatment.
nephrectomy is the removal of a kidney.
Minimally invasive technologies are currently used to eliminate
the consequences of ureteral stenosis.
4. Medical and labor expertise. Dispensary observation.
Indications for hemodialysis: a decrease in glomerular ltration
of 15 - 10 ml / min, it is important not to miss the deadline for enter-
ing the patient into hemodialysis with CKD. Examination of working
capacity. The duration of temporary disability depends on the clinical
form of the disease and the state of kidney function, which occurs
with an exacerbation of the disease: exacerbation of the latent form
- the duration of temporary disability – 14-20 days; mild urinary syn-
drome - 20-25 days; hypertensive form of glomerulonephritis - 25-30
days; nephrotic form - 40-45 days. With an unfavorable course of the
disease, signs of CKD, patients are referred to the MSEC to establish
a disability group.
Patients with CGN in remission are able to work, with rare re-
lapses, having isolated changes in urine, NS without exacerbation,
medically controlled hypertension of I-II degree, in the absence of
signicant complications of active therapy (hormones, cytostatics,
plasmapheresis) and leading GN syndromes (acute nephritic syn-
drome, NS, AH), working in non-contraindicated types and working
conditions. The ability to work persists at the pre-azotemic and initial
stages of CKD.
Contraindicated types and working conditions: 1) absolute: hard
physical labor; work at a rigidly set pace (on the .conveyor), in a static
pose, unfavorable production conditions (low or high temperatures,
high humidity, dust, smoke, drafts, etc.), in contact with nephrotic
poisons; work related to the impact on the body of vibration, high fre-
quency currents; irregular working day, night shifts; 2) relative: mod-
erate physical labor, work associated with prolonged standing, forced
body position, signicant neuropsychiatric stress.
t.me/medicina_free
323
Indications for referral to the medical and social expertise. AGN
with chronic disease, CGN with continuous recurrence, current NS,
progressive or high grade III hypertension, extrarenal complications
of the disease or treatment, newly diagnosed or progressive termi-
nal CKD.
The required minimum of examination: urine tests (repeated);
clinical blood analysis, trombocytes; daily loss of protein in urine;
Rehberg test; creatinine, urea, cholesterol, electrolytes, total protein
and fractions; if CKD ABC indicators, bone radiography, alkaline
phosphatase; ultrasound, scintigraphy, radiography and kidney biopsy
according to indications.
Criteria for disability in adult glomerulonephritis
Disability is not established if the patient has:
Stage 1 CKD, GFR more than 90 ml/min/1.73 m2;
Stage 2 CKD, GFR within 89-60 ml/min/1.73 m2;
Stage 3A CKD, GFR 59-45 ml/min/1.73 m2.
Group III disability is established if the patient has: Stage 3 CKD,
GFR 44-30 ml/min/1.73 m2. Nephrotic / nephritic syndromes with
ineective treatment with moderate impairment of body functions.
Disability of group II is established if the patient has: Stage
4 CKD, GFR 29-15 ml/min/ 1.73 m2, preparation for dialysis. Stage
5 CKD (GFR below 15 ml/min/1.73 m2) in the absence of dialy-
sis complications.
Disability of group I is established if the patient has: Stage 5 CKD,
GFR below 15 ml/min / 1.73 m2, in the presence of complications
with signicant impairment of body functions.
Dispensary observation. Patients are observed for life: with hy-
pertensive form - twice a year, with nephrotic form - four times a year.
Consultations of a phthisiologist 2 times a year. Once a year – ex-
amination of specialists: gynecologist, dentist, urologist, otorhinolar-
yngologist, ophthalmologist. Main activities: rehabilitation of foci of
infection, physiotherapy, spa treatment, diet. Patients are under the
supervision of a nephrologist, in his absence - a district therapist or
a general practitioner.
t.me/medicina_free
324
Chapter 11. ENDOCRINOLOGY SECTION
Clinical case No. 1
Patient N, 28 years old, an interpreter, went to the polyclinic to
see a family doctor with complaints of constant nervousness, tension,
weakness, palpitations, hand tremors. It became dicult to concen-
trate, including at work, became irritable. Symptoms increased over
6 months, notes a decrease in body weight by about 5 kg in 4 months.
Insomnia, dizziness, weakness have joined in the last month, and
therefore she decided to see a doctor. From the anamnesis it is known
that there are no chronic diseases, she does not take medications. He-
redity is not burdened. Menses have been absent for 2 months, before
that they were regular. The patient is not married, denies regular sex
life, doesn’t use contraceptives. The patient does not smoke, does not
use drugs and rarely drinks small amounts of alcoholic beverages.
During the interview, the patient is agitated and mobile.
On objective examination, the height is 174 cm, the body weight
is 51 kg, the skin is hot and moist, the body temperature is 36.9 ° C.
There is a bilateral exophthalmos and a lag of the upper eyelid when
looking down. On palpation of the neck, a symmetrically enlarged
thyroid gland is determined without clearly palpable nodes, elastic
consistency, and mobile, painless. Percussion the size of the heart is
not changed, rhythm is regular, heart rate - 112 per minute, blood pres-
sure - 140/65 mm Hg. Vesicular breathing, no wheezing. The abdomen
is painless, the liver and spleen are not enlarged. The skin of the legs
is compacted, hyperemic on both sides. In the Romberg position, it is
stable, but there is a tremor of the hands.
Questions:
1. What is the preliminary diagnosis?
t.me/medicina_free
325
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. 2
Patient N, 37 years old, a pharmacist, consulted a family doctor in
a polyclinic with complaints of general weakness, rapid fatigue, hair
loss, memory impairment, decreased interest in life, facial swelling,
menstrual irregularities. She considers herself ill for the last 2 years,
when she moved to live in another city. Her condition gradually wors-
ened, she gained 13 kg in weight during the period of illness.
On objective examination: the general condition is satisfactory,
increased nutrition (height 163 cm, weight 92 kg). The skin is pale,
dry, peeling of the skin is pronounced on the legs. There is swelling
of the face, legs. The thyroid gland is not palpable. There is a postop-
erative scar in the neck area. The voice is harsh. The patient is slow.
Mued heart sounds, rhythmic contractions. Heart rate 57 per minute.
BP - 110/60 mm Hg. In the lungs, vesicular breathing with a harsh
shade. The tongue is thickened, along the edges there are traces of
teeth. The abdomen is somewhat swollen, constipation. The liver and
spleen are not enlarged.
Complete Blood Count: RBC – 3,1х10
12
/L, Нb –92 g/L, MCH –
20 pg/cell, WBC – 4,8х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 3 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
t.me/medicina_free
326
Clinical case No. 3
Patient N, 18 years old, a cook, went to the polyclinic to see
a family doctor, but at the reception he suddenly fell out of his chair
and lost consciousness. According his father, over the past few days he
complained of severe weakness, fatigue, drowsiness, and drank a lot
of liquids. 18 days before that, he had a severe viral infection, which
he contracted, presumably from his younger brother.
On objective examination: the patient is unconscious. Weakly re-
acts to painful stimuli. The skin is dry, tissue turgor is reduced. The
eyeballs are soft on palpation. The smell of acetone from the mouth.
Heart rhythm is regular. Heart rate - 122 per minute. BP - 70/40 mm.
Hg. Breathing is noisy, frequent. Respiratory rate - 27 per minute. On
auscultation, wheezing is not heard. The tongue is dry, coated with
a dirty brown coating, the mucous membrane of the mouth is dry. The
abdomen is soft. Liver - along the edge of the costal arch.
Laboratory: blood glucose in cito - 32 mmol / l.
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, 37 years old, a designer, went to see a family doc-
tor in a polyclinic for spasm of facial muscles, discomfort, fear of
death, sweat. It is known from the anamnesis that the patient under-
went a strumectomy operation and a day after it there were signs of
hypertonicity of the symmetrical muscle group: spasm of the facial
muscles “Sardonic smile”, lips in the shape of a “sh mouth”, trismus
of the chewing muscles. When the light is turned on, cramps occur in
the muscles of the upper extremities, “the hand of an obstetrician”.
t.me/medicina_free
327
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, 50 years old, a power engineer turned to the family
doctor for an appointment with complaints of weakness, thirst, and
poor sleep. It is known from the anamnesis that type 2 diabetes mel-
litus was revealed during a medical examination a week ago.
On objective examination: height - 172 cm, weight - 108 kg. Body
mass index (BMI) - 37.5 kg / m2. Waist circumference - 120 cm. Skin
of moderate moisture, deposition of subcutaneous tissue mainly in the
abdomen. Breathing is vesicular. Pulse - 76 beats per minute. Heart
rhythm is regular, mued, blood pressure - 160/90 mm Hg. The liver
is not enlarged. No edema.
Presented the results of sugar on a glucometer: fasting glucose -
7.8 mmol / l, glucose 2 hours after eating - 10 mmol / l. HbA1c - 7.5%.
Biochemical blood test: total protein - 75 g / l, albumin - 46 g / l, total
bilirubin - 13.1 mmol / l, creatinine - 80 μmol / l, ALT - 65, AST - 53.
Glomerular ltration rate (GFR) - 91 ml / min.
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
328
Clinical case No. 6
Patient N, 27 years old, nanny, turned to the family doctor with
complaints of obesity, the appearance of stripes (striae) of various col-
ors on the abdomen, thighs, increased skin pigmentation in places of
friction (neck, elbows, abdomen), the growth of a mustache, beard,
hair on breasts and pubes in the male pattern, for pain in the spine,
bones, muscle weakness, menstrual irregularities.
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, 53 years old, a manager, went to see the family doctor
with complaints of poor sleep. From the anamnesis it is known that
heredity for CVD is burdened by the maternal line (essential hyper-
tension at the age of 50, acute cerebrovascular accident at the age of
60). The patient has been smoking for about 30 years, up to 1.5 packs
of cigarettes a day. Drinks alcohol - about 100 ml of spirits per week.
A diet high in fatty foods and carbohydrates. For 9 months of the year,
he leads a sedentary lifestyle, and for 3 months - with heavy physi-
cal exertion.
On objective examination: the condition is satisfactory. Height
- 177 cm, weight - 102 kg (body mass index - 32.8 kg / m²). Waist cir-
cumference - 108 cm. The skin is clean, normal color. Xanthomas are
absent. No peripheral edema. In the lungs, breathing is hard, there are
no wheezing. heart rhythm is regular, the accent of the II tone above
the aorta. BP - 130/80 mm Hg. Heart rate - 70 beats in min. The abdo-
men is soft, painless on palpation in all parts. The liver and spleen are
t.me/medicina_free
329
not enlarged. Swinging in the projection of the kidneys is painless on
both sides.
In the analyzes: total cholesterol - 5.9 mmol / L, TG - 4.1 mmol
/ L, HDL-C - 0.9 mmol / L; LDL-C 3.22 mmol / l; fasting glucose -
6.2 mmol / l, glucose tolerance test: glucose after 2 hours 7.9 mmol /
l, HbA1c 6.3%, creatinine - 64 μmol / l, GFR (according to the CKD-
EPI formula) = 108 ml / min.
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. 8
Patient N, 32 years old, a ight attendant, turned to the local doc-
tor with complaints of decreased performance, drowsiness, moderate
weakness, memory loss, constipation. Recently, she began to notice
thinning and dulling of hair, a decrease in mood.
From the anamnesis it is known that the woman is being observed
by a gynecologist for primary infertility, her husband has been exam-
ined and is healthy. In addition, the patient repeatedly consulted an
otolaryngologist with complaints of hoarseness.
On objective examination, attention is drawn to the dryness and
pallor of the skin, swelling of the face, and depletion of facial expres-
sions. He answers the doctor’s questions slowly, in monosyllables.
Height - 165 cm, weight - 80 kg. During auscultation of the heart,
the tones are mued. The boundaries of the heart are within normal
limits. Pulse - 50 beats per minute, rhythm is regular, satisfactory ll-
ing and tension. BP-110/70 mm Hg. On palpation, the thyroid gland is
enlarged in size, dense, mobile, and painless.
According to the results of ultrasound, a diuse decrease in
the echogenicity of the gland tissue is noted. The size of the gland:
t.me/medicina_free
330
isthmus - 0.4 cm; right lobe - 2.7-2.5-3 cm; left lobe - 3.2-2.8-2.8 cm.
In the hormonal blood test: TSH (thyroid-stimulating hormone) - 10
mIU / l (0.4-4); Thyroxin - 8 pmol / l (10.5-22), prolactin - 950 m U /
l (40-600)
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. 9
Patient N, 73 years old, housewife, complains to the local thera-
pist about recurrent headaches; weakness and fatigue; shortness of
breath with little physical exertion, and with moderate forms - and
at rest; sleep apnea, chest pain; itching of the skin, maceration of the
skin in the groin and axillary areas; increased appetite; dry mouth,
thirst, polyuria.
On objective examination, attention is drawn to excess body
weight with a predominant abdominal adipose tissue deposition. BMI
over 35 kg / m². On auscultation of the heart, the sounds are mued.
The boundaries of the heart are within normal limits. Pulse - 40 beats
per minute, rhythm is regular, satisfactory lling and tension. BP -
150/90 mm Hg. On palpation of the abdomen: soft, painless.
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
Соседние файлы в папке Библиотека им академика М.И. Перельмана