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In the presence of pleural eusion and conditions for safe pleural

puncture (visualization on a laterogram of freely displaced uid with

a layer thickness > 1.0 cm), the examination of pleural uid should

involve counting leukocytes with a leukocyte formula, determining

pH, LDH, protein level, bacterioscopy of a Gram-stained smear and

other methods to identify mycobacteria, sowing for aerobes, anaer-

obes and mycobacteria.

Fibrobronchoscopy with evaluation of microbial contamination

of the obtained material

3. What is the patient’s management?

Antibacterial therapy should be prescribed empirically and as

early as possible.

Amoxicillin / clavulanate, amoxicillin / sulbactam orally (1 tab-

let (0.625g) 3 times a day) ± macrolide orally, or Respiratory uoro-

quinolone (levooxacin, moxioxacin, hemi-oxacin) orally, or Ce-

furoxime axetil

4. Medical and labor expertise. Dispensary observation.

Temporary disability. The duration of disability in pneumonia de-

pends on the characteristics of the course of the disease, the timeliness

and usefulness of antibacterial therapy; the severity of respiratory dis-

orders; concomitant diseases; the age of the patient, profession.

The average duration of temporary disability of patients treated in

a polyclinic (hospital at home) is 20-25 days.

When patients are discharged to work, it is necessary to take into

account not only the normalization of the clinical and radiological

picture (radiological control in 30-40 days), laboratory parameters,

but also the profession, working conditions. Under favorable work-

ing conditions (absence of drafts, high humidity, temperature uctua-

tions), discharge may occur at an earlier date, and vice versa, under

unfavorable conditions. It is mandatory to be exempt from additional

work loads for 1-2 months.

All patients working in unfavorable conditions should be tempo-

rarily employed by the conclusion of the MAC for appropriate work

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without lowering their qualications for a period of 1 to 6 months in

order to prevent relapse and complications.

With a mild form, the patient is released from work for 5-7 days,

with pronounced manifestations of the disease - for 10-12, with a pos-

sible release of up to 2 weeks under unfavorable weather and produc-

tion factors.

Persistent disability. Disability criteria: the rst signs of the for-

mation of chronic PI from grade I-II and higher, formed in COPD.

Primary prevention. Primary prevention is aimed at preventing

the development of the disease. If you follow simple rules, you can

avoid the occurrence of pneumonia:

1. Quitting smoking.

2. Strengthening the immune system by hardening, walking in the

fresh air.

3. If necessary, the doctor may prescribe multivitamins, restor-

ative drugs.

4. Moderate physical activity, mainly aerobic: walking, running,

swimming, cycling.

5. Fractional nutrition with a sucient amount of vegetables

and fruits.

6. Vaccination.

Vaccines are currently available against many pathogens of pneu-

monia, for example, Streptococcus pneumoniae vaccine, Haemophilus

inuenzae type B vaccine, inuenza A virus vaccine, inuenza B virus

vaccine and measles virus vaccine. Vaccination against inuenza and

pneumococcal infection is strongly recommended for people over 65

years of age, and for severe chronic diseases – regardless of age (due

to the high risk of severe complications of inuenza and pneumonia).

HIV-infected people who still have an immune response are recom-

mended to be vaccinated against inuenza, vaccination against Strep-

tococcus pneumoniae and vaccination against Haemophilus inuen-

zae type B. The twenty-three-valent pneumococcal vaccine currently

used is eective against approximately 90% of virulent serotypes of

Streptococcus pneumoniae.

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Secondary prevention. All actions are aimed at preventing the re-

currence of the disease. To the above-mentioned points of primary

prevention, medical examination is added, that is, accounting for pa-

tients who have suered pneumonia. They are required to do an X-ray

of the lungs once a year, and after recovery, take a general blood test

every month.

During the dispensary observation, a complex of therapeutic and

preventive measures is carried out (daily morning gymnastics, breath-

ing exercises, massage, sauna, if necessary – physiotherapy, it is rec-

ommended to take adaptogens and other drugs that increase immune

and general biological reactivity).

Clinical case No. 4

1. What is the preliminary diagnosis?

Preliminary diagnosis: subacute disseminated pulmonary tuber-

culosis. In favor of the tuberculosis etiology of the process is evi-

denced by: mild manifestations of clinical symptoms, a characteristic

X-ray picture: the presence of polymorphic foci in both lungs, moder-

ate changes in the blood picture.

2. What additional tests would you recommend to the patient,

and what are the expected results?

Sputum and urine analysis for MBT by seeding, general urine

analysis, consultation of an otolaryngologist, tomographic examina-

tion of the lungs, tuberculin tests, bronchoscopy.

3. What is the patient’s management?

The basic principles of treatment of tuberculosis patients: treat-

ment should be comprehensive (etiotropic, pathogenetic, symptomatic

therapy, collapse therapy, surgery); treatment should be long-term,

continuous; continuity in the treatment of patients is necessary. Che-

motherapy is the main method of treating tuberculosis patients. Anti-

tuberculosis drugs should act on intracellularly located mycobacteria,

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penetrate into the foci of caseous decay, do not reduce their activity in

an acidic environment (foci of decay).

According to the degree of activity of anti - tuberculosis drugs,

they are divided into 3 groups:

The most eective drugs are isoniazid and rifampicin

Medium-ecacy drugs - ethambutol, streptomycin, protionamide

(ethionamide), pyrazinamide, kanamycin, cycloserine, orimycin.

3. Drugs of moderate ecacy - PASA, thioacetazone.

There are 2 stages of tuberculosis chemotherapy:

1) Intensive care. The goal is to suppress the reproduction of the

bacterial population and achieve its quantitative reduction.

2) The phase of further treatment. The goal is to aect the remain-

ing bacterial. a population that is more often intracellularly in the form

of persistent forms.

Treatment of this patient is necessary with streptomycin, rifam-

picin, isoniosid, ethambutol. When bacterial excretion stops and the

cavity heals within the rst 3 months from the start of treatment, strep-

tomycin and rifampicin are canceled, treatment is continued with two

drugs (isoniazid and ethambutol) another 6 months.

With the cavity preserved, regardless of the results of the bacte-

riological examination (BC +, BC-), the treatment started with three

drugs is continued for another 3 months. After 6 months, the dynamics

of the process is evaluated again. With the healing of the cavity and

the cessation of bacterial excretion, rifampicin is canceled and treat-

ment with isoniazid and ethambutol is continued for another 3 months.

If, after 6 months of treatment, the cavity does not close, then the

question arises about the need for surgical intervention.

In the treatment of patients who have previously taken chemo-

therapy drugs, the tactics change. Patients previously treated with che-

motherapy drugs often secrete drug-resistant Mycobacteria. In such

cases, therapeutic tactics are determined by the spectrum of resistance

of the pathogen to chemotherapy drugs. Chemotherapy is prescribed

according to the antibioticogram.

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4. Medical and labor expertise. Dispensary observation.

Disability of the 3rd group is established if the patient has:

moderate violations of the respiratory system function in the

absence of positive clinical and radiological dynamics on the back-

ground of chemotherapy; with the preservation of bacterial excretion

(MBT+) in the period of loss of activity; and / or in the presence of

residual changes after cured tuberculosis of the respiratory organs (lo-

cal pneumobrosis, brotic focal changes) with grade II PI, transient

or permanent pulmonary hypertension (CHF 0 or CHF 1 stage). Avail-

ability of MBT + 6 months or more.

Disability of the 2nd group is established if the patient has:

severe violations of the respiratory system function with inef-

fective chemotherapy; with the preservation of bacterial excretion

(MBT+) in the period of loss of activity; and / or in the presence of

residual changes after cured tuberculosis (pneumosclerosis, cirrhosis,

bronchiectasis). The presence of PI II, III degree and CHF IIA stage.

Disability of the 1st group is established if the patient has:

signicantly pronounced disorders of the body’s functions due to

the presence of severe multiple organ complications (amyloidosis, de-

compensated chronic pulmonary heart, polyserositis, cachexia, and so

on). The presence of PI III degree and CHF IIB or III stage.

Tuberculosis prevention includes:

a) sanitary and preventive measures aimed at the source of bacte-

rial release, the conditions in which infection is possible, a healthy

person who is at risk of infection and disease;

b) specic, consisting of vaccination, BCG revaccination, chemo-

prophylaxis.

Temporary disability. Temporary disability and its duration in

patients with tuberculosis of the respiratory system depends on the

characteristics of the course of a specic process, in particular the na-

ture. the prevalence of morphological changes in the lungs, the sever-

ity of the clinical course, the presence of BC in sputum, the type of

complications, such as respiratory and circulatory disorders. hemop-

tysis; spontaneous pneumothorax, amyloids of internal organs, tho-

racic and bronchial stulas, etc. The terms of temporary disability may

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be increased in persons over 50 years of age, if patients have severe,

concomitant diseases. Methods and types of treatment have a signi-

cant impact on the duration of temporary disability. Adequate therapy,

continuity in therapeutic tactics can contribute to reducing the dura-

tion of temporary disability and returning patients to work, preserving

their social status. Epidemiological factors taken into account when

employing patients can also aect the timing of temporary disability.

Dispensary observation

1. Patients with tuberculosis should be under the supervision of

a family doctor, a phthisiologist.

2. According to indications - consultation of a pulmonologist, al-

lergist, otorhinolaryngologist.

3. Patients with an active form of tuberculosis need therapeutic,

diagnostic, anti-epidemic, rehabilitation and social measures.

All patients with active tuberculosis, identied for the rst time

or with a relapse of tuberculosis, are enrolled only in the I group of

dispensary observation.

The chronic course of active forms of tuberculosis is a long (more

than 2 years), including a wave-like (with alternating subsidence and

exacerbation) course of the disease, in which clinical, radiological and

bacteriological signs of the activity of the tuberculosis process persist.

4. At each medical appointment, if the patient smokes, a 3-min-

ute conversation with the smoker about the dangers of smoking with

a recommendation to quit smoking should be conducted.

Clinical case No. 5

1. What is the preliminary diagnosis?

Preliminary diagnosis: left-sided exudative pleurisy of tubercu-

lous etiology.

2. What additional tests would you recommend to the patient,

and what are the expected results?

1) pleural puncture; the cellular composition of the exudate may

be lymphocytic, the protein content is more than 30 g / l;

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2) tuberculin samples may be hypersensitive to tuberculin;

3) X-ray tomography after exudate evacuation;

4) pleuroscopy can reveal macroscopic and microscopic data in

favor of a preliminary diagnosis.

Dierential diagnosis is performed with nonspecic pleurisy. In

favor of tuberculosis etiology indicates:

y gradual development of the disease with symptoms of

tuberculosis intoxication;

y young age of the patient;

y lack of eect from non-specic treatment;

y the nature of the hemogram.

3. What is the patient’s management?

Before receiving the rst results of the examination, prescribe

treatment with broad-spectrum antibiotics.

The basic principles of treatment of tuberculosis patients: treat-

ment should be comprehensive (etiotropic, pathogenetic, symptomatic

therapy, collapse therapy, surgery); treatment should be long-term,

continuous; continuity in the treatment of patients is necessary. Che-

motherapy is the main method of treating tuberculosis patients. Anti-

tuberculosis drugs should act on intracellularly located mycobacteria,

penetrate into the foci of caseous decay, do not reduce their activity in

an acidic environment (foci of decay).

3 groups are used: isoniazid and rifampicin; ethambutol, strepto-

mycin, protionamide (ethionamide), pyrazinamide, kanamycin, cyclo-

serine, orimycin; PASC, thioacetazone.

There are 2 stages of tuberculosis chemotherapy:

1) Intensive care. The goal is to suppress the reproduction of the

bacterial population and achieve its quantitative reduction.

2) The phase of further treatment. The goal is to aect the remain-

ing bacterial. a population that is more often intracellularly in the form

of persistent forms.

With the cavity preserved, regardless of the results of the bacte-

riological examination (BC +, BC-), the treatment started with three

drugs is continued for another 3 months. After 6 months, the dynamics

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