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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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1) radical - surgery (lobectomy, pneumonectomy), combined
(surgery + radiation therapy), chemotherapy, complex (removal of the
primary focus + chemotherapy).
2) palliative.
4. Medical and labor expertise. Dispensary observation.
Temporary disability (TD) is determined for the period:
y diagnosis of lung cancer and examination to determine the
possibilities of surgical treatment;
y surgical treatment and adaptation after it;
y conducting a course of polychemotherapy.
Compensation of impaired functions after lobectomy occurs after
3-4 months, after pneumonectomy - after 4-6 months. Conducting ra-
diation and chemotherapy slightly increases these terms.
The criteria for eective completed treatment are the restoration
of body weight, restoration or stabilization of respiratory and circula-
tory function, restoration of clinical and biochemical parameters of
blood, urine, the formation of a strengthened scar of the chest and the
elimination of asthenoneurotic syndrome.
Eective incomplete treatment with the nearest favorable progno-
sis after lobectomy and bilobectomy for highly dierentiated tumors
of stages I and II allows you to continue treatment according to the
temporary disability certicate.
Disability of the 3rd group is established if the patient has:
1. Bronchial and lung cancer of stage I, II (T1,2,3N0,1M0) after
combined treatment (segmentectomy, lobectomy, bilobectomy with
mediastinal lymphadenectomy in combination with radiation or an-
titumor drug therapy) without local and/or general complications. 2.
Pulmonectomy (with re-examination without signs of a decrease in
cardiorespiratory reserves).
3. Stage I lung cancer after radical radiation therapy.
4. Stage I lung cancer during targeted therapy.
Disability of the 2nd group is established if the patient has:
1. Stage III bronchial and lung cancer (T1,2,3,4N0,1,2,3M0) after
combined treatment without local and/or general complications.
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2. Bronchial and lung cancer of stage I - III (T1,2,3,4N0,1,2,3M0)
after combined treatment with local and/or general complications.
3. Stage II - III lung cancer after combined treatment (if the pa-
tient refuses or for medical reasons from surgical methods of treat-
ment).
4. During the treatment of small cell lung cancer, regardless of the
stage of the disease. 5. Pulmonectomy with a decrease in cardiorespi-
ratory reserves.
Disability of the 1st group is established if the patient has:
Stage IV lung cancer (T1,2,3,4N1,2,3M1), incurable condition.
Dispensary observation. A clear organization of dispensary moni-
toring of those operated for lung cancer allows timely diagnosis of re-
lapses and metastases. Dispensary supervision is carried out by a fam-
ily doctor.
Treatment of the detected disease, after which dynamic monitor-
ing is mandatory:
1 year: once a quarter,
2 year: every six months,
3 year: once a year.
with a successful cure, a citizen is removed from the dispensa-
ry register.
In case of relapse, the person is transferred to group 2 (treatment
is being carried out) or to group 4 if treatment is impossible;
In the absence of a relapse – lifelong dispensary observation:
1 year: once a quarter,
2 and 3 years: every six months,
subsequent years: once a year
Clinical case No. 7
1. Formulate a preliminary diagnosis.
Preliminary diagnosis: Chronic obstructive pulmonary disease,
extremely severe, grade 4, with pronounced symptoms, high risk, in
the phase of infectious exacerbation. Smoking index 45 pack/years.
Pulmonary insuciency of the 2nd degree.
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2. Assign additional research methods.
Laboratory tests
Cultural microbiological examination of sputum is advisable to
carry out with uncontrolled progression of the infectious process and
the selection of rational antibiotic therapy.
Blood testing
The gas composition of the blood. The study of the gas com-
position of arterial blood to detect hypoxemia and hypercapnia - for
routine observation, pulse oximetry can be performed, informative at
saturation (saturation) Blood O2 is more than 92%; with the develop-
ment of complications, it does not replace direct examination.
Immunological examination of blood is additional and is carried
out with the steady progression of the infectious inammatory process
to identify signs of immune deciency.
Instrumental research
Mandatory research methods:
1. Chest X-ray at the rst treatment. Further according to the indi-
cations, but at least once a year.
2. Pulse oximetry is indicated in patients with FEV1 < 50%, as
well as in the period of exacerbation and patients with shortness of
breath at rest (according to availability).
3. Electrocardiography – there may be signs of overload and/or
hypertrophy of the right parts of the heart.
4. CAT-test (to assess the severity of symptoms and the quality of
life of the patient).
5. Assessment of the severity of dyspnea on the mMRC scale.
6. Fagerstrom test (for all smokers, to determine the degree of
tobacco dependence)
3. What is the treatment tactics?
General mode. Quitting smoking. Low-ow oxygen therapy for
at least 15 hours a day through an oxygen concentrator. Therapy of
infectious exacerbation and treatment of patients of group D Berodual
0.5 ml - 1 ml + Sodium chloride 0.9% - 2 ml × 3 times a day through
a nebulizer (a combination of m-holinoblocker and 2-adrenomimetics).
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Inhaled glucocorticosteroids + long-acting beta-adrenomimetics
(combined Salmeterol preparations/Fluticasone - 25/125 mcg 2 vd
2 times, Formoterol/Budesonide - 4.5/160 mcg 2 vd 2 times, etc.) +
prolonged m-cholinolytic (Tiotropium bromide - 18 mcg 1 time per
day (blocker of m3-cholinergic receptors in the respiratory tract) or
Glycopyrronium bromide - 50 mcg 1 time per day
Aclidinium bromide 1 vd 2 times a day, etc.). Expectorant drugs
Ambrogexal - 30 mg 3 times a day or acetylcysteine - 600 mg 1 time
a day dissolved in 100 ml of water. Since there is an infectious exacer-
bation, the most likely pathogens in this case may be Haemophilus in-
uenzae PRSP, Enterobacteria, gram-, P. aeruginosa; it is necessary to
prescribe the antibacterial drug Ciprooxacin (400 mg 2 times a day in
/ in drip) and other drugs with antisinegenic activity. exercise therapy.
Breathing exercises.
4. Medical and labor expertise. Dispensary observation. Terms
TD. The approximate time of the TD is 5-7 days. It can increase in
the cold season, in the presence of industrial hazards (the presence of
toxic, irritating substances in the inhaled air). The cough can last up to
1-1.5 months. If he does not interfere with the patient, then he can be
recognized as able-bodied.
Dispensary observation. A district therapist examines patients
1 time in 2-3 months, an otolaryngologist and a dentist - 2 times a year.
The frequency of observation of the group of family doctor: 2 times
in 6 months. Examination of doctors of other specialties: pulmonolo-
gist, phthisiologist - according to indications. Frequency of laboratory
and diagnostic examinations: general blood test - 1 time (according to
indications more often). Fluorography – according to indications. Spi-
rometry, peak expiratory ow (PEF) - 2 times a year. Sputum analysis
for BC - 1 time. Skin tests with allergens - according to indications.
ECG - 1 time per year. The main therapeutic and health-improving
measures: recommendations of a healthy lifestyle. Tempering pro-
cedures. Rehabilitation of foci of chronic infection. Criteria for the
eectiveness of medical examination: normalization of the ventila-
tion function of external respiration. With recurrent bronchitis after
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exacerbation, it is advisable to stay at least once a year for 2 months
in a local sanatorium.
Clinical case No. 8
1. Formulate a preliminary diagnosis.
Preliminary diagnosis: 1. Atopic bronchial asthma, moderate se-
verity. Emphysema of the lungs. Conrmation: 1) anamnesis data:
daily attacks of suocation, expiratory dyspnea, the release of a small
amount of viscous vitreous sputum; the association of the onset of
seizures with the owering period; the association of the onset of the
disease with a psychoemotional shock; hereditary predisposition (at-
tacks of suocation in close relatives); the presence of allergies to
food and medicines; 2) objective status: during examination: forced
position occupied to facilitate breathing, cyanotic skin tone, barrel-
shaped chest, smoothness of supra- and subclavian pits, expansion of
intercostal spaces, intercostal retraction, swelling of cervical veins,
BR - 26 in min.; with lung percussion, box sound, lowering of the
lower border of the lungs, decreased lung excursion; with ausculta-
tion, dry wheezing wheezes against the background of weakened ve-
sicular breathing, elongation exhale.
2. Assign additional research methods.
About BA:
1) general blood test;
2) biochemical blood analysis;
3) general sputum analysis;
4) Blood test to detect common IgE;
5) skin tests;
6) determination of allergen-specic IgE in the blood;
Instrumental research
Mandatory research methods:
y Daily monitoring of MVE with determination of variability at
home (with an individual device). Characteristic are the “morning
failure symptom” and MVE variability > 20%.
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y Spirometry allows you to conrm the diagnosis when airway
obstruction is detected (a decrease in the FEV1 index and the
FEV1/VLC ratio).
Note. Normal spirometry indicators do not exclude the diagnosis
of bronchial asthma.
y Bronchodilation test conrms the reversibility of bronchial
obstruction – an increase in FEV1 > 12% (+200 ml) or MVE >
20% (+60 l/min) 10-15 minutes after inhalation of 200-400 mcg
of salbutamol.
Note. A negative result of a bronchodilation test does not exclude
the diagnosis of bronchial asthma.
y Bronchoprovocation test (to determine bronchial hyperreactivity)
- reduction of FEV1 > 20% for a standard dose of methacholine or
histamine (carried out only in a specialized hospital with an initial
index of FEV1 ≥ 80%, without exacerbation).
Research on indications:
y Chest radiography - to exclude other pathology from the respiratory
system or to identify complications of bronchial asthma.
y Skin allergological tests (prick-test) – in order to clarify the
allergological status.
y Pulse oximetry (in patients with signs of severe exacerbation of
the disease).
y Determination of blood gases (if possible) - in the presence of signs
of respiratory failure.
3. What is the treatment tactics?
The patient needs the appointment of basic treatment of bron-
chial asthma, consultation with an allergist. Principles of treatment:
Semi-bed rest. The diet is hypoallergenic. Sympathomimetics of short
and prolonged action: berotec, salbutamol, teopec. Combined drugs:
berodual Mast cell membrane stabilizers: intal, tailed Inhaled gluco-
corticosteroids: becotide, beclamet. Breathing exercises. Massage.
Psychotherapy. Spa treatment. The prognosis for life is favorable in
the case of anti-relapse treatment. Prevention of exacerbations: elimi-
nate the eect of allergens (if possible). During the owering period of
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herbs, the window panes should be covered with wet gauze, wet clean-
ing of rooms should be carried out daily, carpets should be removed;
peak owmetry should be carried out in order to monitor bronchial
patency. If the indicators of peak expiratory velocity deteriorate, treat-
ment should be adjusted; dispensary observation, patient training in
asthma schools; specic hyposensitization. 5. The technique of using
a pocket inhaler according to the algorithm of action.
4. Medical and labor expertise. Dispensary observation.
Temporary disability. With a mild form, the patient is released
from work for 5-7 days, with pronounced manifestations of the dis-
ease - for 10-12 days with a possible release of up to 2 weeks under
adverse weather and production factors.
Persistent disability. When assessing the limitations of vital ac-
tivity, the form and severity of the course of bronchial asthma, the
severity of complications, including those caused by the therapy,
the eectiveness of treatment, the severity of concomitant diseases;
education, profession, qualications, nature and working conditions,
work orientation.
Disability of group III is established by patients with bronchial
asthma of mild and moderate severity, including hormone-dependent,
PI I and II st. with limited ability to work, self-service, movement -
I st., working in contraindicated types and working conditions and in
need of rational employment (reduction of qualications or reduction
in the volume of production activity).
Disability of group II is established in patients with moderate and
severe bronchial asthma with persistent severe respiratory and circula-
tory disorders (PI II-III st. and HF IIA st.), as well as disorders of the
endocrine system (diabetes mellitus, adrenal insuciency) caused by
steroid therapy, with limited ability to self-care, movement, learning II
st. In some cases, patients can work in specially created conditions, in
particular - at home, taking into account professional skills.
Disability of group I is established with severe progressive course
of bronchial asthma, refractory to treatment, development of PI III st.,
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HF IIB-III st., other irreversible complications, with limited ability to
self-care, movement, work activity III st.
Primary prevention. Reducing the impact on the patient of factors
that provoke exacerbation of bronchial asthma:
1. Hypoallergenic diet.
2. Smoking cessation (including pregnant women and parents of
young children).
3. Refusal of food additives and certain medications (aspirin and
its analogues, yellow food coloring tartrazine).
4. Reducing or eliminating the impact of professional factors.
5. Exclusion of exposure to other risk factors: allergens, viral in-
fections, air pollutants.
6. Sanitation of foci of chronic nasopharyngeal infection, dental
sanitation, treatment of GERD, prevention of helminthiasis.
7. Healthy lifestyle.
Secondary prevention. Secondary prevention of bronchial asthma
should include the elimination of adverse factors from the environ-
ment (allergens, irritants, etc.), the organization of a lifestyle, physical
education, rational work arrangement, timely training and retraining,
the organization of asthma schools and asthma clubs; the preparation
of printed, video, audio educational products, the creation of an as-
sociation of patients. It is necessary to conduct individual work with
patients, including communication with psychologists.
The basis of secondary prevention is timely and adequate treat-
ment at all stages (outpatient, inpatient, sanatorium-resort); compila-
tion and monitoring of the completeness and quality, timeliness of
the implementation of an individual rehabilitation program for a dis-
abled person.
Dispensary observation
1. A patient with asthma should be monitored by a family doctor.
2. During outpatient follow-up, the family doctor should work out
an individual plan for long-term asthma treatment.
3. All patients with bronchial asthma should be trained in a spe-
cial educational program (asthma school).
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4. If necessary, a specialist should be consulted: a pulmonologist
or an allergist.
5. Examination of an otorhinolaryngologist, dentist, gastroenter-
ologist (with GERD), parasitologist (for the prevention of helminthia-
sis).
Patient education
The patient should:
y Know the main causal factors (possible allergens at home and at
work) and be able to control them.
y Be able to assess your condition and keep a “Self-control Diary”.
y Be able to use a peak owmeter, know the system of zones “red,
yellow, green”.
y Be able to use the inhaler correctly.
y Know the main groups of medicines, be able to control asthma and
use basic and fast-acting medicines available.
y Know when and where he should seek help.
Clinical case No. 9
1. Formulate a preliminary diagnosis.
Preliminary diagnosis: croup pneumonia, unspecied etiology.
Conrmation:
1) anamnesis data:
y intoxication syndrome, chest pain that increases with coughing,
shortness of breath, cough with “rusty sputum”;
y acute onset of the disease;
2) objective data: fever,
y on examination: facial hyperemia, herpetic rashes on the lips,
lagging of the aected side of the chest when breathing;
y with percussion: sound dulling over the lower lobe of the right lung;
y palpation - increased vocal tremor;
y during auscultation - weakened vesicular respiration, crepitation.
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2. Assign additional research methods.
A general blood test (neutrophilic leukocytosis with a shift of the
leukoformula to the left, an increase in ESR).
Microscopic and bacteriological examination of sputum (identi-
cation of the pathogen and determination of its sensitivity to antibiot-
ics).
Chest X-ray (shading of the corresponding lobe of the lung).
Determination of arterial blood gases. Hypoxemia with a de-
crease in the level of pO2 below 60 mmHg (when breathing room air)
is a prognostic unfavorable sign, indicates the need to place the patient
in the ICU and is an indication for oxygen therapy.
Microbiological diagnostics.
Polymerase chain reaction (PCR). This method is promising for
the diagnosis of bacterial pathogens such as C. pneumoniae, M. pneu-
moniae and L. pneumophila.
Instrumental research
X-ray diagnostics
X-ray examination is performed at the beginning of the disease
and not earlier than 14 days after the start of antibacterial treatment.
In the presence of pleural eusion 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 treatment tactics?
Principles of treatment:
Strict bed rest, supervision of the sta on duty.
Diet No. 15, enriched with vitamins, semi-liquid, nutritious food.
Plentiful drink: mineral waters, fruit juices, cranberry juice, tea
with raspberry jam, tea with lime owers.
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