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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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Antibacterial therapy should be prescribed empirically and as
early as possible.
Amoxicillin / clavulanate, amoxicillin / sulbactam orally (1 tablet
(0.625g) 3 times a day) ± macrolide orally, or Respiratory uoroqui-
nolone (levooxacin, moxioxacin, hemioxacin) orally, or Cefurox-
ime axetil
Vascular agents: caeine, cordiamine.
Oxygen therapy.
Breathing exercises.
Chest massage.
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
without lowering their qualications 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.
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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 sucient amount of vegetables
and fruits.
6. Vaccination.
Vaccines are currently available against many pathogens of pneu-
monia, for example, Streptococcus pneumoniae vaccine, Haemophilus
inuenzae type B vaccine, inuenza A virus vaccine, inuenza B virus
vaccine and measles virus vaccine. Vaccination against inuenza and
pneumococcal infection is strongly recommended for people over 65
years of age, and for severe chronic diseases – regardless of age (in
due to the high risk of severe complications of inuenza and pneu-
monia). HIV-infected people who still have an immune response are
recommended to be vaccinated against inuenza, vaccination against
Streptococcus pneumoniae and vaccination against Haemophilus in-
uenzae type B. The twenty-three-valent pneumococcal vaccine cur-
rently used is eective against approximately 90% of virulent sero-
types of Streptococcus pneumoniae.
Secondary prevention. All actions are aimed at preventing the recur-
rence of the disease. To the above-mentioned points of primary preven-
tion, medical examination is added, that is, accounting for patients who
have suered 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,
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53
breathing exercises, massage, sauna, if necessary – physiotherapy, it
is recommended to take adaptogens and other drugs that increase im-
mune and general biological reactivity).
Clinical case No. 10
1. Formulate a preliminary diagnosis.
Preliminary diagnosis: bronchiectatic disease in the acute stage.
2. Assign additional research methods.
Laboratory tests
Sputum examination. Cytological examination of sputum pro-
vides information about the nature of the inammatory process and
its severity and is a mandatory method. Cultural microbiological ex-
amination of sputum is advisable to carry out with uncontrolled pro-
gression of the infectious process and the selection of rational antibi-
otic therapy.
Blood testing
Clinical analysis: with a stable course of COPD, there are no sig-
nicant changes in the content of peripheral blood leukocytes. With
exacerbation, neutrophilic leukocytosis with a rod-shaped shift and an
increase in ESR are most often observed. However, these changes are
not always observed. With the development of hypoxemia, polycy-
themic syndrome is formed in COPD patients, which is characterized
by a change in hematocrit (hematocrit > 47% in women and > 52% in
men), an increase in the number of red blood cells, high hemoglobin
levels, low ESR and increased blood viscosity.
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.
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Instrumental research
Mandatory research methods:
1. Spirometry - performed to diagnose and monitor the eective-
ness of treatment
2. Chest X-ray at the rst treatment. Further according to the indi-
cations, but at least once a year.
3. 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).
4. Electrocardiography – there may be signs of overload and/or
hypertrophy of the right parts of the heart.
5. Bronchography: various forms of bronchiectasis.
3. What is the treatment tactics?
Bed rest mode. Diet No. 15, enriched with proteins (meat, sh,
cottage cheese) and vitamins (fruits, vegetables, juices, syrups). An-
tibacterial therapy: semi-synthetic penicillins (ampicillin, oxacillin),
cephalosporins, gentamicin. Expectorant drugs: a mixture with ther-
mopsis, althea, lazolvan. Plentiful alkaline drink: mineral waters. Pos-
tural drainage: Quincke position (the foot end of the bed is raised by
25-30 cm, the patient is in this position for 3-4 hours with breaks).
Chest massage. Breathing exercises. Lavage (washing) of the bronchi.
4. Medical and labor expertise. Dispensary observation.
A slightly pronounced degree of dysfunction of the respiratory
system, characterized by a moderate form of the course of diseases,
with periodic short-term exacerbations (4-6 times a year, lasting from
three to six weeks), with bronchial obstruction during periods of exac-
erbation with emphysema of the lungs, with chronic respiratory failure
of the I degree - 20%
Moderate degree of impairment of the respiratory system, char-
acterized by a moderate form of the course of diseases, with periodic
exacerbations in which there is an increase in symptoms with short-
ness of breath (4-6 exacerbations per year, lasting from three to eight
weeks), FEV1 is more than 50%, but less than 80% of the proper
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values, the ratio of FEV1 to the forced vital capacity of the lungs is
less than 70%), chronic respiratory insuciency hypoxemic, chronic
respiratory insuciency II degree - 40-50%
A pronounced degree of impairment of the function of the respira-
tory system, characterized by a severe form of the course of diseases,
with frequent exacerbations in which there is an increase in shortness
of breath (exacerbations more than 6 times a year, lasting more than
eight weeks), FEV1 is more than 30%, but less than 50% of the proper
values, the ratio of FEV1 to the forced vital capacity of the lungs is
less than 70%) chronic respiratory insuciency hypoxemic and hy-
percapnic, chronic respiratory insuciency II, III degree; chronic pul-
monary heart failure stage IIA - 70-80%
A signicantly pronounced degree of impairment of the function
of the respiratory system, characterized by a severe form of the course
of diseases, continuously recurring, with constant pronounced dys-
pnea; FEV1 is more than 30%, but less than 50% of the proper values,
the ratio of FEV1 to the forced vital capacity of the lungs is less than
70%; hypercapnia, chronic respiratory hypoxemia, chronic respiratory
alkalosis, chronic respiratory insuciency of II, III degree.; chronic
pulmonary heart failure of IIB, III stage - 90-100%.
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 doctors: 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 proce-
dures. Rehabilitation of foci of chronic infection. Criteria for the ef-
fectiveness of medical examination: normalization of the ventilation
function of external respiration.
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Chapter 3. CARDIOLOGY SECTION
Clinical case No. 1
Patient N, 53 years old, conductor, turned to the family doctor
at the polyclinic with complaints of paroxysmal compressive pain
behind the breastbone at the height of any tension: both emotional
and physical; the nature of the pain is burning, pressing, squeezing.
In mild cases, just chest discomfort; the duration of the attack is from
1 to 10 minutes.
From the anamnesis it is known that the patient is seen by a doctor
for Coronary heart disease, stable exertional angina, Functional class
II, postinfarction cardiosclerosis and circulatory failure, Functional
class 1. Concomitant diagnosis: chronic lumbosacral radiculitis in re-
mission. Angina pectoris was diagnosed within 5 years. 3 years ago
he had an acute myocardial infarction. At present, angina attacks are
troubling with signicant physical exertion, and are easily removed
by nitroglycerin.
On objective examination: general condition of moderate severi-
ty. Body temperature 36.7 ° C. Consciousness is clear. Active position.
Satisfactory nutrition. The skin is pale, high humidity. Subcutaneous
adipose tissue of homogeneous consistency, no edema and pastiness.
Hair and nails are not changed. The thyroid gland is not visually deter-
mined, on palpation of a soft-elastic consistency, painless. Peripheral
lymph nodes are not enlarged. The muscular system is well developed.
The joints are not externally changed. The cardiovascular system. The
apical beat is located in the V intercostal space 1.5-2 cm medially from
the left mid-clavicular line. With percussion, the border of relative
cardiac dullness is within normal limits. On auscultation, heart sounds
are mued, rhythm is regular, no noise is heard. The heart rate is 78
beats per minute. Blood pressure 130/80 mm Hg. Respiratory system.
On examination, the chest is of the correct shape, symmetrical. With
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comparative percussion over the entire surface of the lungs, a pul-
monary sound is determined. Breathing cleanliness - 19 in 1 min. At
auscultation over the lungs, vesicular breathing is determined on both
sides, wheezing is not heard. On palpation, the abdomen is soft, pain-
less. Percussion borders of the liver are within normal limits. The gall-
bladder is not palpable; palpation in its projection is painless. Stool
and urine output are normal.
On the ECG - sinus rhythm, correct rhythm, heart rate 75 beats
per minute, Q waves in leads II, III, aVF, with an exercise ECG test
(“treadmill test”) - exercise tolerance 600 kgm / 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. 2
Patient N, 47 years old, a geologist, turned to the family doctor
at the polyclinic with complaints of pain in the epigastric region, ac-
companied by weakness, sweating, nausea.
From the anamnesis it is known that previously the pain did not
bother him, he considered himself healthy. An attempt to stop the pain
with a baking soda solution did not bring relief. After taking Nitro-
glycerin under the tongue, the pain decreased, but did not completely
disappear. Nausea, weakness, sweating persisted. In the morning, an
ambulance team was called. The ECG showed a deep Q wave in leads
III and aVF; the ST segment in the same leads is raised above the
isoline, arcuate, passes into a negative T wave; ST segment in leads I,
a VL and V1 to V4 below the contour.
On objective examination: general condition of moderate severi-
ty. Body temperature 36.6 ° C. Consciousness is clear. Active position.
Increased nutrition. The skin is pale, high humidity. Subcutaneous
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adipose tissue of a homogeneous consistency, evenly distributed
over the surface of the body, there is no edema. Hair and nails are
not changed. The thyroid gland is not visually determined, on palpa-
tion of a soft-elastic consistency, painless. Peripheral lymph nodes are
not enlarged. The muscular system is well developed. The joints are
not externally changed. The cardiovascular system. The apical beat
is located in the V intercostal space 1.5-2 cm medially from the left
mid-clavicular line. With percussion, the border of relative cardiac
dullness is within normal limits. On auscultation, heart sounds are
mued, rhythm is regular, no noise is heard. The heart rate is 80 beats
per minute. Blood pressure is 125/75 mm Hg. Respiratory system. On
examination, the chest is of the correct shape, symmetrical. With com-
parative percussion over the entire surface of the lungs, a pulmonary
sound is determined. BR - 20 in 1 min. At auscultation over the lungs,
vesicular breathing is determined on both sides, wheezing is not heard.
On palpation, the abdomen is soft, painless. Percussion borders of the
liver are within normal limits. The gallbladder is not palpable; palpa-
tion in its projection is painless. Stool and urine output 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?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 3
Patient N, 57 years old, choreographer, turned to the family doctor
at the polyclinic with complaints of sharp compressive pains behind
the sternum, which spread to the left shoulder and epigastric region.
From the anamnesis it is known that such pains occurred for the
rst time, on the way to work. Since the clinic was nearby, the patient
consulted a doctor. In the past he suered from pneumonia. Smokes
1 pack a day, does not abuse alcohol.
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59
On objective examination: general condition of moderate severi-
ty. Body temperature 36.6 ° C. Consciousness is clear. Active position.
Satisfactory nutrition. The skin is pale, high humidity. Subcutaneous
adipose tissue of homogeneous consistency, there is no edema. Hair
and nails are not changed. The thyroid gland is not visually deter-
mined, on palpation of a soft-elastic consistency, painless. Peripheral
lymph nodes are not enlarged. The muscular system is well developed.
The joints are not externally changed. The cardiovascular system. BH
24 per minute. Pulse 92 per minute, rhythm is regular, satisfactory
lling. Blood pressure - 165/80 mm Hg. Borders of the heart: right -
along the right edge of the sternum, left - 1 cm outward from the left
mid-clavicular line. Heart sounds are mued, no murmurs. Respira-
tory system. On examination, normal shape of the chest, symmetri-
cal. With comparative percussion over the entire surface of the lungs,
a pulmonary sound is determined. Respiratory rate - 19 in 1 min. At
auscultation over the lungs, vesicular breathing is determined on both
sides, wheezing is not heard. On palpation, the abdomen is soft, pain-
less. Percussion borders of the liver are within normal limits. The gall-
bladder is not palpable; palpation in its projection is painless. Stool
and urine output 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?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 4
Patient N, 56 years old, rector, turned to the family doctor at the
polyclinic with complaints of a feeling of interruptions in the work of
the heart.
From the anamnesis it is known that such sensations are noted
for about a year. However, over the past month, interruptions have
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60
become more frequent, often accompanied by weakness and even diz-
ziness. The appearance of interruptions is more often associated with
physical activity. Periodically, there are attacks of squeezing pain in
the chest during brisk walking, passing at rest.
On objective examination: general condition of moderate severi-
ty. Body temperature 36.6 ° C. Consciousness is clear. Active position.
Increased nutrition. The skin is of normal color and moisture. Subcu-
taneous fatty tissue of homogeneous consistency, evenly distributed
over the surface of the body, there is no edema. Hair and nails are
not changed. The thyroid gland is not visually determined, on palpa-
tion of a soft-elastic consistency, painless. Peripheral lymph nodes are
not enlarged. The muscular system is well developed. The joints are
not externally changed. The cardiovascular system. Blood pressure is
140/95 mm Hg. Pulse - 74 per minute, arrhythmic. The borders of the
heart are not changed. Heart sounds are somewhat mued, arrhyth-
mic - against the background of a regular rhythm, an extraordinary
contraction or a longer interval between heart contractions is periodi-
cally determined. Respiratory system. On examination, normal shape
of the chest, symmetrical. With comparative percussion over the entire
surface of the lungs, a pulmonary sound is determined. Respiratory
rate - 15 in 1 min. At auscultation over the lungs, vesicular breathing
is determined on both sides, wheezing is not heard. On palpation, the
abdomen is soft, painless. Percussion borders of the liver are within
normal limits. The gallbladder is not palpable; palpation in its projec-
tion is painless. Stool and urine output 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?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
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