When identifying the reasons contributing to the development emergency, two situations are possible - the causes of the emergency condition are known or the causes of the emergency condition are unknown.

In the first case, the situation can be clarified: influence of environmental factors; chronic diseases of internal organs; the presence of anamnestic information - from the words of the patient, relatives, acquaintances, loved ones or accompanying the patient (victim); information from medical institutions, etc.

For emergencies, first arising in a “practically” healthy person, the doctor finds himself in a more difficult position. However, even in these cases, it must be remembered that emergency and urgent conditions are most often associated with damage to the cardiovascular system, abdominal organs (especially surgical pathology), followed by pathology of the respiratory system and central nervous system in frequency.

When examining such patients, the doctor should adhere to all rules of propaedeutics, and information must be collected quickly and the data obtained must be reliable, otherwise errors are inevitable. In this case, the leading syndrome is identified, which is confirmed (changed, rejected) by subsequent clinical and laboratory-instrumental methods of studying the patient.

The next stage of the doctor’s work- “enumeration” of conditions, diseases accompanied by this syndrome, followed by differential diagnosis. Thus, with acute vascular insufficiency syndrome, we can talk about bleeding, poisoning, acute pancreatitis, ectopic pregnancy, rhythm disturbances, myocardial infarction, or taking a large dose of antihypertensive drugs.

Diagnosis of emergency conditions, accompanied by “precursor” symptoms, is much more complex and sometimes requires the participation of doctors of different specialties, dynamic monitoring of the patient, and the use of a wide arsenal of auxiliary research methods. The clinical diagnosis of such situations is based on the identification of the leading syndrome - this is the syndrome that has the greatest pathogenetic and clinical significance according to the principle of “greatest danger”.

Evaluating emergency symptoms, it is necessary to keep in mind that such phenomena as vomiting, pain and others are universal, i.e. are present in many diseases, and therefore they not only contribute to the diagnosis, but, on the contrary, complicate it. If the doctor fixes his attention on such universal symptoms and does not notice the hidden, most significant, although not so demonstrative, he can establish, for example, food intoxication where there is a myocardial infarction. Therefore, one should never overestimate a symptom that is very convincing at first glance (a negative symptom can become just as convincing), but should always be based on the syndrome. Of course, the appearance of a reliable symptom solves the diagnostic problem. At the same time, one should not delay establishing a diagnosis (“we will observe”, “we will see”, etc.), since you may miss the time necessary to provide effective assistance to the patient. It is appropriate to recall here: “He who waits for fecal vomiting during intestinal obstruction will never make a mistake in diagnosis, but he rarely saves the patient.”

In the absence of a developed, “undeveloped” clinical picture of emergency condition The principle we have developed - “think about a more severe pathology” can warn against diagnostic errors. Thus, the “acute abdomen” syndrome, consisting of 3 symptom complexes - abdominal pain, dyspeptic disorders, signs of peritoneal irritation - often develops gradually with a predominance of one or another symptom at various clinical stages. Therefore, in case of abdominal pain, the immediate task of the first contact doctor should be to exclude surgical pathology.
Thus, in emergency conditions The main method of diagnosis is the method of differential diagnosis.

In all cases of detection reasons for emergency great importance should be attached to the so-called organizational diagnostic measures, such as:
- thoroughly examine the scene of the incident; carefully examine the patient’s belongings (documents, medications, etc.);
- promptly send food, wash water, and suspicious substances found in the patient for toxicological and bacteriological testing;
- one of the mandatory organizational principles for the management of such patients is continuity, which includes a list and assessment of the main clinical syndromes, the sequence of their appearance, and changes in “quantitative” terms; a list of all studies conducted, etc.;
- when filling out a medical history and medical documentation, it is necessary to monitor hourly the occurrence of new clinical manifestations, the administration of medications and their effectiveness, consultations with senior colleagues and doctors of other specialties, etc.

Autonomic dysfunction syndrome combines sympathetic, parasympathetic and mixed symptom complexes of a generalized, systemic or local nature, manifesting permanently or in the form of paroxysms (vegetative-vascular crises), with non-infectious low-grade fever, and a tendency to temperature asymmetry.

Sympathicotonia is characterized by tachycardia, pallor of the skin, increased blood pressure, weakened intestinal motility, mydriasis, chills, a feeling of fear and anxiety. During a sympathoadrenal crisis, a headache appears or intensifies, numbness and coldness of the extremities occurs, the face becomes pale, blood pressure rises to 150/90-180/110 mmHg, the pulse quickens to 110-140 beats/min, pain in the area is noted heart, excitement, motor restlessness appear, sometimes body temperature rises to 38-39 °C.

Vagotonia is characterized by bradycardia, difficulty breathing, redness of the facial skin, sweating, salivation, decreased blood pressure, and gastrointestinal dyskinesia. Vagoinsular crisis is manifested by a feeling of heat in the head and face, suffocation, heaviness in the head, nausea, weakness, sweating, dizziness, the urge to defecate, increased intestinal motility, miosis is noted, a decrease in pulse to 45-50 beats per minute, a decrease in blood pressure. up to 80/50 mm Hg. Art.

Mixed crises are characterized by a combination of symptoms typical of crises, or their alternate manifestation. There may also be: red dermographism, zones of hyperalgesia in the precordial region, “spotted” hyperemia of the upper half of the chest, hyperhidrosis and acrocyanosis of the hands, tremor of the hands, non-infectious low-grade fever, a tendency to vegetative-vascular crises and temperature asymmetries.

Syndrome of mental disorders - behavioral and motivational disorders - emotional lability, tearfulness, sleep disturbance, feeling of fear, cardiophobia. Patients with VSD have a higher level of anxiety, they are prone to self-blame, and experience fear in making decisions. Personal values prevail: great concern for health (hypochondria), activity decreases during illness. When diagnosing, it is important to differentiate between somatoform autonomic dysfunction, in which there are no mental disorders, and hypochondriacal disorder, also considered a somatogenic neurosis-like condition, as well as panic disorder and phobias, other nervous and mental diseases.

Syndrome of adaptation disorders, asthenic syndrome - fatigue, weakness, intolerance to physical and mental stress, weather dependence. Evidence has been obtained that asthenic syndrome is based on disturbances in transcapillary metabolism, decreased tissue oxygen consumption and impaired hemoglobin dissociation.

Hyperventilation (respiratory) syndrome is a subjective feeling of lack of air, chest compression, difficulty in breathing, and the need for deep breaths. In a number of patients it occurs in the form of a crisis, the clinical picture of which is close to suffocation. The most common reasons that provoke the development of respiratory syndrome are physical exertion, mental stress, staying in a stuffy room, sudden changes in cold and heat, and poor transport tolerance. Along with the mental factors of shortness of breath, a decrease in the compensatory and adaptive capabilities of the respiratory function to hypoxic loads is of great importance.

Neurogastric syndrome - neurogastric aerophagia, esophageal spasm, duodenostasis and other disorders of the motor-evacuation and secretory functions of the stomach and intestines. Patients complain of heartburn, flatulence, constipation.

Cardiovascular syndrome - cardialgia in the left half of the chest that occurs during emotional rather than physical stress, is accompanied by hypochondriacal disorders and is not relieved by coronal drugs. Blood pressure fluctuations, pulse lability, tachycardia, functional murmurs. ECG and ledergometry most often reveal sinus and extrasystolic arrhythmias; there are no signs of myocardial ischemia.

Cerebrovascular syndrome - headaches, dizziness, noise in the head and ears, tendency to faint. Their development is based on cerebral angiodystonia, the pathogenetic basis of which is dysregulation of cerebral vascular tone of a hypertonic, hypotonic or mixed nature. In some patients with persistent cephalgic syndrome, there is a violation of the tone of not only arterial, but also venous vessels, the so-called functional venous hypertension.

Syndrome of metabolic tissue and peripheral vascular disorders - tissue edema, myalgia, angiotrophoneurosis, Raynaud's syndrome. Their development is based on changes in vascular tone and vascular permeability, disturbances in transcapillary exchange and microcirculation.

Cardiac syndrome

VSD of the cardiac type is the most common form. It is this that causes overdiagnosis of organic heart pathology, which in turn is fraught with serious consequences: excommunication from physical education and sports, exemption from military service, warnings regarding pregnancy and childbirth, frivolous removal of tonsils, unnecessary prescription of thyreostatic, anti-inflammatory, antianginal and other drugs.

Among the leading cardiac syndromes are: cardialgic, tachycardial, bradycardic, arrhythmic, hyperkinetic.

Cardialgic syndrome

Cardialgic syndrome occurs in almost 90% of patients. Cardialgia is associated with increased susceptibility of the central nervous system to interoceptive stimuli; vegetologists regard them as sympathalgia. Once it occurs, cardialgia is consolidated using the mechanisms of self-hypnosis or a conditioned reflex. May be a form of addiction to psychoactive substances (for example, valocordin and other barbiturates). The pain can be of a different nature: constant aching or pinching in the area of the apex of the heart, intense prolonged burning in the area of the heart, paroxysmal prolonged cardialgia, paroxysmal short-term pain or pain that occurs in connection with physical activity, but does not interfere with the continuation of the exercise. Stress and drug tests are undoubtedly helpful in making a diagnosis. When the terminal part of the ventricular complex changes on the ECG, a stress test in the case of functional cardialgia leads to a temporary reversion of the T wave, and in patients with coronary artery disease it is aggravated. Drug tests in the first case also lead to temporary reversion, but not in the second. For differential diagnosis, non-invasive methods are used, studying the dynamics of lactate during atrial stimulation. It is more difficult to differentiate between functional cardialgia and stress cardiomyopathy.

Tachycardia syndrome

Tachycardia syndrome characterized by increased automaticity of the sinoatrial node (SA node) with an increase in the number of heartbeats to 90 or more per minute. More often, the syndrome is based on an increase in the tone of the sympathetic nervous system, less often - a decrease in the tone of the vagus nerve.

Sinus tachycardia significantly limits the physical performance of patients, which is confirmed by testing with dosed physical activity. The heart rate reaches submaximal values for a given age even when performing low-power work - 50-75 W. With sinus tachycardia, the number of heart contractions at rest rarely exceeds 140-150 beats per minute.

Bradycardic syndrome

Bradycardic syndrome involves a slowdown of heartbeats to 60 per minute or less due to a decrease in the automaticity of the SA node due to an increase in the tone of the vagus nerve. The criterion for sinus bradycardia should be a reduction in contraction frequency to 45-50 beats per minute or less. The bradycardic variant is much less common. With more pronounced bradycardia, there may be complaints of headaches and precordial pain, dizziness with rapid extension of the body or transition to orthostasis, and a tendency to fainting and fainting states. Other signs of vagoinsular predominance are also identified: poor cold tolerance, excessive sweating, cold hyperhidrosis of the palms and feet, cyanosis of the hands with a marbled skin pattern, spontaneous dermographism. On the ECG, “giant” (“vagal”) T waves may appear in the precordial leads, especially in V2-V4.

Arrhythmic syndrome

Arrhythmic syndrome. In patients with VSD, as part of the arrhythmic syndrome, extrasystole is more common, supraventricular forms of paroxysmal tachycardia are less common, and paroxysms of atrial fibrillation or flutter are extremely rare. Rhythm disturbances in functional heart diseases most often have to be differentiated from mild myocarditis (rheumatic and non-rheumatic), myocardial dystrophies, reflex effects on the heart (osteochondrosis, gallbladder pathology), hyperfunction of the thyroid gland.

Hyperkinetic cardiac syndrome

Hyperkinetic cardiac syndrome is an independent clinical type of VSD. Like other cardiac syndromes, it is a centrogenically caused autonomic disorder. The final link in its pathogenesis is an increase in the activity of beta-1 adrenergic receptors of the myocardium against the background and due to sympathadrenal predominance. As a result, a hyperkinetic type of blood circulation is formed with a characteristic hemodynamic triad: 1) an increase in stroke and cardiac output, far exceeding the metabolic needs of tissues; 2) an increase in the rate of blood expulsion from the heart and 3) a compensatory drop in total peripheral vascular resistance.

Treatment

Two treatment approaches should be considered: treatment of general disorders, which is carried out as part of the treatment, first of all, of diseases in which VSD manifests itself, and individual treatment of specific cardiac syndromes.

Etiotropic treatment should start as soon as possible. If psychogenic influences predominate on the patient, the impact of psychoemotional and psychosocial stressful situations should, if possible, be eliminated (normalization of family and household relations, prevention and elimination of hazing in the troops).

Neuroleptics have a powerful effect on the cardiovascular system and are able to produce antiarrhythmic, hypotensive, analgesic effects, and relieve permanent autonomic disorders.

Other areas of etiotropic therapy: for infectious-toxic form - sanitation of the oral cavity, tonsillectomy; for VSD associated with physical factors, including military labor (ionizing radiation, microwave field, etc.) - elimination of occupational hazards, rational employment; in case of VSD against the background of physical overstrain - avoidance of excessive physical exertion, gradual expansion of physical activity.

Pathogenetic therapy consists in normalizing the disturbed functional relationships of the limbic zone of the brain, hypothalamus and internal organs.

Taking the herbs valerian and motherwort for 3–4 weeks has a beneficial effect "stem effect"; tranquilizers (seduxen, relanium, mebikar - daytime tranquilizer) relieve anxiety, fear, emotional and mental tension (duration of therapy - 2-3 weeks); belloid, bellaspon - “vegetative correctors”, normalize the function of both parts of the autonomic nervous system: antidepressants (amitriptyline, azaphene, coaxil) reduce feelings of anxiety and depression; nootropics, neurometabolites improve energy processes and blood supply to the brain; cerebrocorrectors (Cavinton, Stugeron, course of treatment - 1–2 months) normalize cerebral circulation; β-blockers reduce the increased activity of the sympathoadrenal system.

Physiotherapy, balneotherapy, massage, acupuncture - electrosleep, electrophoresis with bromine, anaprilin, novocaine, seduxen, water treatments (showers, baths), aeroionotherapy, acupressure and general massage.

General strengthening and adaptation therapy recommended for the treatment of VSD in moderate to severe cases. It includes a healthy lifestyle, elimination of bad habits, moderate physical activity, aesthetic therapy, therapeutic nutrition (fighting obesity, limiting coffee, strong tea), exercise therapy in combination with adaptogens, and breathing exercises.

Of particular importance in some forms of VSD (asthenia, hypotonic forms, orthostatic disorders) is the intake of adaptogens, which have a tonic effect on the central nervous system and the body as a whole, metabolic processes and the immune system: ginseng - 20 drops 3 times a day, eleutherococcus - 20 drops 3 times, lemongrass - 25 drops 3 times, zamanika, aralia, pantocrine - 30 drops 3 times a day. The course of treatment is 3–4 weeks, 4–5 courses per year, especially in the fall, spring and after the flu epidemic.

Spa treatment is important as a factor in the rehabilitation of patients with moderate VSD. The main resort factors are climatotherapy, mineral waters, sea bathing, exercise therapy, health path, balneotherapy, physiotherapy, nature. Individual treatment of patients with VSD involves the treatment of specific cardiac syndromes. Cardialgic syndrome. Of the psychotropic drugs, the most effective is the use of mezapam, grandaxin and especially “mild” neuroleptics - frenolone or sonapax.

Classic sedatives, especially valerian tea, are of auxiliary importance. For those already accustomed to barbiturates, you can use the sedative and analgesic effects of drops such as Corvalol Valocordin and others, although it is not recommended to prescribe such psychotropic drugs. Sublingual use of validol containing menthol calms pain well. Local influence also brings relief: self-massage of the precordial area, mustard plasters, pepper patch, applications with menovazine for persistent pain, physical methods of treatment - acupuncture, electroanalgesia, laser treatment, dorsonvalization.

In the case of vegetative crises, the α-adrenergic blocker pyrroxan should be added 0.015–0.03 g 2–3 times a day, anaprilin 20–40 mg 2–3 times a day. To stop the crisis itself, use Relanium - 2–4 ml of a 0.5% solution or droperidol - 1–2 ml of a 0.5% solution intravenously and pyrroxan - 2–3 ml of a 1% solution intramuscularly.

Tachycardia syndrome

Beyond competition are b-blockers; they reduce the increased activity of the sympathetic nervous system (one of the methods of pathogenetic treatment of VSD). 2 drugs of medium duration of action (6–8 hours) are prescribed - propranolol (Anaprilin, Obzidan) and metoprolol (Spesicor, Betalok) and 2 drugs of long-term (up to 24 hours) action - atenolol (Tenormin) and nadolol (Korgard). If treatment with b-blockers is difficult, you can use tincture of lily of the valley (strictly follow the dosage and duration of the course, take potassium supplements to prevent side effects, monitor blood pressure). Courses of treatment are 1–2 months, maintenance therapy is possible.

Bradycardic syndrome

Bradycardia is less than 50 beats per minute, accompanied by cerebral or cardiac symptoms. To restore vegetative balance, peripheral M-anticholinergic blockers are used - atropine and belladonna preparations. The initial amount of atropine is 5-10 drops 3-4 times a day. If the result is not achieved, the dose is increased. The dose of belladonna tincture is the same. Tablets with dry belladonna extract - becarbonate - are used. The drug Itrol, 1/2 tablet (0.01 g) 2-3 times a day, has proven itself well.

Tonic balneotherapy has a beneficial effect on neurogenic bradycardia: cool (22–30 °C) pine or salt baths, radon baths with a low concentration of radon, carbon dioxide and pearl baths, fan and especially circular cold showers. All patients are recommended physical therapy - from morning exercises to running, swimming and sports games.

Arrhythmic syndrome

For patients with functional heart diseases, the use of antiarrhythmic drugs without psychosedative therapy is futile. Particularly indicated are: mezapam, grandaxin, nozepam, which can help without antiarrhythmic drugs. The main indication for the treatment of extrasystoles is their poor subjective tolerability. With obvious sympathoadrenal predominance, that is, with “extrasystoles of tension and emotions,” especially against the background of an accelerated rhythm, b-blockers (propranolol, metoprolol, atenolol, nadolol) are out of competition.

With “vagal” supraventricular extrasystoles, especially against the background of a rare rhythm, at the first stage it is advisable to use anticholinergic agents: atropine, belladonna preparations or itrol. If the effectiveness of anticholinergics is insufficient, they are replaced by b-adrenergic agonists or combined with them. It is advisable to start treating the ventricular form of resting extrasystole with Strasikor and Viscena. For the supraventricular form of extrasystole, verapamil can be prescribed; for the ventricular form, antiarrhythmic drugs deserve attention: etmozin, etacizin, and cordarone. All antiarrhythmic drugs can cause arrhythmias, especially when combined, so the indication for their use should be organic pathologies.

It should be noted that VSD can be a manifestation of various diseases. It is especially important to differentiate somatoform autonomic dysfunction of the heart and cardiovascular system with both stress cardiomyopathy and post-traumatic stress disorder, panic disorder, phobias and other mental and behavioral disorders, including neuroses, as well as neurosis-like somatogenic conditions. Somatoform autonomic dysfunction of the heart and cardiovascular system is often combined with either neurological diseases or mesenchymal dysplasia. A comprehensive examination by therapists, cardiologists, endocrinologists, neurologists, hematologists is required, with the involvement of medical geneticists, if necessary. Unfortunately, for example, pheochromocytoma in patients with VSD is usually diagnosed only posthumously - and this is evidence that patients with VSD are not properly examined.

Diseases in which VSD syndrome is observed (stress cardiomyopathy, phobias, diabetes, parkinsonism, especially Shy-Drager syndrome, radiation sickness, etc.) and diseases whose prestage is manifested by VSD syndrome can pose a threat to the lives of patients. For example, somatoform autonomic dysfunction of the heart and cardiovascular system can be a prestage of essential hypotension, diffuse toxic goiter, hypertension, which threatens life and health during hypertensive crises as a result of the development of heart failure, renal failure, etc.

25.Traumatic brain injury(TBI) - damage to the bones of the skull or soft tissues, such as brain tissue, blood vessels, nerves, meninges.

Classification Brain concussion. It is characterized by short-term loss of consciousness at the time of injury, vomiting (usually one-time), headache, dizziness, weakness, painful eye movements, etc. There are no focal symptoms in the neurological status. Macrostructural changes in the brain substance during a concussion are not detected.
Mild brain contusion. Characterized by loss of consciousness up to 1 hour after injury, complaints of headache, nausea, and vomiting. In the neurological status, rhythmic twitching of the eyes when looking to the sides (nystagmus), meningeal signs, and asymmetry of reflexes are noted. X-rays may reveal fractures of the cranial vault. There is an admixture of blood in the cerebrospinal fluid (subarachnoid hemorrhage).
Moderate brain contusion. Consciousness turns off for several hours. There is a marked loss of memory (amnesia) for the events preceding the injury, the injury itself, and the events after it. Complaints of headache, repeated vomiting. Short-term disorders of breathing, heart rate, and blood pressure are detected. There may be mental disorders. Meningeal signs are noted. Focal symptoms manifest themselves in the form of uneven pupil size, speech impairment, weakness in the limbs, etc. Craniography often reveals fractures of the vault and base of the skull. Lumbar puncture revealed significant subarachnoid hemorrhage.
Severe brain contusion. Characterized by prolonged loss of consciousness (lasting up to 1-2 weeks). Gross violations of vital functions are detected (changes in pulse rate, pressure level, frequency and rhythm of breathing, temperature). The neurological status shows signs of damage to the brain stem - floating movements of the eyeballs, swallowing disorders, changes in muscle tone, etc. Weakness in the arms and legs, up to paralysis, as well as convulsive seizures may be detected. A severe bruise is usually accompanied by fractures of the vault and base of the skull and intracranial hemorrhages.
Brain compression. The main cause of brain compression during traumatic brain injury is the accumulation of blood in a closed intracranial space. Depending on the relationship to the membranes and the substance of the brain, epidural (located above the dura mater), subdural (between the dura mater and the arachnoid mater), intracerebral (in the white matter of the brain and intraventricular (in the cavity of the ventricles of the brain) hematomas are distinguished. The cause of compression of the brain can be There may also be depressed fractures of the bones of the cranial vault, especially penetration of bone fragments to a depth of more than 1 cm.

Treatment

Treatment of traumatic brain injuries can be divided into 2 stages. The stage of providing first aid and the stage of providing qualified medical care in a hospital.

If there is an episode of loss of consciousness, the patient, regardless of his current condition, needs to be transported to a hospital. This is due to the high potential risk of developing severe life-threatening complications.

After admission to the hospital, the patient undergoes a clinical examination, anamnesis is collected, if possible, and the nature of the injury is clarified with him or those accompanying him. Then a set of diagnostic measures is performed aimed at checking the integrity of the bone frame of the skull and the presence of intracranial hematomas and other damage to brain tissue.

The simplest diagnostic method is skull radiography, however, due to the peculiarities of the method, its effectiveness is relatively low, even with the use of special installations; approximately 20-30% of the area of the skull bones remains inaccessible for assessing their integrity. Also, this method does not allow assessing the condition of brain tissue. The method of choice for this type of injury is computed tomography. This technique allows you to obtain an image of all the bones of the cranial vault and assess the condition of the brain. The disadvantage of the technique is the high cost of computed tomographs and, as a consequence, their low prevalence. As a rule, only relatively large clinics have such devices.

In Russia and the CIS countries, as a rule, victims admitted primarily with TBI are examined using radiography methods, and in cases where this technique does not give a clinically significant result, patients are sent to CT.

After the examination determines the type of traumatic brain injury, the traumatologist decides on the treatment tactics for the patient. Treatment methods and regimens differ depending on the type of injury, but in general they pursue the same goals.

The main goal is to prevent damage to brain tissue, and as a result, maintain normal intracranial pressure and protect the cerebral cortex from hypoxia. In some cases, trepanations are performed for this purpose in order to drain intracranial hematomas. In the absence of bleeding into the cranial cavity, patients are usually treated with conservative therapy.

Forecast

The prognosis of the disease largely depends on the nature and severity of the injury. For minor injuries, the prognosis is conditionally favorable; in some cases, complete recovery occurs without medical care. With severe injuries, the prognosis is unfavorable; without immediate adequate medical care, the patient dies.

There are cases when, even with serious traumatic brain injuries, doctors managed to save patients. A striking example of this is the case of Carlos Rodriguez, who was left almost completely without the frontal part of his head.

26.Migraine- a neurological disease, the most common and characteristic symptom of which is episodic or regular severe and painful attacks of headache in one (rarely in both) half of the head. In this case, there are no serious head injuries, stroke, or brain tumors, and the intensity and pulsating nature of the pain is associated with vascular headache, and not with tension headache. Migraine headache is not associated with an increase or sharp decrease in blood pressure, an attack of glaucoma, or an increase in intracranial pressure. (ICP).

Prevalence

Migraine is a chronic disease common in the population (10% of diagnosed patients, and another 5% of undiagnosed or misdiagnosed patients). It is most often found in women, as it is transmitted mainly through the female line, however, it often also affects men. The severity of the disease varies from rare (several times a year), relatively mild attacks, to daily; but, most often, migraine attacks recur at intervals of 2-8 times a month. Specific treatment is often expensive. Intermittent or unpredictable loss of work capacity during and shortly after attacks may result in the patient being considered disabled due to the patient's inability to work sufficient hours per week, or at all.

The leading clinical syndrome of syncope is momentary loss of consciousness . The development of fainting can be divided into three stages.

Presyncope (beginning disruption of the blood supply to the brain). In some cases, fainting is preceded by a number of clinical symptoms - dizziness, weakness, nausea, yawning, increased intestinal motility, a feeling of “lightheadedness,” visual impairment in the form of diplopia, darkening or fogging before the eyes, bright flashes of light, noise and ringing in the ears. Some fainting episodes develop suddenly without any warning. Sometimes a complete loss of consciousness does not occur and everything is limited to the symptoms described above, the so-called. swoon.

State of fainting (GM hypoxia). There is pallor of the skin, often hyperhidrosis. Muscular hypotonia, hyporeflexia, the patient slowly settles down. Pulse weak, small, maybe thread-like, sinus arrhythmia, moderate bradycardia or tachycardia, arterial hypotension. Breathing is shallow, rapid or rare, in severe cases it may be Cheyne-Stokes breathing. The depth of loss of consciousness varies. The pupil is narrow, however, if fainting lasts for more than 3 minutes, the pupil dilates, and sometimes nystagmus appears. When fainting lasts more than 3 minutes, a convulsive syndrome in the form of tonic/clonic convulsions is often observed, drooling, involuntary urination and defecation are possible.

Post-syncope period (restoration of blood supply to the brain). Recovery of consciousness after fainting may be rapid or gradual. General weakness, dizziness, a feeling of “light-headedness,” and pale skin often persist. There is no amnesia.

4. Diagnostic criteria for fainting:

sudden loss of consciousness lasting from several seconds to several minutes;

pale skin, hyperhidrosis, beads of sweat, cold extremities;

the pupils are constricted (can dilate with loss of consciousness for more than 3 minutes);

pupillary and corneal reflexes are reduced or absent;

pain sensitivity is reduced, but not lost;

breathing is shallow, often rare;

the pulse is weak, small, and may not be detected in the peripheral arteries;

Blood pressure is usually reduced, but may be within the individual normal range;

when fainting lasts more than 3 minutes - tonic convulsions, sometimes single clonic twitching, involuntary urination and defecation;

complete recovery of consciousness after recovering from fainting.

In the daily practice of a general practitioner, the most important thing is to differentiate fainting from an epileptic seizure and hysteria (Table 48).

Table 48

Differential diagnostic signs of fainting, epileptic seizure and hysteria

Determination of the leading syndrome. Liver cirrhosis of mixed etiology, Child class B

XIII. preliminary diagnosis. differential diagnosis with syndromic-similar diseases.

Once the leading syndromes have been identified, it becomes possible to localize the pathological process in any body system or individual organ (for example, liver, heart, kidney, lungs, bone marrow, etc.). Syndromes make it possible to determine (clarify) the pathoanatomical and pathophysiological essence of the pathological process (for example, bronchial obstruction, circulatory disorders in a particular vascular area, immune or infectious inflammation, etc.). This brings the curator closer to nosological diagnosis, since this or that syndrome (or group of syndromes) is characteristic of a very limited number of diseases and allows the curator to narrow the range of diseases in differential diagnosis.

Thus, highlighting symptoms and syndromes, the curator constantly (as information is received) compares them with the “standards” of the disease and decides which disease the “image” of the patient’s disease obtained during the study of the patient corresponds to.

In this case, 2 situations may arise:

Ø the “image” of the disease identified in the patient under study is completely identical to a specific (one) disease. This is the so-called direct diagnosis, which does not happen too often in clinical practice.

Ø a different situation is more typical: the “image” of the disease is “similar” to two, three or more diseases. Then a “circle” of diseases that need to be differentiated is outlined, and the curator carries out differential diagnosis, determines which of the differentiated diseases his information corresponds to the greatest extent.

XIV. Clinical diagnosis and its rationale

A clinical diagnosis should be made after differential diagnosis with syndromic diseases within 3 days of the patient’s hospital stay.

When setting it, generally accepted classifications of the disease are taken into account.

The formulation of a clinical diagnosis should highlight:

1. Main disease

2. Complications of the underlying disease

3. Concomitant diseases

The formulation of a clinical diagnosis is followed by its fragmentary justification, i.e. Each part of the diagnosis is justified separately.

XV. SURVEY PLAN

The survey plan consists of several sections:

I. Mandatory studies carried out on all patients without exception.

II. Studies necessary for differential diagnosis and clarification of the diagnosis (additional research methods).

III. Consultations with specialists.

Mandatory studies include:

Ø general blood test

Ø General urine test

Ø stool analysis for worm eggs

Ø biochemical blood test: total protein, blood sugar, cholesterol, bilirubin, creatinine.

Ø blood test for RW, Rh – factor, HIV infection.

Ø X-ray examination of the chest organs.

Scope of additional research determined in each specific diagnostic situation.

Thus, in a pulmonary patient, a general sputum analysis, microbiological analysis (culture) of sputum, and a study of the sensitivity of microflora to antibiotics are added to the clinical tests; a list of necessary biochemical, immunological, enzymatic and other studies is determined; instrumental studies (spirography, bronchoscopy, computed tomography, Doppler echocardiography, etc.). In difficult diagnostic situations, it is necessary to carry out repeated studies over time, as well as perform complex studies: magnetic resonance imaging, scintigraphy, stress echocardiography, coronary angiography.

Signs

Fainting

Epileptic

seizure

Hysteria

Harbingers

Darkening in the eyes, numbness of fingers and toes, severe weakness, noise or ringing in the head

There may be an aura - visual, olfactory, auditory, gustatory

Poor tolerance to orthostasis, stuffiness

Recurrent seizures, according to the patient or relatives

Demonstrativeness and hysterical mental traits

Heredity

By vegetative

dysfunction

For epilepsy

Convulsions

Rarely, tonic

Generalized

tonic-clonic

For demonstration purposes

Tongue bite

Involuntary urination

Development time

Usually during the day

Anytime

In public

Normal

or increased

Normal

Weak, small or

filiform

Tense

Unchanged or moderate tachycardia

Breathing problems

Superficial

Stopping breathing

in the tonic phase

Duration of attack

From a few seconds

up to several minutes

Variable, depends on the situation

Drowsiness after an attack

Post-attack

No, but possible

simulation

Injury from a fall

Tongue bite

Vegetative

Hyperhidrosis,

pale skin

Facial cyanosis

Not expressed

Pupillary reactions

None

4. Evaluate the complete blood count. How do its results characterize the pathological process?

Examination task No. 1 (pediatric faculty)

Sample answer to problem No. 1

2. Formulation and justification of the leading clinical syndrome.

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate clinical syndromes.

4. Evaluate the complete blood count. How do its results characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate clinical syndromes.

4. Evaluate the complete blood count. How do its results characterize the pathological process?

9. Plan additional research methods. Explain their purpose.

10. Assess the situation from the point of view of the presence of an emergency condition. If necessary, indicate the amount of emergency care.

5. Evaluate the complete blood count. How do its results characterize the pathological process?

5. Evaluate the complete blood count. How do they characterize the pathological process?

5. Evaluate the complete blood count. What information does the blood test provide about the pathogenesis of the patient's symptoms?

4. Analyze a biochemical blood test, evaluate the ratio of direct and indirect bilirubin. How do these changes characterize the pathological process?

1. Identify the leading symptoms and suggest the localization of the pathological process.

2. How would you evaluate the data obtained from palpation of the abdomen, as evidenced by the positive symptoms of Ker, Georgievsky-Mussy, Ortner?

3. Formulate the clinical syndrome.

4. Analyze a biochemical blood test, evaluate the ratio of direct and indirect bilirubin. How do these changes characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Identify the leading clinical syndromes.

4. Evaluate the complete blood count. How do changes in the blood test explain (clarify) the patient's physical symptoms?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate clinical syndromes.

4. Evaluate the complete blood count. How do its results characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

4. What is bronchial breathing, what is the mechanism of its formation in this case.

5. What auscultation techniques can be used to clarify the nature of adverse respiratory sounds?

6. Evaluate the general blood test, how do its results characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate clinical syndromes.

4. Evaluate the general blood test, how do its results characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate clinical syndromes.

4. Evaluate the complete blood count. How do its results characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Using clinical symptoms, formulate the syndrome.

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate a clinical syndrome using clinical symptoms.

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate the syndromes.

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. The diagnosis of which syndrome should be suspected based on the clinical symptoms of the disease?

4. Evaluate the complete blood count. How does it characterize the pathological process and explain clinical symptoms?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. The diagnosis of which syndrome should be suspected based on the clinical symptoms of the disease?

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate the clinical syndrome.

4. Evaluate the complete blood count. How do its results characterize the pathological process?

5. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. The diagnosis of which syndrome should be suspected based on the clinical symptoms of the disease?

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. The diagnosis of which syndromes should be assumed using data from anamnesis and objective examination?

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate the syndromes.

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. Explain the pathogenesis of these symptoms and indicate their specific characteristics.

3. Formulate the syndromes.

4. Evaluate the complete blood count. How does it characterize the pathological process?

1. Identify the leading symptoms.

2. The diagnosis of which syndromes should be suspected based on the clinical symptoms of the disease?

3. Assess the complete blood count. How does it characterize the pathological process?

2. Formulation and justification of the leading clinical syndrome.

Syndrome of compaction of lung tissue in the lower lobe of the left lung.

A decrease in pneumatization (hardening) of the lower lobe of the left lung is indicated by physical symptoms: increased vocal tremors, dullness of percussion sound, the appearance of pathological bronchial breathing, increased bronchophony.

Assessment of general blood test indicators, connection with the clinical picture.

Neutrophilic leukocytosis, an increase in ESR confirm the infectious-inflammatory nature of the process, and a left nuclear shift confirms its severity.

Assessment of general urine analysis indicators, connection with the clinical picture.

The indicators are within the physiological norm, which indicates the absence of a negative impact of the main pathological process on the state of the urinary system.

Assessment of indicators of general sputum analysis, connection with the clinical picture.

The muco-hemorrhagic nature indicates the inflammatory nature of the pathological process and confirms the symptom of hemoptysis; the presence of alveolar macrophages – o involvement of the alveoli in the process; absence of VC - about the nonspecific nature of the process (denial of TBS); flora is typical for lobar pneumonia.

Assessment of biochemical blood test parameters, connection with the clinical picture.

Dysproteinemia (increase in α2 and γ-globilins) is characteristic of the inflammatory process.

Evaluation of the result of a blood sugar test, connection with the clinical picture.

The indicator is within the physiological norm, which indicates the absence of carbohydrate metabolism disorders.

ECG analysis, connection with the clinical picture.

The rhythm is sinus (P II positive).

The rhythm is correct (RR intervals are the same).

Heart rate = 60/0.54 = 111 per minute.

Vertical position of the electrical axis of the heart (R III ≥ R II >R I,R III, and VF – max,R I =S I).

Conduction is not impaired (P wave duration = 0.1 sec., PQ int. = 0.14 sec., QRS = 0.08 sec.).

No atrial hypertrophy was detected (P II wave without pathological changes).

Ventricular hypertrophy was not detected (the amplitude of the R V 1-V 2 and R V 5-V 6 waves was not increased).

No nutritional disturbances (ischemia, damage and necrosis) of the myocardium were detected (pathological Q is absent, the ST segment and T wave are unchanged in all leads).

Conclusion: sinus tachycardia with heart rate 111 per minute, vertical position of the electrical axis of the heart.

ECG data confirm the clinically detected tachycardia associated with an increase in the metabolic activity of the myocardium against the background of fever.

A reasoned plan for additional methods of examining the patient, allowing to clarify the syndromic diagnosis.

A) X-ray examination of the lungs in two projections will make it possible to clarify the presence, localization, shape and size of the focus of compaction (inflammatory homogeneous infiltrate of lung tissue in the lower lobe of the left lung), and the participation of the pleura.

B) A study of the external respiration function will confirm the presence of respiratory failure, its nature and severity (DN stage II, restrictive type).

Assessing the situation from the point of view of the presence of an emergency condition, indicating the level and volume of emergency care.

There are clinically significant signs of an emergency condition (level 2 NS) - fever 39.0 °C against the background of general intoxication and respiratory failure (DNIIst). It is necessary to carry out detoxification therapy using antipyretic, antibacterial (taking into account the sensitivity of the flora) agents, symptomatic and oxygen therapy.

EXAMINATION TASK No. 47

Patient N., 85 years old, a veteran of the Second World War, was called by his local physician for a preventive examination. Complains of mixed shortness of breath, worsening with physical activity, morning cough with scanty mucous sputum.

From the anamnesis: he has been suffering from chronic bronchitis for 15 years, smoking experience - 45 years, prefers cigarettes without a Prima filter, smoking intensity is 15 cigarettes per day.

Objectively: general condition is satisfactory. Consciousness is clear. Position active. The physique is correct. Cyanosis of the skin is determined. The skin is clean, moderate moisture. Visible mucous membranes are moist. Subcutaneous fat tissue is well developed and evenly distributed.

Mixed breathing type, respiratory rate - 24 per minute. A barrel-shaped chest, an obtuse epigastric angle, and a horizontal arrangement of the ribs were revealed. The supraclavicular and subclavian fossae are smoothed. Palpation: vocal tremor is carried out equally on both sides, somewhat weakened. With comparative percussion, a boxed sound is determined.

With topographic percussion: the height of the apexes of the lungs on both sides in front is 5 cm above the collarbone, in the back - 1 cm above the spinous process of the VII cervical vertebra. The width of Krenig's fields is 10 cm. The lower border of the lungs along the mid-axillary line on both sides is along the 9th rib.

Excursion of the pulmonary edge along the mid-axillary line on the right and left is 4 cm.

Auscultation: equally weakened vesicular breathing and weakened bronchophony are heard over both lungs. There are no adverse breath sounds.

The pulse on the radial arteries is rhythmic, 90 beats per minute, with satisfactory filling and tension. The zone of absolute cardiac dullness is not determined. Heart sounds are muffled, rhythmic, heart rate is 90 per minute, the accent of the 2nd tone is determined over the pulmonary artery. Blood pressure 120/80 mm Hg. Art.

1. Identify the leading symptoms.

Analyze the identified symptoms and group them into clinical syndromes.

Additional examination was carried out

General blood analysis: erythrocytes - 4.5 T/l, Hb - 160 g/l, c.p. - 1.0, leukocytes - 7.0 G/l, e-2%, p-2%, s - 60%, l – 28%, m – 8%, ESR – 20 mm/hour.

General urine analysis: color – yellow, transparent, beat. weight – 1018, flat epithelial cells – 2-4 in the field of view, leukocytes – 1-2 in the field of view, mucus + +.

General sputum analysis: color - gray, character - mucous, consistency - liquid, squamous epithelium - 2 - 4 in the field of view, columnar epithelium 4 - 6 in the field of view, leukocytes - 1 - 2 in the field of view.

FVD study was performed:

FEV 1/VC 89%

Determine the type and degree of respiratory dysfunction.

8. Perform ECG analysis. How do its data characterize the pathological process?

indicate the scope of emergency care.

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 25 pediatric faculty.

Patient M., 45 years old, was admitted to the emergency department with complaints of shortness of breath at rest, a feeling of heaviness in the right half of the chest, fever up to 40°C, weakness, and sweating.

From the anamnesis: fell ill acutely a week ago, when he noted the appearance of chills, fever up to 400 C, then pain in the right half of the chest associated with coughing and deep breathing. shortness of breath at rest. I took paracetamol without effect. The disease is associated with hypothermia. The chest pain stopped, shortness of breath intensified, which was the reason for calling an ambulance team, who was taken to the department.

Objectively: The general condition is serious. Consciousness is clear. Lying on his right side. The physique is correct, normosthenic. The skin is hyperemic, hot, moist, clean. Feverish gleam of eyes. Visible mucous membranes are moist and shiny. There are no trophic changes in the nails.

The submandibular lymph nodes are palpated (on the left - 0.5 cm in D, on the right 0.7 cm in D), elastic, mobile, painless. Other groups of lymph nodes are not palpable. Muscle tone is preserved. There is no deformation of the joints. Active and passive movements in the joints in full.

Breathing through the nose is not difficult. The chest is asymmetrical. Its right half bulges and lags behind in the act of breathing. Litten's sign is positive. The type of breathing is abdominal, respiratory rate - 24 per minute. On palpation in the inferolateral part of the chest on the right, vocal tremor is sharply weakened; upon comparative palpation, a zone of dull sound is determined in the same place. Over other parts of the lungs, the vocal tremor is not changed, there is a clear pulmonary percussion sound.

With topographic percussion: the height of the apexes of the lungs in front is 3.5 cm above the collarbone, in the back - at the level of the spinous process of the VII cervical vertebra. The width of Krenig's fields is 6 cm. The lower border of the lungs is along the mid-axillary line on the right - along the 5th rib, on the left - along the 8th rib. Excursion of the lower pulmonary edge along the mid-axillary line on the right - 2 cm, on the left - 6 cm.

During auscultation, breathing and bronchophony are not observed in the right subscapular region, over other parts of the lungs there is vesicular breathing, bronchophony is not changed. Adverse breath sounds are not detected.

The pulse on the radial arteries is rhythmic, 100 beats per minute, with satisfactory filling and tension. Heart sounds are sonorous, rhythmic, tachycardia. Blood pressure 110/70 mm Hg. Art.

The thyroid gland is not visually and palpably determined.

Questions: 1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

Additional research conducted

General blood analysis: erythrocytes - 4.5 T/l, Hb - 140 g/l, c.p. - 0.9, leukocytes - 14.0 G/l, p - 10%, s - 73%, l - 21%, m – 6%, ESR – 48 mm/hour, toxic granularity of neutrophils – ++.

General urine analysis: color – deep yellow, transparent, reaction – alkaline, beat. weight – 1020, protein – no, leukocytes – 1 - 2 in visual field, er-0.

Blood chemistry: total protein – 70 g/l, sial. acids – 4.0 mmol/l, C – reagent. protein - ++++.

ECG attached.

Research completed FVD:

Vital capacity fact – 2.52 should – 3.96 l 64%

FEV 1 fact – 2.24 should – 2.66 l 85%

FEV 1/VC 89%

9. Make a reasoned plan for additional methods of examining the patient.

Head department ___________________

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 24

In the emergency room, patient T., 60 years old, complains of an attack of suffocation, a cough with scanty mucous sputum that is difficult to separate.

From the anamnesis: suffers from an allergy to household dust for 3 years in the form of episodes of watery eyes and sore throat. Over the last 2 years, he has noticed the appearance of paroxysmal shortness of breath with difficulty exhaling, which is accompanied by paroxysmal unproductive cough. He was treated as an outpatient. He took expectorant bronchodilators. Deterioration of health on the second day in the form of more frequent attacks of suffocation. I tried to relieve suffocation with salbutamol inhalations, but did not notice any effect. He called an ambulance team, aminophylline was administered intravenously, but the attack of suffocation was not stopped. The ambulance team transported him to the hospital.

Objectively: The general condition is serious. Consciousness is clear. Sitting position with emphasis on the hands, a short, short inhalation and a painful, noisy exhalation extended over time are heard, which is sometimes interrupted by coughing and the discharge of a small amount of difficult-to-discharge viscous transparent sputum. The physique is correct, hypersthenic. The skin is clean, moist, diffuse cyanosis. Swelling of neck veins. There are no trophic changes in the nails.

Breathing through the nose is difficult, but there is no discharge. Mixed breathing type, respiratory rate - 36 per minute. The chest is evenly swollen, “frozen” in the deep inspiration phase. The upper shoulder girdle is raised. Distant wheezing is heard. With comparative percussion, a boxy sound.

With topographic percussion: the height of the lungs in front on both sides is 5 cm above the clavicle, in the back - 1 cm above the level of the spinous process of the VII cervical vertebra. The width of the Krenig fields is 9 cm. The lower border of the lungs along the mid-axillary line on both sides is along the 9th rib. The excursion of the lower edge is difficult to determine due to severe shortness of breath. Over the entire surface of the lungs, weakened vesicular breathing, dry whistling and buzzing rales are detected.

The pulse on the radial arteries is rhythmic, 100 beats per minute, with satisfactory filling and tension. Heart sounds are muffled, rhythmic, tachycardia, accent of the 2nd tone over the pulmonary artery. Blood pressure 150/90 mm Hg. Art.

The tongue is moist and clean. The papillae are satisfactorily developed. Zev is clean. The tonsils are not enlarged. The abdomen is soft and painless on palpation in all parts. The liver does not protrude from under the edge of the costal arch. The spleen is not palpable. There is no edema. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

QUESTIONS: 1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

General blood analysis: er – 3.7 T/l, Nb – 145 g/l, c.p. – 0.9, leukocytes – 7.0 G/l, e – 15%, p – 2%, s – 58%, l – 20%, m – 5%, ESR – 12 mm/hour.

General urine analysis: color – straw-yellow, slightly acidic reaction, complete transparency, spec. weight – 1024, protein is not detected, flat epithelium – 1-4 in the field of view, leukocytes – 1-2 in the field of view.

General sputum analysis: color - gray, character - mucous, consistency - viscous, squamous epithelium - 2 - 4 in the field of view, columnar epithelium 4 - 6 in the field of view, leukocytes - 6 - 8 in the field of view, eosinophils - 10 - 20 in the field of view, alveolar macrophages – 6 - 8- in the field of view, Kurshman spirals +++, Charcot-Leyden crystals ++.

ECG attached.

Peak expiratory flow (PEF): 220 l/min, which is 50% of normal (445 l/min).

8. Give an ECG conclusion using the ECG interpretation algorithm.

9. Make a reasoned plan for additional methods of examining the patient.

Head department ___________________

I approve "_____"_____________2005

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 23

Patient M., 36 years old, was admitted to the department with complaints of cough with mucopurulent sputum, shortness of breath, and fever up to 38.3°C.

From the anamnesis: sick for a week. The disease began gradually with the appearance of a dry cough, low-grade fever, weakness, and malaise. By the end of the third day, against the background of an increase in temperature, the cough acquired a productive character, mucopurulent sputum began to separate, and shortness of breath appeared. I went to the clinic, and after being examined by a doctor, I was sent to the hospital.

Objectively: The general condition is of moderate severity. Consciousness is clear. Position active. The physique is correct, normosthenic. The skin is clean, moist, and has a feverish appearance. Visible mucous membranes are moist and shiny. There are no trophic changes in the nails.

Subcutaneous fat tissue is well developed and evenly distributed.

Breathing through the nose is free. Mixed breathing type, respiratory rate - 24 per minute. The chest is of regular shape, symmetrical, both halves are equally involved in the act of breathing. Voice tremor is carried out equally on symmetrical areas of the chest. With comparative percussion in the left subscapular region, in a limited area, a zone of shortening of the percussion sound is determined, bronchovesicular breathing, increased bronchophony, sonorous moist fine-bubble rales, decreasing after coughing, are also heard. With topographic percussion: the height of the apexes of the lungs in front on both sides is 3 cm above the collarbone, in the back - at the level of the spinous process of the VII cervical vertebra. The width of Krenig's fields is 6 cm, the lower border of the lungs along the middle axillary line on both sides is along the 8th rib. The excursion of the pulmonary edge along the mid-axillary line on the right is 8 cm, on the left – 6 cm.

The pulse on the radial arteries is rhythmic, 95 beats per minute, satisfactory filling and tension. Heart sounds are sonorous, rhythmic, clear. Blood pressure 120/80 mm Hg. Art.

There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

QUESTIONS:

1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

3. Formulate the leading clinical syndromes.

General blood analysis: erythrocytes - 4.3 T/l, Hb -138 g/l, c.p. -0.9, leukocytes - 10.4 G/l, p - 6%, s - 70%, l - 18%, m – 6%, ESR – 30 mm/hour.

General urine analysis: color yellow, transparent, beat. weight – 1017, flat epithelial cells 2-3 per field of view, leukocytes – 1-2 per field of view.

General sputum analysis: color - gray, character - mucopurulent, consistency - viscous, squamous epithelium - 2 - 4 in the field of view, columnar ciliated epithelium 14 - 18 in the field of view, leukocytes - 20 - 40 in the field of view, alveolar macrophages - 18 - 24 in sight.

ECG attached.

FVD :

Vital capacity fact – 3.50 l should – 4.94 l 71%

FEV 1 fact – 3.20 l should – 3.62 l 88%

8. Perform ECG analysis using the ECG interpretation algorithm.

9. Make a reasoned plan for additional methods of examining the patient.

Head department ___________________

I approve "_____"_____________2005

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 22 pediatric faculty.

Patient K., 36 years old, was admitted to the hospital with complaints of a productive cough with a full mouthful of sputum with an unpleasant putrefactive odor (about 300-400 ml per day), in which, upon examination, 3 layers can be distinguished: the upper one is serous, the middle one is watery, the lower one is purulent. The cough worsens when the patient lies on the right side. Worry about fever up to 39°C, weakness, sweating.

From the anamnesis: Got acutely ill after hypothermia 2 weeks ago. He noted severe chills, fever up to 40 0, profuse sweating, and weakness. At home I took aspirin and ampicillin - without effect. Was observed by a local doctor. After another examination by a doctor, he was sent to the hospital for emergency reasons.

Objectively: general condition of moderate severity. Consciousness is clear. The position is forced: the patient lies on the right side. The physique is correct, normosthenic. The skin is hyperemic, hot, and moist. Cyanosis of the nasolabial triangle. There are no trophic changes in the nails.

Subcutaneous fat tissue is well developed and evenly distributed.

Breathing through the nose is not difficult. The chest is asymmetrical, the right half of it lags behind in the act of breathing. Abdominal breathing type. BH - 26 per minute. Vocal tremor on the right at the level of the 3rd-4th intercostal space along the midclavicular line is intensified. With comparative percussion in this area, a tympanic sound is determined. Above the rest of the lungs there is a clear pulmonary sound.

With topographic percussion: the height of the apexes of the lungs on both sides in front is 3 cm above the collarbone, in the back - at the level of the spinous process of the VII cervical vertebra. The width of Krenig's fields is 6 cm. The lower edge of the lungs along the right midclavicular line is along the 3rd rib, along the left midclavicular line is along the 6th rib, along the midaxillary line on both sides is along the 8th rib. The excursion of the pulmonary edge along the midaxillary line on the right is 4 cm, on the left – 6 cm. During auscultation in the area of the tympanic sound, amphoric breathing, coarse bubble moist rales, increased bronchophony are heard. Vesicular breathing is heard over the remaining parts of the lungs.

The pulse on the radial arteries is rhythmic, 96 beats per minute, satisfactory filling and tension. Heart sounds are sonorous and rhythmic. Blood pressure 110/80 mm Hg. Art.

The tongue is moist and clean. Zev is clean. The tonsils are not enlarged. The abdomen is soft and painless on palpation in all parts. The liver does not protrude from under the edge of the costal arch. The spleen is not palpable.

There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

QUESTIONS: 1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

3. Formulate the leading clinical syndromes.

General blood analysis: erythrocytes - 4.3 T/l, Hb -118 g/l, c.p. -0.8, leukocytes - 19.4 G/l, s - 7%, p - 13%, s - 55%, l – 20%, m – 5%, ESR – 55 mm/hour, toxic granularity of neutrophils.

General urine analysis: deep yellow color, transparent, beat. weight – 1024, protein – no, flat epithelial cells 2-4 in the field of view, leukocytes – 1-2 in the field of view.

General sputum analysis: color – yellow, purulent in nature, consistency – liquid, columnar ciliated epithelium 24 – 28 per field of view, leukocytes – 30 – 40 per field of view, alveolar macrophages – 20 – 25 per field of view, erythrocytes – 10 – 15 per field of view, elastic fibers +++, cholesterol crystals ++.

ECG attached.

FVD :

Vital capacity fact – 3.40 l should – 4.94 l 69%

FEV 1 fact – 2.60 l should – 3.62 l 72%

8. Give an ECG conclusion using the ECG interpretation algorithm.

9. Make a reasoned plan for additional methods of examining the patient.

Head department ___________________

I approve "_____"_____________2006

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 21 pediatric faculty.

Patient S., 23 years old, was admitted to the SP clinic with complaints of an increase in temperature to 39-40 C, hemoptysis of the “rusty” sputum type, shortness of breath at rest, pain in the right half of the chest when breathing.

From the anamnesis: fell ill acutely 3 days ago, after hypothermia, when the body temperature rose to 40 C, chills appeared. He independently took non-steroidal anti-inflammatory drugs, against the background of which the body temperature dropped to low-grade levels, but shortness of breath and pain in the chest on the right when breathing occurred, which was the reason for calling the emergency medical team. Hospitalized for emergency care.

Objectively: The general condition is moderate. Consciousness is clear. Lying position on the right side. The physique is correct, normosthenic. Feverish shine of the eyes, facial flushing. The skin is clean and moist. Cyanosis of the nasolabial triangle. Herpetic eruptions on the wings of the nose and lips. Mucous membranes are moist and shiny. There are no trophic changes in the nails.

Subcutaneous fat tissue is well developed and evenly distributed.

The submandibular lymph nodes are palpated (on the left - 0.5 cm in D, on the right 2.0 cm in D), elastic, mobile, painless. Other groups of lymph nodes are not palpable. Muscle tone is preserved. There is no deformation of the joints. Active and passive movements in joints in full volume.

Breathing through the nose is not difficult. The chest is of regular shape, its right half lags behind in the act of breathing. Mixed breathing type, respiratory rate - 26 per minute. Vocal tremor is intensified on the right in the posterolateral region, and here, with comparative percussion, a zone of dullness of percussion sound is determined. Over other parts of the lungs, vocal tremor is not changed, with percussion there is a clear pulmonary sound.

Topographic percussion of the lungs: the height of the apexes of the lungs in front on both sides is 3 cm above the collarbone, in the back - at the level of the spinous process of the VII cervical vertebra. The width of the Krenig fields is 6 cm. The lower border of the lungs along the mid-axillary line on the right is along the VI rib, on the left – along the VIII rib. Excursion of the pulmonary edge along the midaxillary line on the right - 4 cm and on the left - 8 cm.

On auscultation on the right in the posterolateral region, breathing is bronchial with increased bronchophony. The pleural friction noise is also heard here (more clearly along the posterior axillary line). Over the remaining parts of the lungs, breathing is vesicular, bronchophony is not changed.

The pulse on the radial arteries is rhythmic, 90 beats per minute, with satisfactory filling and tension. Heart sounds are sonorous, rhythmic, tachycardia. Blood pressure 120/80 mm Hg. Art.

The tongue is moist and clean. The papillae are satisfactorily developed. Zev is clean. The tonsils are not enlarged. The abdomen is soft and painless on palpation in all parts. The liver does not protrude from under the edge of the costal arch. The spleen is not palpable. There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

QUESTIONS: 1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

3. Formulate the leading clinical syndromes.

General blood analysis: erythrocytes - 4.3 T/l, Hb -138 g/l, c.p. -0.9, leukocytes - 10.4 G/l, p - 8%, s - 58%, l - 28%, m – 6%, ESR – 36 mm/hour.

General urine analysis: deep yellow color, transparent, beat. weight – 1024, flat epithelial cells 4-6 per field of view, leukocytes – 1-2 per field of view.

General sputum analysis: color - brown, character - muco-hemorrhagic, consistency - viscous, squamous epithelium - 2 - 4 in the field of view, columnar ciliated epithelium 14 - 18 in the field of view, erythrocytes - 15 - 20 in the field of view, leukocytes - 4-6 in p/z, alveolar macrophages – 10 - 12 per field of view.

ECG attached. FVD :

Vital capacity fact – 4.40 l should – 5.18 l 85%

FEV 1 fact – 3.50 l should – 3.92 l 89%

8. Analyze the ECG using the decoding algorithm.

9. Make a reasoned plan for additional methods of examining the patient.

10. What emergency condition(s) might the patient have? If necessary, indicate the amount of emergency care.

Head department ___________________

I approve "_____"_____________2006

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 20

Patient N., 36 years old, was admitted to the hospital according to the "SP" with complaints of suffocation with difficult and prolonged exhalation, an unproductive, paroxysmal cough, and palpitations.

From the anamnesis: for 5 years he has been experiencing attacks of suffocation when taking antipyretics and painkillers. Today my health worsened 30 minutes after taking an Ortofen tablet for pain in the knee joints. Inhalation of salbutamol did not improve my health. She called the emergency medical service team, aminophylline was administered intravenously, but the attack of suffocation was not stopped. Delivered to the hospital.

Objectively: the general condition is serious. Consciousness is clear. The patient is in a sitting position with emphasis on her hands; a short, short inhalation and a painful, noisy exhalation extended over time are heard, which is sometimes interrupted by coughing and the discharge of a small amount of light, viscous sputum. Distant wheezing is heard. The physique is correct, hypersthenic. The skin is moist. Diffuse cyanosis. There are no trophic changes in the nails.

Subcutaneous fat is overdeveloped and evenly distributed.

The chest is cylindrical, symmetrical, rigid. The upper shoulder girdle is raised. Mixed breathing type, respiratory rate 36 per minute. Voice tremors are symmetrically weakened. With comparative percussion, a boxed sound .

The height of the apexes of the lungs in front is 5 cm above the collarbone, in the back - 1 cm above the VII cervical vertebra. The width of Krenig's fields is 9 cm, the lower border of both lungs along the middle axillary line is the 9th rib. The excursion of the lower edge is difficult to determine due to severe shortness of breath. Auscultation reveals weakened vesicular breathing and diffuse dry wheezing.

The pulse on the radial arteries is rhythmic, 100 beats per minute, with satisfactory filling and tension. Heart sounds are muffled, rhythmic, accent of the second tone over the pulmonary artery. BP 138/88. mmHg Art.

There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

1. Identify the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

3. Formulate the leading clinical syndromes.

General blood analysis: er – 4.0 T/l, Hb – 145 g/l, CP – 0.9, leukocytes – 7.0 G/l, e – 15%, p – 2%, s – 58%, l – 20%, m – 5%, ESR – 12 mm/hour.

General urine analysis: color – straw-yellow, slightly acidic reaction, complete transparency, spec. weight – 1024, flat epithelium – 1-4 in the field of view, leukocytes – 2-4 in the field of view, erythrocytes – 0–1 in the field of view.

General sputum analysis: transparent, mucous, viscous, squamous epithelium - 2 - 4 in the field of view, columnar ciliated epithelium 4 - 6 in the field of view, leukocytes - 6 - 8 in the field of view, eosinophils - 10 - 20 in the field of view, Kurshman spirals +++, Charcot-Leyden crystals ++.

ECG attached.

Peak expiratory flow(PSV): 250 l/min, which is 67% of the norm (377 l/min).

8. Analyze the ECG using the decoding algorithm.

9. Make a reasoned plan for additional methods of examining the patient.

Head department ___________________

I approve "_____"_____________2005

Dean______________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 28 (Faculty of Pediatrics)

A 46-year-old man was brought to the emergency department. At the time of inspection, he makes no complaints. Today, about 2 hours ago, at work (he works as a welder), severe pressing pain occurred in the chest, radiating to the left shoulder. I took 3 tablets of nitroglycerin at intervals of 5 minutes. I did not notice any clear improvement, although the intensity of the pain decreased somewhat. The pain was relieved by the intravenous administration of drugs. The duration of the painful attack is about 40 minutes. During the attack, an increase in blood pressure to 160/100 mm Hg was noted. Art. After providing assistance and recording an ECG (ECG 1), he was taken to the hospital. An attack of a similar nature occurred about 3 months ago, and he was hospitalized. Discharged from the hospital with a diagnosis of coronary artery disease: new-onset angina. At discharge, VEM was performed, and functional class 1 of angina was determined. There are no other chronic diseases.

Objectively: general condition is satisfactory. Consciousness is clear. Position active. The physique is correct, normosthenic. The skin is pale pink, clean, and has moderate moisture. Visible mucous membranes are moist and shiny. There are no trophic changes in the nails.

Subcutaneous fat tissue is well developed and evenly distributed.

Mixed breathing type, respiratory rate - 18 per minute. With comparative percussion of the lungs: clear pulmonary sound in symmetrical areas. On auscultation: vesicular breathing over the entire surface of the lungs.

The pulse on the radial arteries is rhythmic, 79 beats per minute, satisfactory filling and tension. Heart sounds are sonorous and rhythmic. Blood pressure 140/90 mm Hg. Art.

There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.

Questions:

What pathological symptoms does the patient have?

Explain the pathogenesis of these symptoms and highlight their specific characteristics.

Give an electrocardiographic conclusion of ECG No. 1 using the decoding algorithm.

Formulate clinical syndromes.

Examination completed after 1 day:

1. General blood test: Hb 134 g/l, Er 4.9 T/l, L - 9.7 G/l, E-5%, s/i -64%, L -29%, M -2% , ESR 10 mm/h.

2. Biochemical blood test: troponin T positive, ALT 0.9 mmol/l, AST 1.2 mmol/l, sugar 6.5 mmol/l.

Give the ECG conclusion of the proposed ECG No. 2 using the decoding algorithm.

What clinical syndromes can we think about, taking into account the dynamics of these laboratory and instrumental research methods?

Plan additional research methods. Explain their purpose.

Head department______________________________

I approve "____"________________________200 g.

Dean_____________________________________________

Department of Propaedeutics of Internal Diseases, IvSMA

EXAMINATION TASK No. 32 (Faculty of Pediatrics)

Patient K., 62 years old, consulted a doctor with complaints of paroxysmal compressive pain behind the sternum radiating under the left shoulder blade that occurred when walking. The pain first appeared 3 days ago during a walk in the forest, accompanied by a feeling of fear of death and palpitations. The pain stopped on its own during rest. However, during physical activity (walking) they are repeated for up to 15 minutes. Smokes one pack of cigarettes a day. Drinks alcohol in moderation. Physically active. Considers himself healthy.

Objectively.

The general condition is moderate. Consciousness is clear. Position active. The physique is correct, increased nutrition. The skin is pale pink, clean, moderately moist, cyanosis of the lips and fingertips. Visible mucous membranes are moist and shiny. There are no trophic changes in the nails.

Subcutaneous fat is overdeveloped and evenly distributed.

Mixed breathing type, respiratory rate - 20 per minute. With comparative percussion of the lungs: clear pulmonary sound in symmetrical areas. On auscultation: vesicular breathing over the entire surface of the lungs.

The pulse on the radial arteries is rhythmic, 76 beats per minute, satisfactory filling. Heart sounds are rhythmic, the first sound at the apex is weakened. Borders of the heart: right - along the right edge of the sternum in the 4th intercostal space, left - along the midclavicular line in the 5th intercostal space, the upper 3rd rib 1 cm outward from the left edge of the sternum. Blood pressure 160/80 mm Hg. Art.

There is no swelling. Pasternatsky's symptom is negative on both sides.

The thyroid gland is not visually and palpably determined.