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Flu

Emergency Syndromes

Infectious and toxic damage to the brain is the most common emergency for very severe influenza. The syndrome develops against the background of a severe course of the disease with high fever and is caused by severe microcirculation disorders in the brain and increased intracranial pressure. This is an acute cerebral (brain) insufficiency, occurring against the background of severe general intoxication, cerebral disorders, and sometimes signs of meningoencephalitis (damage to the meninges of the brain).

Clinical manifestations of the syndrome are severe headache, vomiting, stupor, possibly psychomotor agitation and impaired consciousness. In severe cases (edema and swelling of the brain), bradycardia and increased blood pressure, respiratory distress, and coma are noted.

Acute respiratory failure - the most frequent after the previous influenza emergency syndrome. Clinically manifested in the form of severe shortness of breath, bubbling breathing, cyanosis (cyanosis), abundant foamy sputum mixed with blood, tachycardia, anxiety of patients.

Infectious-toxic shock develops with influenza and other acute respiratory viral infections infrequently, mainly in cases of extremely severe and complicated by pneumonia. Clinical manifestations: in the early stages - hyperthermia, then a decrease in body temperature, pallor of the skin, the appearance of a marble color of the skin, cyanotic (bluish) spots, a rapid decrease in blood pressure, tachycardia, shortness of breath, nausea and vomiting are possible, hemorrhagic syndrome, a sharp decrease in diuresis (urination) ), a progressive impairment of consciousness (increasing lethargy, indifference of patients, turning into stupor).

Acute cardiovascular failure can proceed according to the type of predominantly acute cardiac or acute vascular insufficiency. Acute heart failure develops more often in patients with hypertension and heart disease. It proceeds according to the type of left ventricular failure and is manifested by pulmonary edema. Acute vascular insufficiency is a consequence of a drop in vascular tone, which is characteristic of severe influenza, and vascular collapse is a manifestation of infectious-toxic shock.

Complications of influenza and other acute respiratory viral infections are varied. In their clinical manifestation, the leading place in terms of frequency and significance is occupied by acute pneumonia (80-90%), which in most cases have a mixed viral-bacterial nature, regardless of the timing of their occurrence. Other complications of influenza - sinusitis, otitis, pyelonephritis, inflammation of the biliary system and others - are relatively rare (10-20%).

Complications in ARVI can be divided into specific (due to the specific action of the virus), non-specific (secondary, bacterial) and associated with the activation of a chronic infection.

pneumonia occur in 2-15% of all patients with influenza and in 15-45% or more of hospitalized patients. In the inter-epidemic period for influenza, pneumonia develops much less frequently (0.7-2%) than during epidemics (10-12%). The incidence of complications is influenced by the type of influenza virus and the age of patients.

The most susceptible to complications from pneumonia are people over 60 years of age, in whom influenza and other acute respiratory viral infections are more often complicated by pneumonia and are more severe.

The vast majority of pneumonia develops in patients with severe and moderate forms of influenza. Pneumonia can develop in any period of the disease, however, with influenza in young people, pneumonia occurs in 60% of cases, occurring on the 1-5th day from the onset of the disease, usually with severe catarrhal syndrome and general intoxication that has not yet ended. Often (in 40%), pneumonia also occurs at a later date (after the 5th day of illness).

If pneumonia in young people is mainly due to the addition of pneumococcal flora (38-58%), then Staphylococcus aureus and gram-negative microorganisms (pseudomonas, Klebsiella, Enterobacter, Escherichia, Proteus) are dominant in the etiology of pneumonia in elderly patients. Pneumonia caused by this microflora is the most severe.

Of great practical importance are the early diagnosis of pneumonia, as well as their prediction before the development of complications.

In typical cases, the course of ARVI complicated by pneumonia is characterized by:

1) the absence of positive dynamics during the disease, prolonged fever (more than 5 days) or the presence of a two-wave temperature curve;

2) an increase in symptoms of intoxication - an increase in headache, the appearance (resumption) of chills, myalgia (pain in the muscles), adynamia, severe general weakness, a sharp increase or the appearance of excessive sweating with minimal exertion;

3) the appearance of signs of damage to the lung tissue - progressive dyspnea over 24 breaths per minute, a change in the nature of the cough (wet, with sputum).

Sinusitis(sinusitis, frontal sinusitis) is characterized by the appearance of complaints in patients of increased headache or a feeling of heaviness in the area of ​​the eyebrows, forehead and nose, fever up to 38-39 ° C, nasal congestion, purulent runny nose. On external examination, there is swelling of the soft tissues of the cheek and (or) the eyebrows on the side of the lesion, pain on palpation and tapping at the projection of the paranasal sinuses on the bones of the facial skull, and difficulty in nasal breathing. When examining the nasal cavity - hyperemia and swelling of its mucous membrane, the presence of purulent discharge in the nasal passages on the side of the lesion. There is a decrease in olfactory sensations (hypoosmia).

Acute catarrhal eustachitis(syringitis), tubo-otitis, otitis media. Subjectively, patients experience a feeling of congestion in one or both ears, noise in one or both ears, hearing loss, a feeling of overflowing fluid in the ear when the head position changes. On examination, the tympanic membrane is retracted, the tympanic membrane has a pale gray or bluish tint, it is possible to observe the level of fluid and bubbles behind the tympanic membrane. In an audiometric study, hearing impairment is determined by the type of damage to the sound-conducting apparatus.

Acoustic neuritis is a rare complication of influenza and can, on the one hand, simulate tubo-otitis, and on the other, proceed under its mask. Patients also complain of constant tinnitus, hearing loss and impaired speech intelligibility. However, the process is more often bilateral, and on examination, the tympanic membrane is not changed. An audiological examination of hearing reveals a hearing impairment according to the type of damage to the sound-perceiving apparatus.

Meningism(symptoms of damage to the membranes of the brain). In addition to general toxic symptoms, mild meningeal symptoms may appear at the height of the disease, which disappear after 1-2 days. In the cerebrospinal fluid, pathological abnormalities are not detected.

Hemorrhagic syndrome(bleeding syndrome). During an epidemic outbreak, 25-30% of patients with influenza have a hemorrhagic syndrome in the form of increased vascular fragility, nosebleeds, and the presence of blood in the urine. Epistaxis is characterized by the patient's complaints about the discharge of blood from the nose and coughing it up through the mouth, general weakness and dizziness. Pallor, sometimes icterus (jaundice) of the skin and mucous membranes, nasal bleeding of varying severity - compensated (slight), subcompensated (moderate), decompensated (strong) are objectively noted. When examining the nasal cavity, the presence of blood clots in the nasal passages and on the back of the pharynx is noted, sometimes it is possible to identify the source of bleeding (including a bleeding polyp) in the nasal cavity. To determine the severity of the hemorrhagic syndrome, an assessment of the general and biochemical blood tests is carried out.

Infectious-allergic myocarditis can complicate the course of influenza and other acute respiratory viral infections. For the timely detection of infectious-allergic myocarditis, an electrocardiographic study is important. Indications for it is the appearance of at least one of the following symptoms:

1) pain in the region of the heart, sometimes radiating to the left hand, palpitations, "interruptions" in the work of the heart;

2) shortness of breath with minor physical exertion;

3) tachycardia (increased heart rate) that does not correspond to body temperature;

4) arrhythmias (extrasystoles, atrial, rarely paroxysmal arrhythmia);

5) muffled heart sounds, an increase in its size, the appearance of noise above the apex, cyanosis, and edema.

Identification of ECG signs of myocarditis requires consultation with a cardiologist to correct treatment.

An ECG is done in dynamics - upon admission of the patient (or if there are indications during the illness) and before his discharge.

Reye's syndrome- a rare complication described in influenza B, which develops in the phase of recovery from a viral infection and is characterized by the development of an infectious-toxic brain lesion (profuse vomiting, depression, drowsiness, turning into lethargy, confusion, convulsions) and fatty degeneration of the liver.

Diagnosis of other complications of ARVI is carried out on the basis of an analysis of clinical, laboratory and instrumental data.

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Determining the severity of the conditionFlu

3.Provide emergency care at the medical center and district hospital.

4. What additional examinations should be carried out in the district hospital to make a final diagnosis?

5. After the successful completion of hospital treatment, what would be the decision of the military medical commission ? What advice would you give on secondary prevention disease, its further treatment ? What are the modern methods of monitoring the effectiveness of therapy ?

1. Lead Syndrome: suffocation.

2. Preliminary diagnosis: : hay fever with asthma, stage 3 (moderate severity), exacerbation phase.(The diagnosis is formulated according to the international classification of diseases X revision of ICD-10 / WHO, Geneva, 1992). Justification of the diagnosis: manifestations vasomotor rhinitis could be regarded as a harbinger of suffocation; however, the situation of the occurrence of vasomotor reactions from the mucous membranes of the nose and eyes, associated with the seasonality of flowering herbs, the combination with bronchial obstruction, as well as attacks repeated earlier, indicate the allergic nature of rhinitis, which is called hay fever. Typical complaints and clinical manifestations of bronchial obstruction syndrome are transient and associated with the action of herbal allergens, the symptoms disappear when the patient's location changes (cessation of the action of inducers of the mediator inflammatory process in the respiratory tract), or as a result of the use of a bronchodilator and an anti-inflammatory drug that blocks the release of mast cells mediators of the allergic process. All this points to the presence of predominantly allergic asthma occurring against the backdrop of hay fever. This nosological form is characterized by a combination of respiratory symptoms (allergic / vasomotor / rhinitis) and a positive family history of atopy (hereditary predisposition to the disease is realized, according to the literature / Chuchalin A.G., 1985 / in 75% of cases. Asthma symptoms, occurring 3 times a week, including nocturnal attacks 3 times a month, indicate the average severity of asthma-stage 3, and the very fact of the occurrence of suffocation indicates the phase of exacerbation of the disease.

3. Emergency care in the medical center of the unit(First aid):

1. Reassure the patient; 2. Give him the most comfortable sitting position in the chair; 3. Put mustard plasters on your back, make hand and foot hot baths; 4.Usage alpha and beta adrenergic stimulants: give ephedrine tablet(25 mg) or theofedrine(theofellin, theobromine, coffeine 50 mg each, amidopyrine and phenacetin 0.2 g each, ephedrine hydrochloride and phenobarbital 20 mg each, belladonna extract 4 mg and cytisine 0.1 mg), or Antasman(theofellin 0.1 g, caffeine 50 mg, amidopyrine and phenacetin 0.2 g each, ephedrine hydrochloride and phenobarbital 20 mg, belladonna extract 10 mg, labelia leaf powder 90 mg); as can be seen from the above components of combined drugs, an important active agent is xanthine preparations(tablets are recommended to be crushed beforehand and washed down with water), it can be used in the same way aminophylline tablet(0.15 g) after meals; The therapeutic effect of methylxanthines is based on the myolytic action and inhibition of the release of mediators, which in turn is associated with the suppression of phosphodiasterase activity, as a result of which the concentration of intracellular cAMP increases, blocking adenosine receptors, increasing the synthesis and release of endogenous catecholamines, drugs also improve microcirculation. In recent years, it has been successfully used prolonged forms of theophyllines. Domestic drug introduced into clinical practice theopak- 2 times a day, 0.3 g; similar drug theobiolong(0.3 g each); both drugs are taken after meals (not crushed and not dissolved in water!). Chuchalin A.G. (1991) recommends increasing the daily dose of theophylline orally (not 150 mg 3 times), but 400-3200 mg/day. (in our country, theophylline drugs are more common than sympathomimetic inhalers). Theodur-24, unifril, euphylong accepted once. This patient with moderate severity PARTICULARLY INDICATED LONG-LASTING BRONCHIDILATORS,

FIRST OF ALL TO CONTROL NIGHT SYMPTOMS.

5.Application betta-1,-2- stimulants in inhalations: isadrin inhalation (euspiran, novodrina) at a dose of 0.5-1 ml of a 0.5% solution per inhalation or alupent aerosol 2% 1 ml for 10-15 puffs or other Orciprenaline sulfate preparation - Asthmopent(dosage 400 doses of 0.75 mg), the duration of the drug is 3-5 hours.

6.Usage beta-2 agonists (selective beta-2 agonists/ sympathomimetics/ short action: salbutamol (Poland)- metered aerosol (200 doses of 0.1 mg , i.e. 100 mcg/ synonyms: asthmatol, ventolin/; terbutaline (brikanil), as well as the German drug Berotek (fenoterol), usually these drugs are used in the form of aerosol inhalers, the latter is considered the most effective and least toxic (duration of action - 7-8 hours; contains 300 single doses of 0.2 mg.). Disk form of a preparation - ventodisk, contains the smallest powder of salbutamol in doses of 200 or 400 mcg for inhalation through the Diskhailer. Tableted preparations of salbutamol- Volmax, containing 4 and 8 mg of the drug, is applied 1-2 times a day, as well as a domestic remedy saltos, with controlled and delayed release of the active substance (6 mg); the average daily dose is 12 mg. Beta-2-agonists cause relaxation of the smooth muscles of the bronchi due to the activation of adenelyl cyclase, which increases the content of cAMP in the cells, and also inhibit the release of biologically active substances by mast cells and increase the mobility of the cilia of the epithelium of the bronchial mucosa, thereby improving mucociliary transport.

An important place in the treatment of asthma attacks is occupied by new inhalation betta-2 long-acting adrenostimulants: salmeterol (servent inhaler) for 120 doses of 25 mcg, taken 2 times a day and rotodisk- Disk forms of the server, 50 mcg ) And formatrol. They inhibit the early and late phases of inflammation and reduce non-specific airway hypersensitivity. The duration of action is 10-12 hours. THIS PATIENT IS INDICATED LONG-LASTING SYMPTOMIMETICS, PARTICULARLY TO CONTROL NIGHT SYMPTOMS.

Although beta-2 agonists do not have pronounced side effects on the cardiovascular system (tachycardia, arterial hypertension, rhythm disturbance, toxic effects on the heart muscle), these drugs should not be used uncontrollably. With excessive therapy, blockade of beta-adrenergic receptors may occur or increase, as noted above. Patients should limit the use of sympathomimetics to 3-4 times a day (6-8 inhalations).

7.Application inhalation of anticholinergics (M-anticholinergics): german aerosol inhaler atrovent (ipratropium bromide) contains 300 doses of 20 mg per inhalation. It is prescribed for 20-40 mcg (1-2 breaths) 3 times a day. Atrovent inhibits the activity of the vagus nerve, which causes bronchospasm, it binds to muscarinic receptors in the smooth muscles of the bronchial tree, more selectively than atropine, therefore, unlike the negative effects of the latter, a sharp decrease in the secretion of bronchial glands and thickening of sputum, drying of mucous membranes - atrovent differs more high (1.4-2 times) bronchospasmolytic activity). THIS PATIENT SHOWED THE USE OF INHALATION ANTICHOLINERGIC MEDICINES.

8. The presence of pronounced mediator inflammation in the respiratory tract in this patient with moderate asthma requires active anti-inflammatory treatment with an increase in the daily dose of anti-inflammatory drugs. Inhaled anti-inflammatory drugs (sodium cromoglycate/intal/ or sodium nedocromil/ tayled/ are prescribed for a long time (daily) As you know, they are practically devoid of significant side effects. In the absence of the latter, tablet preparations of similar action can be used as basic anti-inflammatory therapy. zaditen (ketotifen) 1 tablet (0.001) 2 times a day; the negative effect of these drugs is drowsiness. It is important to explain to the patient that as a result of the use of these nonsteroidal anti-inflammatory drugs (not to be confused with antirheumatic drugs!) The effect usually occurs after 2-4 weeks from the start of taking the drugs.

9. In case of insufficient efficiency, 5-10 ml of 2.4% should be injected intravenously slowly eufillin solution with 10 ml of 5-40% glucose solution, or isotonic sodium chloride solution or 0,25% novocaine solution.

10. If this is not enough, we can recommend intravenous drip of 200 ml of isotonic sodium chloride solution of a mixture of the following composition: 10 ml 2, 4% solution of eufillin, 1 ml diphenhydramine or pipolfen, 0 , 5 ml strophanthin and 2 ml cordiamine.

Not having an independent bronchodilator effect, antihistamines inhibit the secretion of bronchial glands and have a weak antispasmodic and central analgesic and sedative effect. Therefore, at the height of an asthma attack, intravenous or intramuscular administration is justified. Diphenhydramine(1-2 ml of 1% solution) or suprastin-2% solution 1-2 ml or pipolfena(1-2 ml 2.5% solution).

11. Hypoxia is reduced by inhalation of humidified oxygen through a nasal catheter or mask. Oxygen therapy is carried out until the attack is completely relieved.

12. If there is no effect from the administration of aminophylline intravenously, prednisolone (60 mg) or 100 mg of hydrocortisone intravenously is prescribed intravenously. There are no contraindications for the appointment of large doses of steroids for a short time (3-5 days).

Treatment of moderate asthma(available in this patient) provides MANDATORY daily administration of inhaled glucocorticosteroids, which do not have an undesirable systemic effect and penetrate into the bronchi after prior administration of bronchodilators, providing a powerful local anti-inflammatory effect and, thus, eliminate the basis of the pathogenetic mechanism of the existence of asthma. So, with moderate severity of asthma, daily inhalations are made. GCS 200-800 mcg per day.

Inhaled glucocorticosteroid hormones are used continuously for a period of at least 6 months, usually at least 1 year (as the effectiveness increases, these are the following drugs : ingacort/ flunisolide/ ,budesonide /pulmicort/ , beclomethasone dipropionate/ becotide/, flixotide/ fluticasone propionate/) . Before inhalation of hormones, bronchodilators are taken to relieve bronchospasm, hypersecretion and better penetration into the respiratory tract.

Emergency qualified and specialized care in principle, it does not differ from the first medical one. It includes a more significant arsenal of therapeutic agents (a full range of the above measures) and opportunities (in a district hospital).

4. In the district hospital (and other skilled and specialized medical care institutions), the following tests can be done to make a definitive diagnosis of asthma :

Instrumental measurement of respiratory function provides an assessment of the severity of bronchial obstruction, and determining the degree of their variability indirectly indicates bronchial hyperreactivity. These methods are important for diagnosing and managing the severity of asthma, which is the basis of a new strategy for long-term asthma control and a stepwise approach to long-term asthma therapy. Two methods are widely used: spirometric measurement of forced expiratory volume in 1 second / FEV1, l/ With/ , and determination of peak / maximum / volumetric expiratory flow / POS vyd., l/ min/ , well correlated with FEV1 and measured with a personal peak flow meter.

An early and sensitive indicator of bronchial obstruction is the ratio FEV1/ VC(vital lung capacity, l) -test Tiffno. Its measurements make it possible to distinguish between obstructive and restrictive types of respiratory dysfunction. Normally, this figure exceeds 75%. Smaller numbers indicate a violation of bronchial patency: the lower this figure, the more severe the bronchial obstruction.

An idea of ​​the severity of bronchial hyperreactivity can be obtained from the dynamics of daily fluctuations in the value of the peak expiratory flow rate. For exacerbation of bronchial asthma, fluctuations are characteristic PIC vyd. during the day with a difference of up to 20% or more, relative to night or morning values.

The bronchodilatory test also reflects the magnitude of bronchial hyperreactivity, which is associated with increased basal bronchial tone:

Increase FEV1 or POS vyd. More than 20% 10-20 minutes after inhalation beta-2 agonist/, berotek, salbutamol/ indicates increased tone and hyperreactivity of the bronchi. It should be noted that this test can only be applied in cases where the initial values FEV1 or POS vyd. Make up 80% or less of due.

Thus, 3rd stage - moderate severity of asthma (in this patient) should confirm the following clinical and instrumental data: / asthma symptoms 3 times a week, that is, more than 2 times a week; nocturnal symptoms 3 times a month, that is, more than 2 times a month, POS ex./FEV1 - 60-80% of the expected values, daily variation in indicators 20-30% ).

5. After completion of treatment, this private is submitted to the VVK to determine the category of fitness for military service. In the schedule of diseases (an appendix to the Regulations on the military medical examination, approved by the Decree of the Government of the Russian Federation of April 20, 1995 No. 390), there is an outdated, but effective classification of bronchial asthma, in this case related to Article 52, paragraph b) form moderate severity (asthma with attacks of suffocation at least once a month, which are stopped by the introduction of various bronchodilators; between attacks, respiratory failure of 1-2 degrees persists, which must be confirmed by appropriate studies of the function of external respiration conducted in the hospital / see paragraph 4 above /). Besides , examination, usually, occurs after determining the outcome, in this situation, after the removal of exacerbation. In the schedule of diseases, a concomitant disease is also distinguished: allergic rhinitis - according to article 49 c). A certificate of illness is drawn up, which indicates the following decision of the freelance IHC of the hospital (approved by the conclusion of the higher full-time IHC):

Diagnosis and conclusion about the causal relationship of the disease, injury, injury:

Predominantly allergic asthma: hay fever with asthma, stage 3 (moderate), unstable remission phase. The disease was received during military service.

Based on the article 52 b, 49 c columns II of the Schedule of Diseases and TDT (annex to the Regulations on the military medical examination, approved by Decree of the Government of the Russian Federation of April 20, 1995 No. 390, order of the Minister of Defense of the Russian Federation of September 22, 1995 No. 315

“ IN“- limited fit for military service(which in the previous edition of the now inactive order of the Ministry of Defense No. 260 would have had the wording - “ unfit for military service in peacetime, fit for non-combatant service in wartime” , therefore, a certificate of illness is drawn up, since the definition of unfitness for military service is implied.).

6.1.3. Relief of severe asthma attacks (stage 4/ frequent exacerbations and nocturnal symptoms, permanently expressed blunts with limitation of physical activity, POS vyd./FEV 1 less than 60% of the due values, daily variation of indicators more than 30%/ ) :

First aid:

1.Increasing the daily dose inhaled steroids up to 800-1000 mcg (more than 1000 mcg under the supervision of a specialist).

2. Long-acting bronchodilators, especially to control nocturnal symptoms, inhaled anticholinergics may be used.

3. Short-acting beta-2 agonists as needed, but not more than 3-4 times a day.

4. Intravenous infusions of aminophylline 15-20 ml of a 2.4% solution in a slow stream with 10 ml of a 5-40% glucose solution or isotonic sodium chloride solution, or 0.25% novocaine solution. With poor tolerance of aminophylline, as well as in the elderly, it is preferable to intravenously drip it with a preliminary dilution of 100-200 ml of saline. Subsequently, repeated injections of 5-10 ml of the drug every 4-6 hours are possible.

5. If there is no effect from the administration of aminophylline intravenously, prednisolone (60 mg) or 100 mg of hydrocortisone intravenously is prescribed intravenously. There are no contraindications for prescribing large doses of steroids for a short time (3-5 days), since in severe asthma and asthmatic status the risk of progressive bronchial obstruction is higher than the possibility of complications from glucocorticoid therapy (GCS) . The most commonly used medium doses of corticosteroids ( 250-500 mg hydrocortisoneper day/ its concentration in the blood is required with the introduction of 4-8 mg/ kg with an interval of 4-6 hours/; accordingly, the equivalent dose of prednisolone is 4 times less, and the duration of action becomes average (12-36 hours), in contrast to the fast-acting hydrocortisone - 8-12 hours. Dose reduction after elimination of the obstruction phenomenon is usually gradual (5-7 days) with the transfer of the patient to maintenance doses of corticosteroids administered orally or inhaled in combination with other anti-asthma drugs.

6..Oral corticosteroids taken daily or according to an alternating scheme (intermittent method), when the appointment of other types of therapy, including parenteral administration of GCS, is not effective enough and long-term systemic administration of drugs is required. It is possible to conduct short-term (10-14 days) courses of oral corticosteroids. Initial doses are usually average - a daily dose of 20-30 mg (in terms of prednisolone). Side effects with short courses (less than 10 days), as a rule, are not observed, GCS can be canceled after short-term treatment immediately. In the last two days, you can connect the intake of inhaled corticosteroids, for example, becotide at a dose of 2 breaths 4 times a day, continuing to take it for a long time (at least 6 months).

If treatment with oral corticosteroids is carried out for several weeks or months, a gradual withdrawal of the drug is advisable (the rate of dose reduction is individual). Long-term use of corticosteroids in maintenance doses exceeding 10 mg can cause known side effects.

7. In some cases, subcutaneous rhomboid novocaine blockade in the back from the 6th cervical to 5th thoracic vertebrae or vagosympathetic blockade can give an effect, if necessary, again after 48-72 hours (usually already carried out at the stage of providing qualified and specialized care - in hospital).

Qualified and specialized medical care:

1. A full complex of treatment is prescribed. In addition to the above measures, the alignment of the altered acid-base balance is essential: infusion therapy is carried out with the introduction of sodium bicarbonate, isotonic solutions of sodium chloride, especially when an attack is prolonged and sputum is very poorly discharged.

Having received the necessary information about the patient, the doctor subjects them to a critical assessment, highlighting the main signs of the disease and secondary ones. The identified signs are grouped according to their degree of importance and mutual logical connection. Symptoms of the disease are combined into syndromes. Among the identified syndromes, pathognomonic ones for this disease are distinguished.

In almost all cases of disease recognition, differential diagnosis is used. It is the basis for diagnosing a specific disease.

When making a differential diagnosis, the doctor should seek to take into account all the identified symptoms, syndromes and symptom complexes in the patient and correlate them with other diseases in which they can occur.

In the differential diagnosis, 5 phases are distinguished.

• The first phase is the determination of the leading symptom or syndrome observed in the patient, and its comparison with other diseases.
• The second phase is the study of all the symptoms identified in the patient.
• The third phase is a comparison of this disease with a number of symptomatic diseases.
• The fourth phase is the exclusion of the initially suspected disease with a deeper study of the patient.
• The fifth phase is the rationale for the diagnosis being made.

Difficulties in differential diagnosis

Difficulties in differential diagnosis arise in the presence of both a small number (1-2) of syndromes, such as fever, accelerated ESR, which mainly reflect a general pathological process, and a large number (diffuse connective tissue diseases, blood diseases, metastatic cancer, etc.). Under such conditions, a critical analysis of the data obtained and an additional examination of the patient using modern clinical and laboratory, biochemical, immunological, instrumental and other research methods are necessary.

The doctor should strive to make an early and reliable diagnosis. The success of the treatment largely depends on this.

The success of diagnosis lies in the correct combination of subjective data and objective examination methods. In the diagnostic process, in addition to knowledge and skills, a certain role is played by the experience and personal characteristics of the doctor - the speed of reaction, analytical ability, the ability to establish psychological contact with the patient. Underestimation of one or another factor in the diagnostic process can lead to a diagnostic error.

1. 2. Formulation and justification of the leading clinical syndrome.

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

The decrease in pneumatization (compaction) of the lower lobe of the left lung is evidenced by physical symptoms: increased voice trembling, dullness of percussion sound, the appearance of pathological bronchial breathing, increased bronchophony.

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

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

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

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

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

The muco-hemorrhagic character speaks of the inflammatory nature of the pathological process and confirms the symptom of hemoptysis; the presence of alveolar macrophages - about the involvement of the alveoli in the process; the absence of VC - about the non-specific nature of the process (negation of TBS); flora - typical for croupous pneumonia.

Evaluation of indicators of a biochemical blood test, connection with the clinical picture.

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

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

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

ECG analysis, connection with the clinical picture.

The rhythm is sinus (P II positive).

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

HR=60/0.54=111 in 1 minute.

The vertical position of the electrical axis of the heart (R III ≥ R II > R I, R III, and VF - max, R I \u003d S I).

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

Atrial hypertrophy was not detected (P II wave without pathological changes).

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

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

Conclusion: sinus tachycardia with a heart rate of 111 per 1 minute, the 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.

Reasoned plan of additional methods of examination of the patient, allowing to clarify the syndromic diagnosis.

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

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

Assessment of the situation in terms of the presence of an emergency, indicating the level and volume of emergency care.

There are clinically significant signs of an emergency (HC level 2) - fever 39.0 С against the background of general intoxication and respiratory failure (DNIIst). It is necessary to conduct detoxification therapy with the use of antipyretic, antibacterial (taking into account the sensitivity of the flora) agents, symptomatic and oxygen therapy.

EXAM PROBLEM No. 47

Patient N., aged 85, a participant in the Second World War, was called by a local therapist for a preventive examination. Complains of mixed dyspnea, aggravated by physical exertion, morning cough with scanty mucous sputum.

From the anamnesis: suffers from chronic bronchitis for 15 years, smoking experience - 45 years, prefers cigarettes without the Prima filter, smoking intensity 15 cigarettes per day.

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

The type of breathing is mixed, BH - 24 in 1 minute. Revealed barrel-shaped chest, obtuse epigastric angle, horizontal ribs. The supraclavicular and subclavian fossae are smoothed out. Palpation: voice trembling is carried out equally on both sides, somewhat weakened. With comparative percussion, a box sound is determined.

With topographic percussion: the height of the tops of the lungs on both sides in front - 5 cm above the clavicle, behind - 1 cm above the spinous process of the VII cervical vertebra. The width of the Krenig 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 lung edge along the midaxillary line on the right and left - 4 cm.

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

The pulse on the radial arteries is rhythmic, 90 beats per 1 minute, satisfactory filling and tension. The zone of absolute cardiac dullness is not defined. Heart sounds are muffled, rhythmic, heart rate is 90 in 1 min, the accent of the 2nd tone over the pulmonary artery is determined. BP 120/80 mm Hg. Art.

1. Identify leading symptoms.

Analyze the identified symptoms and group them into clinical syndromes.

An additional examination was carried out

General blood analysis: erythrocytes - 4.5 T / l, Hb - 160 g / l, cp - 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, ud. weight - 1018, squamous 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.

The FVD study was performed:

FEV 1/VC 89%

Determine the type and degree of violation of respiratory function.

8. Analyze the ECG. How does its data characterize the pathological process?

indicate the amount of emergency care.

Department of propaedeutics of internal diseases of IvGMA

EXAM PROBLEM 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 С, weakness, sweating.

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

Objectively: The general condition is severe. Consciousness is clear. Lies on the right side. The physique is correct, normosthenic. The skin is hyperemic, hot, moist, clean. Feverish glint of eyes. Visible mucous membranes are moist, 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 defiguration 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, BH - 24 in 1 minute. On palpation in the lower-lateral part of the chest on the right, the voice trembling is sharply weakened, with a comparative one, a zone of dull sound is also determined there. Above other parts of the lungs, voice trembling is not changed, a clear pulmonary percussion sound.

With topographic percussion: the height of the tops of the lungs in front is 3.5 cm above the clavicle, 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 V rib, on the left - along the VIII rib. Excursion of the lower lung edge along the mid-axillary line on the right - 2 cm, on the left - 6 cm.

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

The pulse on the radial arteries is rhythmic, 100 beats per 1 minute, satisfactory filling and tension. Heart sounds are sonorous, rhythmic, tachycardia. BP 110/70 mm Hg. Art.

The thyroid gland is not visually and palpation determined.

Questions: 1. Highlight the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

Additional research done

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

General urine analysis: color - rich yellow, transparent, reaction - alkaline, beats. weight - 1020, protein - no, leukocytes - 1 - 2 per vision, er-0.

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

ECG attached.

Research completed FVD:

VC fact - 2.52 should - 3.96 liters 64%

FEV 1 fact - 2.24 should - 2.66 liters 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 of IvGMA

EXAM PROBLEM No. 24

In the emergency room, patient T., aged 60, complains of an asthma attack, coughing with scanty, difficult-to-separate mucous sputum.

From the anamnesis: has been allergic to household dust for 3 years in the form of episodes of lacrimation, sore throat. The last 2 years marks the appearance of paroxysmal dyspnea with difficulty exhaling, which is accompanied by a paroxysmal unproductive cough. Treated on an outpatient basis. He took expectorant bronchodilators. Deterioration of health the second day in the form of frequent attacks of suffocation. Tried to stop suffocation with salbutamol inhalations, but did not notice any effect. He called the SMP team, intravenously administered aminophylline, but the asthma attack was not stopped. The ambulance crew took him to the hospital.

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

Breathing through the nose is difficult, but there is no discharge. The type of breathing is mixed, BH - 36 in 1 minute. The chest is evenly swollen, "frozen" in the phase of deep inspiration. The upper shoulder girdle is raised. Remote wheezing is heard. With comparative percussion, a box 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 determined.

The pulse on the radial arteries is rhythmic, 100 beats per 1 minute, satisfactory filling and tension. Heart sounds are muffled, rhythmic, tachycardia, accent of the 2nd tone over the pulmonary artery. BP 150/90 mmHg Art.

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

The thyroid gland is not visually and palpation determined.

QUESTIONS: 1. Highlight the leading symptoms.

2. Explain their pathogenesis and indicate their specific characteristics.

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

General urine analysis: color – straw-yellow, slightly acid reaction, complete transparency, b.p. weight - 1024, protein is not determined, squamous 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-Leiden crystals ++.

ECG attached.

Peak expiratory flow (PSV): 220 l / min, which is 50% of the norm (445 l / min).

8. Give an ECG conclusion using the ECG 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 of IvGMA

EXAM PROBLEM #23

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

From the anamnesis: sick for a week. The disease began gradually with the appearance of dry cough, subfebrile temperature, weakness, malaise. By the end of the third day, against the background of an increase in temperature, the cough became productive, mucopurulent sputum began to separate, shortness of breath appeared. He went to the clinic, after examining the doctor he was sent to the hospital.

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

Subcutaneous fat is satisfactorily developed, evenly distributed.

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 defiguration of the joints. The volume of active movements is full.

Breathing through the nose is free. The type of breathing is mixed, BH - 24 in 1 minute. The chest is of the correct form, symmetrical, both halves of it are equally involved in the act of breathing. Voice trembling is carried out in the same way on symmetrical parts of the chest. With comparative percussion in the left subscapular region, in a limited area, a zone of shortening of percussion sound is determined, bronchovesicular breathing, increased bronchophony, sonorous moist small bubbling rales, decreasing after coughing, are heard there. With topographic percussion: the height of the tops of the lungs in front on both sides is 3 cm above the clavicle, 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 middle axillary line on both sides is along the 8th rib. Excursion of the lung edge along the mid-axillary line on the right - 8 cm, on the left - 6 cm.

The pulse on the radial arteries is rhythmic, 95 beats per 1 minute, satisfactory filling and tension. Heart sounds are sonorous, rhythmic, clear. BP 120/80 mm Hg. Art.

The tongue is moist and clean. The papillae are well developed. Zev is clean. The tonsils are not enlarged. On palpation, the abdomen is soft, painless in all departments. The liver does not protrude from under the edge of the costal arch. The spleen is not palpable.

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

The thyroid gland is not visually and palpation determined.

QUESTIONS:

1. Highlight 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, cp - 0.9, leukocytes - 10.4 G / l, p - 6%, s - 70%, l - 18%, m - 6%, ESR - 30 mm / h.

General urine analysis: color yellow, transparent, ud. weight - 1017, flat epithelial cells 2-3 in the field of view, leukocytes - 1-2 in the field of view.

General sputum analysis: color - gray, character - mucopurulent, consistency - viscous, squamous epithelium - 2 - 4 in the field of view, cylindrical 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 :

VC fact - 3.50 liters due - 4.94 liters 71%

FEV 1 fact - 3.20 liters due - 3.62 liters 88%

8. Analyze the ECG 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 of IvGMA

EXAM PROBLEM No. 22 pediatric faculty.

Patient K., 36 years old, was admitted to the hospital, complaining of a productive cough with sputum discharge in a full mouth with an unpleasant putrefactive odor (about 300-400 ml per day), in which 3 layers can be distinguished during examination: the upper one is serous, the middle one is watery, lower - purulent. The cough is aggravated in the position of the patient on the right side. Concerned about fever up to 39 С, weakness, sweating.

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

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

Subcutaneous fat is satisfactorily developed, evenly distributed.

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 defiguration of the joints. Active and passive movements in the joints in full.

Breathing through the nose is not difficult. The chest is asymmetric, the right half of it lags behind in the act of breathing. The type of breathing is abdominal. BH - 26 in 1 minute. Voice trembling on the right at the level of the 3rd-4th intercostal space along the mid-clavicular line is increased. With comparative percussion, a tympanic sound is determined in this area. Above the rest of the lungs - a clear pulmonary sound.

With topographic percussion: the height of the tops of the lungs on both sides in front - 3 cm above the clavicle, behind - at the level of the spinous process of the VII cervical vertebra. The width of the Krenig fields is 6 cm. The lower edge of the lungs along the right midclavicular line is along the III rib, along the left midclavicular line - along the VI rib, along the midaxillary line on both sides - along the VIII rib. Excursion of the pulmonary edge along the mid-axillary line on the right - 4 cm, on the left - 6 cm. During auscultation in the area of ​​tympanic sound, amphoric breathing, coarse bubbling wet rales, increased bronchophony are heard. Vesicular breathing is heard above the rest of the lungs.

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

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

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

The thyroid gland is not visually and palpation determined.

QUESTIONS: 1. Highlight 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, u - 7%, n - 13%, s - 55%, l - 20%, m - 5%, ESR - 55 mm / h., toxic granularity of neutrophils.

General urine analysis: deep yellow color, transparent, ud. 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 character, consistency - liquid, cylindrical ciliated epithelium 24 - 28 in the field of view, leukocytes - 30 - 40 in the field of view, alveolar macrophages - 20 - 25 in the field of view, erythrocytes - 10 - 15 in the field of view, elastic fibers +++, cholesterol crystals ++.

ECG attached.

FVD :

VC fact - 3.40 liters due - 4.94 liters 69%

FEV 1 fact - 2.60 liters due - 3.62 liters 72%

8. Give an ECG conclusion using the ECG decoding 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 of IvGMA

EXAM PROBLEM No. 21 pediatric faculty.

Patient S., 23 years old, was admitted to the clinic according to the "SP" with complaints of fever up to 39-40 C, hemoptysis like "rusty" sputum, shortness of breath at rest, pain in the right half of the chest during breathing.

From history: 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 which the body temperature dropped to subfebrile numbers, but shortness of breath, pain in the chest on the right when breathing joined, which was the reason for calling the SMP team. Hospitalized for emergency care.

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

Subcutaneous fat is satisfactorily developed, evenly distributed.

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 defiguration of the joints. Active and passive movements in the joints in a hollow volume.

Breathing through the nose is not difficult. The chest is of the correct form, its right half lags behind in the act of breathing. The type of breathing is mixed, BH - 26 in 1 minute. Voice trembling is increased on the right in the posterolateral region, here, with comparative percussion, a zone of dullness of percussion sound is determined. Over other parts of the lungs, the voice trembling is not changed, with percussion - a clear pulmonary sound.

Topographic percussion of the lungs: the height of the tops of the lungs in front on both sides - 3 cm above the clavicle, behind - 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 lung edge along the midaxillary line on the right - 4 cm and on the left - 8 cm.

On auscultation to the right in the posterolateral region, breathing is bronchial with increased bronchophony. Here, a pleural friction rub is heard (more clearly along the posterior axillary line). Above the rest of the lungs, vesicular breathing, bronchophony is not changed.

The pulse on the radial arteries is rhythmic, 90 beats per 1 minute, satisfactory filling and tension. Heart sounds are sonorous, rhythmic, tachycardia. BP 120/80 mm Hg. Art.

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

The thyroid gland is not visually and palpation determined.

QUESTIONS: 1. Highlight 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, cp - 0.9, leukocytes - 10.4 G / l, p - 8%, s - 58%, l - 28%, m - 6%, ESR - 36 mm / h.

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

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

ECG attached. FVD :

Vital fact - 4.40 liters due - 5.18 liters 85%

FEV 1 fact - 3.50 liters due - 3.92 liters 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) can the patient experience? If necessary, indicate the amount of emergency care.

Head department ___________________

I approve "_____" ______ 2006

Dean______________________________

Department of propaedeutics of internal diseases of IvGMA

EXAM PROBLEM #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 notes asthma attacks on the reception of antipyretics and painkillers. Today, the state of health worsened 30 minutes after taking the Ortofen tablet for pain in the knee joints. Inhalation of salbutamol did not improve the state of health. She called the SSMP team, intravenously administered aminophylline, but the asthma attack was not stopped. Delivered to the hospital.

Objectively: the general condition is severe. Consciousness is clear. The patient is in a sitting position with an emphasis on her hands, a short short breath is heard and a painful, noisy exhalation extended in time, which is sometimes interrupted by coughing and discharge of a small amount of light, viscous sputum. Remote 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, evenly distributed.

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 defiguration of the joints. The volume of active movements is full.

The chest is in the form of a cylinder, symmetrical, rigid. The upper shoulder girdle is raised. Type of breathing mixed, respiratory rate 36 in 1 min. Voice trembling is symmetrically weakened. With comparative percussion box sound .

The height of the tops of the lungs in front is 5 cm above the clavicle, in the back - 1 cm above the VII cervical vertebra. The width of the Krenig 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 is determined by weakened vesicular breathing, diffuse dry wheezing.

The pulse on the radial arteries is rhythmic, 100 beats per 1 minute, satisfactory filling and tension. Heart sounds are muffled, rhythmic, accent II tone over the pulmonary artery. AD 138/88. mmHg Art.

The tongue is moist and clean. The papillae are well developed. Zev is clean. The tonsils are not enlarged. On palpation, the abdomen is soft, painless in all departments. The liver does not protrude from under the edge of the costal arch. The spleen is not palpable.

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

The thyroid gland is not visually and palpation determined.

1. Highlight 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 / h.

General urine analysis: color – straw-yellow, slightly acid reaction, complete transparency, b.p. weight - 1024, squamous 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, cylindrical 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 of IvGMA

EXAM PROBLEM No. 28 (pediatric faculty)

A 46-year-old man was brought to the emergency department. At the time of inspection, no complaints. Today, about 2 hours ago at work (works as a welder), there was a strong pressing nature of pain behind the sternum with irradiation to the left shoulder, he took 3 tablets of nitroglycerin with an interval of 5 minutes. I did not notice a clear improvement, although the intensity of the pain decreased somewhat. Pain was relieved by SP by intravenous administration of drugs. The duration of the pain attack is about 40 minutes. During the attack, there was an increase in blood pressure to 160/100 mm Hg. Art. After rendering assistance and recording an ECG (ECG 1) he was taken to the hospital. An attack of this nature took place about 3 months ago, was on inpatient treatment. Discharged from the hospital with a diagnosis of coronary artery disease: first-time angina pectoris. At discharge, VEM was performed, 1 functional class of angina pectoris was determined. There are no other chronic diseases.

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

Subcutaneous fat is satisfactorily developed, evenly distributed.

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 defiguration of the joints. The volume of active movements is full.

The type of breathing is mixed, BH - 18 in 1 minute. With comparative percussion of the lungs: a clear lung 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 1 minute, satisfactory filling and tension. Heart sounds are sonorous, rhythmic. BP 140/90 mmHg Art.

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

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

The thyroid gland is not visually and palpation determined.

Questions:

What pathological symptoms do the patient have?

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

Give the electrocardiographic conclusion of ECG #1 using the transcription algorithm.

Formulate clinical syndromes.

Examination performed 1 day later:

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 an ECG summary of the proposed ECG #2 using the transcription algorithm.

What clinical syndromes can be thought of, given the dynamics of these laboratory and instrumental research methods?

Make a plan for additional research methods. Explain their purpose.

Head department______________________________

I approve "____" ________________________ 200

Dean ___________________________________________

Department of propaedeutics of internal diseases of IvGMA

EXAM PROBLEM No. 32 (pediatric faculty)

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

Objectively.

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

Subcutaneous fat is overdeveloped, evenly distributed.

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 defiguration of the joints. The volume of active movements is full.

The type of breathing is mixed, BH - 20 in 1 minute. With comparative percussion of the lungs: a clear lung 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 1 minute, satisfactory filling. Heart sounds are rhythmic, I tone at the top is weakened. Borders of the heart: right - along the right edge of the sternum in the 4th intercostal space, left - along the mid-clavicular line in the 5th intercostal space, the upper 3rd rib 1 cm outward from the left edge of the sternum. BP 160/80 mmHg Art.

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

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

The thyroid gland is not visually and palpation determined.