Determination of the leading syndrome. Establishing diagnosis. Stage I: Assess symptoms and physical examination findings. Emergency syndromes

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When a doctor meets a new patient, he should always be prepared to meet any manifestations of the disease. The first conversation with the patient and his examination, even before the use of instrumental and laboratory methods research provides a competent doctor with unique data that largely determines his further diagnostic and therapeutic efforts.

Complaints

Complaints such as deterioration in health, malaise and decreased ability to work occur in most diseases and do not help in making a diagnosis. It is necessary to actively clarify symptoms that are more specific to determine the nature of the pathology and then detail them as much as possible. An example would be vomiting blood or “coffee grounds” when gastrointestinal bleeding; cramping pain in the abdomen, bloating and lack of stool in acute intestinal obstruction; “intermittent claudication” in chronic arterial insufficiency of the lower extremities.

In order to focus on the patient’s specific problems and accurately determine their nature, doctors, according to established tradition, try to find out the leading symptom that forced the person to seek treatment. medical care. This symptom is called patient's main complaint. There may be several similar signs. Ideally, the formulation of the main signs of the disease focuses the attention of the doctor and the patient on the reasons and purpose of visiting a doctor. Determining the true reason for visiting a doctor is often helped by the following question: “Why now?” Why did a patient with a complex and confusing medical history consult a doctor right now? What changed? What is currently bothering the patient? By understanding “why now”, in many cases it is possible to establish the real reason contacting a doctor and using this as a starting point for a detailed medical history. The surgeon collecting anamnesis and subsequently recording it in the medical history must find out the dynamics of the development of the disease, and not the history of the patient’s wanderings among doctors of various profiles, clinics and hospitals.

Determining the time of onset of symptoms and the dynamics of their development allows the clinician to determine the severity of the disease, and identifying previously suffered diseases helps to assess the background against which the disease occurs. It is extremely important to identify life-threatening situations that require immediate hospitalization of the patient in surgical hospital and urgent therapeutic measures. In such cases, a detailed interview with the patient and detailed history data is impossible; he should be asked extremely brief, specific questions that can be answered unambiguously. Following this, it is necessary to determine the leading manifestations of the disease, such as symptoms of peritoneal irritation in a patient with abdominal pain.

Physical examination

Physical examination in a number of cases allows us to make the correct diagnosis and decide on the nature of treatment. If the diagnosis remains unclear, then the totality of complaints and anamnesis serves as the basis for developing a plan for further examination of the patient. Still within the walls medical institute the doctor must accustom himself to a certain order of physical examination of the patient. His data will then be presented in the medical history: determination of the general condition and characteristics of the physique, examination of the respiratory organs, blood circulation, digestion and neurological status. For each system, specific complaints should be identified, external examination, palpation, percussion and auscultation. Following this, the surgeon should evaluate local status for those diseases in which this is of decisive importance: diseases of the thyroid and mammary glands, external abdominal hernia, damage to the blood vessels of the extremities, various wounds. He must also complete digital vaginal and rectal examinations.

A methodical examination of all organs and systems allows one to avoid serious diagnostic miscalculations and identify concomitant diseases, which can be decisive in the choice of treatment tactics. The severity of gastric bleeding, the severity of intoxication during peritonitis, the nature of motor disorders caused by acute disturbance of arterial circulation in the extremities are best determined by physical examination.

Isolating one main symptom can push the doctor to make hasty decisions. To avoid this trap, the doctor must consider as many symptoms as possible before starting to compose their pathogenetic combinations. Definition leading syndrome allows you to significantly narrow the range of suspected pathologies. For example, with abdominal pain combined with systemic inflammatory response syndrome (fever, tachycardia, leukocytosis), you can with some confidence limit the circle possible diseases, excluding from them nosological forms that do not have an inflammatory nature.

The sequence of the diagnostic process in the classical version can be seen in the following clinical example.

A 52-year-old patient consulted a doctor about attacks of pain “in the right side” that had been bothering her for the last 2 months. Typically, an attack occurs after errors in the diet, especially after eating fatty foods, and is accompanied by nausea and bloating. Outside of exacerbation, heaviness in the right hypochondrium and a feeling of bitterness in the mouth persist. IN Lately health deteriorated and performance decreased. The results of the fiscal study are within normal limits.

Our patient's main complaint is pain in the epigastric region and right hypochondrium. She sought help because the pain was recurring and had become more intense. Thus, isolating attacks of pain as the leading symptom allows the doctor to concentrate on the important manifestation of the disease that most worries the patient and forces her to seek medical help.

This patient has a very definite clinical picture. In such cases, doctors act remarkably similarly.

However, there are cases when the main complaint does not fit into the role of the leading symptom. For example, the patient may experience nausea, weakness, or deterioration in health. It is almost impossible to base a diagnostic search on such complaints; they cannot be accurately characterized, since they are observed in many diseases and can be caused by various pathophysiological mechanisms. On the contrary, pain in the epigastric region and weight loss are more specific symptoms; they are characteristic of a limited number of diseases, which makes differential diagnosis easier.

Sometimes characteristic manifestations of the disease cannot be detected at all. Then, due to circumstances, to make a preliminary diagnosis and carry out differential diagnosis, it is necessary to take nonspecific symptoms as a basis. If the main complaint is weakness, it is useful to focus on the accompanying pallor of the skin and darkening of the stool. If the main complaint is nausea, then to judge the nature of the disease one should take the accompanying bloating and stool retention.

Identifying connections between individual manifestations of the disease helps to understand the entire clinical picture and highlight leading clinical syndrome.

Savelyev V.S.

Surgical diseases

Clinical manifestations

Basic clinical feature patients with VSD is the presence of numerous complaints in patients, diversity various symptoms and syndromes, which is due to the peculiarities of pathogenesis and the involvement of hypothalamic structures in the process.

Frequent symptoms of VSD: cardialgia, asthenia, neurotic disorders, headache, sleep disturbance, dizziness, respiratory disorders, palpitations, cold hands and feet, vegetative-vascular paroxysms, hand tremors, internal tremors, cardiophobia, myalgia, joint pain, tissue swelling, heart failure, feeling of heat in the face, low-grade fever, fainting.

The most stable signs: 1) cardialgia; 2) heartbeat; 3) vascular dystonia; 4) autonomic dysfunctions; 5) respiratory disorders; 6) systemic neurotic disorders.

Manifestations of vegetative-vascular dystonia are very diverse. Depending on the disturbances in the functioning of one or another organ system, they are divided into several groups, although these symptoms can manifest themselves either separately or together:

Cardiac (heart) manifestations - pain in the heart area, rapid heartbeat (tachycardia), a feeling of cardiac arrest, interruptions in heart function;

Respiratory (breathing) manifestations - rapid breathing (tachypnea), inability to take a deep breath or, conversely, unexpected deep breaths; feeling of lack of air, feeling of heaviness, congestion in the chest; sudden attacks of shortness of breath, similar to seizures bronchial asthma, but provoked by other situations: excitement, fear, awakening, falling asleep;

Dysdynamic manifestations - fluctuations in arterial and venous pressure; disturbances of blood circulation in tissues;

Thermoregulatory manifestations are unpredictable fluctuations in body temperature: it can rise to 37-38 degrees C or drop to 35 degrees C and below. Fluctuations can be constant, long-term or short-term;

Dyspeptic manifestations - disorders of the gastrointestinal tract (abdominal pain, nausea, vomiting, belching, constipation or diarrhea);

Sexual disorders, for example, anorgasmia - lack of orgasm with persistent sexual desire; various dysfunctions of the urinary system - frequent, painful urination in the absence of any real pathology, etc.;

Psychoneurological manifestations - weakness, lethargy, decreased performance and increased fatigue under light load, tearfulness, irritability, headaches, dizziness, increased sensitivity to changes in weather, disruption of the sleep-wake cycle, anxiety, shuddering during sleep, which is most often superficial and short-lived.

Leading clinical syndromes

Vagotonia is characterized by cold, damp, pale skin, hyperhidrosis and hypersalivation, bright red dermographism, bradycardia, a tendency to arterial hypotension, respiratory arrhythmia, a tendency to fainting and weight gain. Apathy, asthenia, low endurance, low initiative, indecisiveness, timidity, sensitivity, a tendency to depression, and better productive activity are observed in the morning. The generalization of individual vegetative disorders into these syndromes contributed to the development of clinical vegetology. The doctrine of sympathicotonia and vagotonia was subjected to frequent criticism, which was based on ideas about the rarity of such pure syndromes in real practice. Based on this, Guillaume identifies an intermediate symptom complex - neurotonia, and Danielopoulo designates it as hyper- or hypoamphotonia. Indeed, more often we have to deal with mixed sympathetic or parasympathetic manifestations, but it is often possible to identify the predominant direction of the disorders or different directions in individual functional systems(for example, sympathetic activation in the cardiovascular and parasympathetic in the gastrointestinal systems). With all the reservations and additions, it should be recognized that the principle of identifying autonomic disorders according to sympathicotonic and vagotonic manifestations remains fruitful today.

The second principle is associated with the permanence and paroxysmal nature of autonomic disorders. If the latter are time-bound and intense vegetative storms, then the designation of other disturbances as permanent is to a certain extent arbitrary. All vegetative symptoms are mobile. This applies to hyperhidrosis, heart rate, and blood pressure. Thus, permanent disorders are not absolutely stable indicators, but their frequent fluctuations, which are not detected clinically and do not reach the level of vegetative crises. The latter have been described in the specialized literature for quite a long time and are referred to as vagovasal crises of Govers, sympathetic crises of Barre and mixed sympathetic-vagal attacks of Polzer.

Sympathetic-adrenal crises are characterized by unpleasant sensations in the chest, head, tachycardia, increased blood pressure, mydriasis, chill-like hyperkinesis, severe feelings of fear and anxiety. The attack ends with lyuria (light urine).

Vagoinsular crises are manifested by dizziness, nausea, decreased blood pressure, sometimes bradycardia, extrasystole, difficulty breathing, and gastrointestinal dyskinesia.

Often crises are of a mixed nature, when the features of sympathetic and vagal activation occur simultaneously or replace each other in phases.

Autonomic disorders can be generalized, systemic or local. The former manifest themselves simultaneously in all visceral systems, including skin autonomic disorders and thermoregulation disorders. Often, vegetative manifestations predominantly affect one system. First of all, we are talking about the cardiovascular system, the most dynamic and psychologically significant for the patient. The clinical picture consists of palpitations, pain in the left half of the chest, asthenia, irritability, sleep disturbances, headache, dizziness, paresthesia, and belching. It is not possible to detect clear somatic disorders.

Neurodigestive asthenia, or neurogastric dystonia, has also been described, where subjective complaints from the digestive tract come to the fore, and objectively there is a dyskinetic syndrome.

Autonomic disorders can predominantly manifest themselves in a thermoregulatory environment: prolonged post-neuroinfectious low-grade fevers, febrile crises.

Local autonomic disorders can occur in one half of the head, distal parts of the limbs, mainly in the form of lateralized manifestations on the trunk and limbs.

Sympathetic, parasympathetic, mixed permanent and paroxysmal syndromes, which are generalized, predominantly systemic or local in nature, are united by us into the syndrome of vegetative-vascular dystonia.

The syndrome of vegetative-vascular dystonia is not a nosological form and only syndromatically reflects the presence of constitutional or acquired autonomic dysfunction. Its diagnosis consists of two stages.

1. In the presence of characteristic complaints and certain objective symptoms of dysfunction of various body systems, it is necessary to exclude organic pathology of certain visceral systems. Thus, the diagnosis is based on a positive analysis of the existing manifestations of the disease and a negative diagnosis of somatic organic disease. As a rule, this stage of diagnosis goes quite satisfactorily.

2. Nosological and topographic analysis of vegetative-vascular dystonia syndrome (analysis of the level of involvement) is more complex. However, it is necessary both from theoretical and (and especially) from practical positions. The sufficient stability of vegetative disorders and their low curability are well known. All this is often a consequence of attempts to treat vegetative disorders directly without taking into account their nature.

Factors causing vegetative-vascular dystonia syndrome and the main stages of its manifestations are presented in Diagram 1.

1. Syndrome of vegetative-vascular dystonia of constitutional nature.

It usually appears early childhood and is characterized by instability of vegetative parameters. Rapid change in skin color, sweating, fluctuations in heart rate and blood pressure, pain and dyskinesia in gastrointestinal tract, tendency to low-grade fever, nausea, poor tolerance of physical and mental stress, meteotropicity. These disorders are familial and hereditary in nature. With age, with proper hardening education, they achieve a certain compensation, although they remain vegetatively stigmatized all their lives. However, sometimes there are very severe vegetative disorders. We are talking about familial dysautonomia, Riley-Day syndrome, in which severe disturbances occur in the internal environment of the body that are incompatible with life.

2. Syndrome of vegetative-vascular dystonia, which occurs against the background of endocrine changes in the body.

These include the periods of puberty and menopause. At puberty, there are two prerequisites for the appearance of vegetative syndromes: the emergence of new endocrine-vegetative relationships that require the formation of other integrative patterns, and a rapid, often accelerated, increase in growth - this creates a gap between new physical parameters and the possibilities of vascular support. Typical manifestations are autonomic disorders against the background of mild or severe endocrine disorders, fluctuations in blood pressure, orthostatic syndromes with pre-fainting and fainting states, emotional instability, and thermoregulation disorders.

Autonomic processes are also exacerbated during menopause, which is associated with the physiological endocrine and emotional accompaniment of this condition. Autonomic disorders are both permanent and paroxysmal in nature, and among the latter, in addition to the characteristic hot flashes, feelings of heat and profuse sweating, vegetative-vascular crises may occur.

3. Vegetative-vascular dystonia syndrome with primary damage to visceral organs.

We are talking about diseases that do not have a leading neurogenic factor in their pathogenesis. These include cholelithiasis, chronic pancreatitis, diaphragmatic hernia, chronic appendicitis, kidney stones. The mechanisms causing autonomic disorders come down to irritation of autonomic receptors present in these organs, involvement of nearby autonomic formations in the process, chronically existing algic syndrome. chronic course diseases arise first as reflex local, and then generalized autonomic disorders. Cure of the underlying disease is often accompanied by improvement or disappearance of autonomic dysfunction.

4. Vegetative-vascular dystonia syndrome in primary diseases of the peripheral endocrine glands: thyroid, adrenal glands, ovaries, hormonally active parts of the pancreas. A decrease or increase in the secretion of these glands entails disturbances in the endocrine-vegetative balance. The release of active biological substances into the blood (thyroxine, catecholamines, steroids, insulin), which closely interact with the autonomic systems, and a decrease in their secretion are factors contributing to the occurrence of generalized autonomic disorders.

5. Allergies.

This disease is often accompanied by autonomic disorders. Allergies are a consequence of many factors: mass vaccinations, changes environment, the use of drugs that are products of organic chemistry, contact in everyday life with many products of the chemical industry, etc. The autonomic nervous system in allergies, on the one hand, is involved in the pathogenesis of the formation of autonomic disorders. The role of insufficiency of sympathetic-adrenal influences in this regard is known. On the other hand, the formed allergy is accompanied by distinct autonomic disorders, often in the nature of full-blown sympathetic-adrenal crises.

6. Syndrome of vegetative-vascular dystonia in pathology of the segmental autonomic nervous system.

The latter consists of vegetative centers located in the central nervous system (vegetative nuclei III, IX and X cranial nerves, lateral horns spinal cord), preganglionic and postganglionic fibers, sympathetic chain and autonomic plexuses. Severe, often vital, disorders of the respiratory and cardiovascular systems are detected in pathology of the bulbar parts of the brain stem. The clinical significance of autonomic disorders in cases of spinal cord damage (tumor process, syringomyelia) is relatively small and they are overlapped by massive motor and sensory disorders.

More often than others, preganglionic fibers are involved in the process at the level of the anterior roots of the spinal cord. As a rule, the cause of autonomic disorders of this level is spinal osteochondrosis. The resulting radicular disorders include both sympathalgic manifestations and autonomic-vascular symptoms. The latter can be local, mainly manifesting themselves in the area of ​​the affected roots, but they can also cause more generalized disorders. This especially applies to complications cervical osteochondrosis, in which general autonomic-vascular crises may occur associated with the involvement of the autonomic plexuses of the vertebral artery in the process (posterior sympathetic syndrome, cervical migraine, Barre syndrome).

The pathology of the anterior roots and the vegetative fibers passing with them can also manifest itself in a number of pseudovisceral syndromes, in which painful sensations specific localization. The most studied syndrome is “cervical angina”, manifested by pain in the left half of the chest with irradiation to left hand, spatula, sometimes left half heads. Clinically, this syndrome can be distinguished from true angina by the following characteristics: the pain is long-lasting, worsens with anxiety and is less associated with physical activity, is localized not behind the sternum, but in the apex of the heart, tolerant to antispasmodic drugs (but can be reduced by painkillers) , there are no pathological changes on the ECG, there are positive signs of cervical osteochondrosis, tension and pain pectoral muscles. Although all of these signs are quite convincing, it should be remembered that the “cervical angina” syndrome, more often developing in middle-aged and older people, can be combined with true coronary insufficiency. Painful sympathalgic phenomena may also occur at the radicular level of the lesion. abdominal cavity simulating diseases internal organs. It should be noted that organic pathology of the visceral systems has a certain impact on the occurrence of lateralized radicular-sympathalgic syndromes. The latter occur more often on cervical level on the left, while right-sided lesions usually accompany liver pathology and biliary tract. Unilateral pulmonary processes, kidney stones, chronic appendicitis, and ovarian pathology also have an impact.

An important branch of vegetology has always been syndromes associated with damage to the sympathetic chain (ganglionitis, truncitis). However, in clinical practice they are rare and, as a rule, they were described in the “pre-osteochoid era.” Their occurrence may be due to adhesions, tumors and inflammatory processes. Localization clinical manifestations(sympathalgic and autonomic-vascular disorders) is determined by the topic of damage to certain nodes. Thus, with stellate ganglion syndrome on the left, a pronounced pain syndrome in the left half of the chest and arm.

The cause of the pathology is usually adhesions arising from visceral diseases. The clinical picture of solaritis consists of permanent pain and dyskinetic disorders in the abdominal area and general vegetative-vascular paroxysms arising against this background, including discomfort and pain in the heart area, high blood pressure, a feeling of lack of air. These attacks are accompanied by vivid emotional manifestations. There is local pain in the solar plexus areas on the line between the xiphoid process of the sternum and the navel. Syndromes of damage to the vegetative nodes in the facial area are also characteristic. This is primarily the involvement of the pterygopalatine node (Slader syndrome) and the nasociliary node (Charlen syndrome). A common feature for them there are sharp, simsalgic pains in one of the halves of the face, occurring in paroxysms and accompanied by vegetative symptoms(lacrimation and rhinorrhea) on the side of the painful attack. Slader's syndrome is characterized by pain in the eye, cheek, upper and lower jaws, spreading to the neck and arm on the corresponding side, as well as myoclonus of the soft palate. With Charlen's syndrome, the pain is localized mainly in the temple area, the eye, and trophic disorders occur on the cornea.

7. Vegetative-vascular dystonia syndrome with organic damage brain.

Almost always, with any form of cerebral pathology, autonomic disorders occur. However, they are most pronounced with damage to the deep brain systems (brain stem, hypothalamus and rhinencephalon), which are important structural links of the limbic-reticular complex. These systems are designated as vegetative suprasegmental formations, in which there are no specific autonomic centers, but there are integrative brain systems that provide autonomic support various forms behavior.

When the caudal parts of the brainstem are involved, vestibulo-vegetative disorders manifest themselves quite clearly. The crises that arise in this case have two features: 1) often the crisis begins with dizziness; 2) in the paroxysm itself, vagoinsular manifestations predominate. The same is typical for permanent symptoms that occur in this localization pathological process. With pathology of the mesencephalic structures, sympathetic-adrenal paroxysmal and permanent disorders are clearly manifested, close to those observed with hypothalamic insufficiency. We find an explanation for this not only in the topographic proximity, but also in the close functional connection of the oral sections and the hypothalamus. The pathology of the hypothalamus is of particular importance for practice. In connection with the current tendency in practice towards overdiagnosis of hypothalamic syndromes, it became necessary to formulate diagnostic criteria. These include: 1) neuroendocrine syndromes with the exception of primary damage to the peripheral glands internal secretion; 2) motivational disorders (hunger, thirst, libido); 3) neurogenic disorders of thermoregulation; 4) pathological drowsiness of a paroxysmal nature. Each of the identified criteria becomes pathognomonic when endocrine, visceral and neurotic disorders are excluded. It is important to emphasize that even clear autonomic disorders in the form of autonomic-vascular crises are not sufficiently characteristic for the diagnosis of hypothalamic pathology, and we do not include them in the criteria for diagnosis. However, with hypothalamic syndrome, striking permanent and paroxysmal disorders are often observed, combined with the above pathogenic manifestations. There is usually a predominance of sympathetic disturbances.

Riencephalic pathology is manifested primarily by the syndrome temporal lobe epilepsy. Unlike all autonomic disorders described so far, which are non-epileptic in nature, autonomic disorders in temporal lobe epilepsy can be included in the model of an epileptic attack as its aura. The most typical manifestations are abdominal (sharp pain in the epigastric region) or cardiovascular (discomfort in the heart, arrhythmias). Permanent disorders are relatively mild, often subjective in nature, and their symptoms are mainly vagoinsular. There are also combined rhinencephalic-hypothalamic lesions, when, following an epileptic autonomic aura, a vivid autonomic crisis unfolds, allowing us to think about the involvement of the hypothalamic region.

8. Neuroses and vegetative-vascular dystonia syndrome.

Most likely, it is neuroses that more often than other causes cause vegetative disorders, which are an obligate manifestation of it. A special connection between vegetative and emotional spheres noticed quite a long time ago. Recently, this has been reflected in the formulation of psychovegetative syndrome. At the same time, the mandatory combination of these violations is emphasized. However, the mechanism of formation of this syndrome may be different. Thus, with many of the factors we have considered, autonomic disorders may initially arise (pathology of internal organs, segmental autonomic syndromes), and after them, emotional disorders may develop. In other cases, both manifestations may appear simultaneously (pathology of suprasegmental formations, endocrine age-related changes), and, finally, emotional disorders may be primary, and vegetative ones follow them. The latter depend on the form and intensity of neurotic disorders. In practice, it is important to remember that the symptoms that characterize vegetative dystonia obligately include asthenic, depressive, phobic, hypochondriacal manifestations, and sleep disorders. Clinical manifestations of autonomic disorders are described in the section on neuroses. Just a few factors need to be emphasized. With neuroses, there is a clear permanent and paroxysmal dysfunction, which is either polysystemic or predominantly monosystemic in nature. The leading ones are sympathetic-adrenal manifestations.

1. 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.

Evaluation of indicators general analysis blood, 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.

Indicator within 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.

Reasoned plan additional methods examination of the patient 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 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, WWII participant, was called by the local therapist to preventive examination. Complains of mixed shortness of breath, worsening with physical activity, morning cough with scanty mucous sputum.

From the anamnesis: suffering 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 cough and deep breathing. shortness of breath at rest. I took paracetamol without effect. The disease is associated with hypothermia. Pain in chest stopped, shortness of breath intensified, which was the reason for calling the emergency medical team, which 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: General state heavy. 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 above 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, 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-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.

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. The range of active movements is full.

Breathing through the nose is free. Mixed breathing type, respiratory rate - 24 per minute. Rib cage correct form, 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.

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 - 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.

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, 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 mid-axillary line on the right is 4 cm, on the left – 6 cm. During auscultation in the area of ​​the tympanic sound, amphoric breathing, large 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 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. The range of active movements is full.

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.

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.

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), strong pressing pain occurred behind the sternum with irradiation into the left shoulder, 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. Others chronic diseases No.

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.

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. The range of active movements is full.

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.

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:

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 laboratory and instrumental methods research?

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.

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. The range of active movements is full.

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.

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.

Having received the necessary information about the patient, the doctor subjects it to a critical assessment, highlighting the main signs of the disease and the secondary ones. The identified features are grouped according to the degree of their importance and mutual logical connection. Signs 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 strive to take into account all the identified symptoms, syndromes and symptom complexes in the patient and correlate them with other diseases in which they may occur.

There are 5 phases in differential diagnosis.

• The first phase is determining the leading symptom or syndrome observed in the patient and comparing it with other diseases.
• The second phase is the study of all the symptoms identified in the patient.
• Third phase - comparison of this disease with a number of symptomatic diseases.
• The fourth phase is the exclusion of the initially suspected disease through a more in-depth study of the patient.
• The fifth phase is the substantiation of the diagnosis.

Difficulties in differential diagnosis

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

The doctor should strive to make an early and reliable diagnosis. The success of 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 skill, a certain role is played by the experience and personal characteristics of the doctor - speed of reaction, analytical ability, and the ability to establish psychological contact with the patient. Underestimation of one or another factor in the diagnostic process can lead to diagnostic error.

Before starting a differential diagnosis, it is necessary to identify and decipher the syndromes present in the patient, and from them, identify the leading syndromes (determining the severity of the patient’s condition during this hospitalization)!

Differential diagnosis is carried out according to the leading syndrome, or the so-called “Diagnostic combination of symptoms”, since the syndromes in modern medicine not so much. Sometimes it is necessary to resort to differential diagnosis of the patient based on the leading symptom.

Construction method

differential diagnosis involves three levels of research: symptom, syndrome, diagnosis.

The path to the final diagnosis goes through the following sequence of work:

1- formation of syndromes,

2- identification of the main syndrome,

3- determination of the range of diseases that are manifested by the leading syndrome (or combination of syndromes) for a specific patient!

4- appointment of additional examination (if necessary),

exclusion from among those diagnostic hypotheses that were not confirmed during the examination. In this case, 3 principles are used:

1) The principle of significant difference. No symptoms related to this pathology were found.

2) Principle – exception through opposition. This means that symptoms have been found that contradict the corresponding nosological form.

3) The principle of compiling a differential table.

If the symptoms of the underlying disease and the symptoms of the disease included in the differential diagnosis are similar (according to the table), the severity of the symptoms in the corresponding diseases is indicated

5- formulation of clinical diagnosis.

Isolating the underlying syndrome is a difficult task. The main syndrome can be considered the syndrome that most clearly manifests itself and characterizes the underlying disease, i.e. determining the severity of the patient's condition. In some cases, the main syndrome should be considered a complication of the disease. For example, infectious-toxic shock with pneumonia.

When formulating a diagnosis, one of the main tasks is to establish connections between syndromes. Ultimately, from the point of view of determining the diagnosis, the disease is a complex of interrelated syndromes. Establishing connections between syndromes allows us to approach the identification of various diseases and their complications in the patient. The diagnosis must be written in accordance with the requirements modern classification diseases.

As a result, a clinical diagnosis is formed in which individual diseases are distributed in the form of a hierarchical structure:

1. Main (simple diagnosis or combined) disease;

2. Complications of the underlying disease;

3. Concomitant diseases.

The connection between syndromes can be expressed:

The simultaneous appearance of syndromes

A certain sequence in the appearance of syndromes,

Pathogenetic relationships.

The medical history must reflect sequentially all stages of the differential diagnosis.

Example 1. “The patient has a leading syndrome of gastric dyspepsia (including severe burning pain in the epigastrium immediately after each meal, nausea, decreased appetite, rarely vomiting of eaten food, as well as progressive weight loss, hypochromic anemia) makes you think about stomach cancer. However, the patient has a very characteristic “ulcerative” history (seasonality and frequency of occurrence of clinical manifestations); after treatment with omeprazole and eradication therapy, the leading syndrome was completely stopped, the patient gained weight, during the control FGDS study, the existing ulcer of the antrum of the stomach completely healed and repeated histological studies A biopsy from the ulcer did not reveal any signs of malignancy. Thus, the diagnosis of stomach cancer can be rejected."

Example 2. “The patient has a leading mixed articular syndrome – mechanical (crunching in the small joints of the hands and knee joints, a symptom of “jamming” and pain in the knee joints after exercise in the evening, “starting” pain) and inflammatory (swelling and local increase in temperature in the small joints of the right hand and the right knee joint). The inflammatory nature of the articular syndrome in the small joints of the hands (swelling and hyperemia of 2 and 3 proximal and distal interphalangeal joints, some restriction of movements in them, makes one think about rheumatoid arthritis. However, the onset of the disease in old age (75 years), a burdened professional history (typist), anamnesis data (the mechanical nature of the articular syndrome preceded the inflammatory one by 10 years), the combined nature of the articular syndrome (inflammatory and mechanical) still force us to settle on osteoarthritis complicated by secondary synovitis . In addition, the patient does not have characteristic rheumatoid arthritis morning stiffness, and her pain syndrome is expressed mainly after prolonged physical activity, and in the knee joints - in the evening. In addition, there are no other diagnostic criteria for rheumatoid arthritis (you need to know which ones). Thus, primary osteoarthritis complicated by synovitis is most likely.”

After completing the diagnostic program, when the doctor has settled on any disease, a comprehensive rationale for clinical diagnosis taking into account the stage, form, phase of the disease, its complications, all the characteristics of the disease in a particular patient, as well as concomitant pathology.

Example 1. Clinical diagnosis: Peptic ulcer with an ulcer localized 1.5 by 2 cm in size in the pyloric part of the stomach, chronic recurrent course, exacerbation phase.

Complication: gastric bleeding occurred on September 15, 2008.

Rationale for the diagnosis: Gastric ulcer is confirmed by a long history with a typical seasonality of clinical manifestations, the exacerbation phase is diagnosed on the basis of a suddenly renewed clinical picture(pain, vomiting, nausea) and FGDS data (open ulcer of the pyloric stomach and signs of chronic inflammation according to histological data), a chronic recurrent course follows from the anamnesis. Complication – ongoing gastric bleeding is confirmed by typical symptoms (vomiting “coffee grounds”, melena), as well as signs of ongoing bleeding (without signs of continuation) according to endoscopic data.

The term “ final diagnosis" Because this is not only nonsense from the point of view of scientific epistemology, but also a dangerous psychological barrier that limits further search for a doctor after a clinical diagnosis has been established. The diagnostic search continues as long as the patient is under medical supervision and cannot be artificially suspended.