The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical and pedagogical faculty
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Practical session 3. Topic: "The pain in the chest associated with lung disease. Differential diagnosis of dry and exudative pleurisy. Types of exudative pleurisy.The principles of clinical supervision, control and rehabilitation in SVP or joint venture. The principles of prevention. The principles of teaching topics. "
Flow chart classes
2. Motivation
Chest pain is often encountered in the practice of primary care physicians. In this situation, the force of a general practitioner (GP) is directed to the diagnosis of diseases caused by various reasons. In the case of pleurisy GPs must not only diagnose it, but he needs to identify the reasons behind the disease to provide medical care in a hovercraft or a joint venture, or referral to specialized hospitals. These and other conditions are the basis for the inclusion of this subject in the training of GPs. 3. Interdisciplinary communication and Intra
You must have a basic knowledge of anatomy, physiology, pharmacology, propaedeutics internal medicine faculty and hospital treatment. Given that the shortness of breath and choking are a symptom of many diseases, GPs have to attract many specialists - cardiologists, cardiac surgeons, rheumatologists, neurologists and pulmonologists. When parsing of the subject there is a close relationship with the pulmonologist, rheumatology, cardiac surgery and functional diagnostics. 4. The content of classes
On a practical lesson in the theoretical part series discusses the differential diagnosis of pleurisy of various etiologies. Dry pleurisy.Clinical symptoms: chest pain, aggravated by breathing, coughing, with diaphragmatic pleurisy irradiruyut pain in the upper abdomen or in the course of the phrenic nerve - in the neck, weakness, low-grade fever of the body, with the apical pleurisy - tenderness and large trapezoidal pectoral muscle (symptoms Sternberg and Pottenger), limiting the mobility of the respiratory lung auscultation - pleural friction rub. Laboratory data. 1. Jabs: increased erythrocyte sedimentation rate, leukocytosis small. 2. LHC: improving the content of fibrin seromucoid and sialic acids. X-ray examination of the lungs, "isolated" dry pleurisy is not recognized, but can be installed symptoms of the underlying disease (pneumonia, tuberculosis, tumor, etc.). Pleural effusion.Clinical symptoms: general weakness, shortness of breath, high body temperature with chills (empyema), sweating, loss of appetite; lag corresponding part of the chest during breathing and flattening intercostal spaces, with mediastinal encysted pleurisy - dysphagia, swelling of the face, neck, hoarseness; on percussion - a massive dull sound, auscultation - no breathing, tachycardia, muffled heart sounds. Laboratory data. 1 .: increased sialic acid, fibrin, seromucoid, α 2 - and γ-globulins.3. Examination of pleural fluid: protein content greater than 3%, the relative density of more than 1,018, the content of LDH greater than 1.6 mmol (lh); positive test Rivalta, in the sediment is dominated by neutrophils, straw-yellow color, with empyema - pus. Tool study. X-ray examination: intense darkening of the oblique upper boundary, mixing the mediastinum to the opposite side. Ultrasound examination: fluid in the pleura. Differential diagnosis of different types of exudative pleurisy is based on their clinical and laboratory features. Parapneumonic pleurisy usually masked by symptoms of acute pneumonia and are characterized by a small effusion. When expressed pain syndrome at the beginning of pneumonia should be carried out persistent search pleurisy. Tuberculous pleural effusion occurs at a relatively young age, a history of contact with TB patients, characterized by intoxication and moderate temperature reaction, positive tuberculin skin test, the predominance of lymphocytes in the pleural effusion. Pleurisy pulmonary infarction have a hemorrhagic exudate in a small amount, which is often seen. Carcinomatous pleurisy accompanied by pain, massive hemorrhagic exudation, leading to disorders of breathing and blood circulation to the presence of atypical cells in the sediment. The blockade of metastatic thoracic duct may be chylous effusion. After receiving turbid fluid or pus typical seeded them on nutrient media to establish the etiology. When the diagnosis of obscure recommended careful X-ray examination after the evacuation of the fluid, and plevroskopiya plevrobiopsiya. Classification (N.V.Putov, 1984). I. According to the etiology of pleurisy.1. Infectious and 2. Aseptic. II. The nature of the pathological process.1. Dry (fibrinous). 2. Ekssu-dative pleurisy. III. Depending on the exudate distinguished.1. Serous. 2. Seroplastic. 3. purulent. 4. Putrid. 5. Hemorrhagic. 6. Eosinophilic. 7. Cholesterol. 8. Chylous. 9. Mixed. IV. For pleurisy.1. Sharp. 2. Subacute. 3. Chronic pleurisy. V. Localization of pleurisy.1. Diffuse. 2. Encysted (delimited). 2.1. The apical (apical). 2.2. Parietal (parakostalny). 2.3. Kostnodiafragmalny. 2.4. Phrenic (basal). 2.5. Paramediastinalny. 2.6. Interlobar (interlobarny).
The method of "snowballs" Objective: The involvement in the educational process of all students while controlling their knowledge of the topic under discussion. The main provisions of the technique: Group 2-3 is divided into smaller sub-groups which discuss the same problem or situation to set the highest number of correct answers. Each correct answer is recorded as a credit to this group as "snowballs." Group receiving the highest number of points, give higher ratings.
1. Define the term "pleurisy" and list the etiology, classification pleurisy. 2. Tell the clinical picture and the necessary laboratory and instrumental methods for the diagnosis of dry and exudative pleurisy. 3. Types of exudative pleurisy and differential diagnosis of exudate and transudate. Tell us about the basic principles of treatment and prevention of pleurisy from a position of GPs
Answer: Pleurisy is inflammation of the pleural sheets to form on the surface of fibrin (dry, fibrinous pleurisy), or the accumulation of fluid in the pleural cavity of a different nature (pleural effusion).Depending on the etiology of all of pleurisy can be divided into two broad groups: infectious (bacteria, Mycobacterium tuberculosis, rickettsia, protozoa, fungi, parasites, viruses) and non-infectious (aseptic: malignant tumors, 40%, system Zab. Connective tissue: SLE, SSc , dermatomyositis, rheumatoid arthritis, trauma, chest, etc.).
4.2. The analytical part of Case Studies: 1. A patient 40 years old, welder complains of feeling short of breath, wheezing, headaches, pain in the right upper quadrant, loss of appetite, fever up to 37.6 C, total. weakness. Of history 13 years ago was treated for tuberculosis of the lungs. OBJECTIVE: Society. state of moderate severity, forced position, cyanosis of the lips, swelling of the neck veins, respiratory excursion is limited. BH-32 min. Percussion: dullness of the left lung behind, breathing does not listen. Heart: muted tones, accent II tone of the pulmonary artery.Pulse 90 beats / min. Blood pressure 130/80 mm Hg 1. List at least four diseases for which there are the above mentioned signs and symptoms; 2. Preliminary diagnosis: 3. Informative survey methods; 4. The tactics of the GP; Answers:
2. A patient 58 years old, post-acute myocardial infarction, a week after the treatment in the hospital there were pains in the left chest, fever up to 38.2 C, hemoptysis, pain in the small joints. The increase in erythrocyte sedimentation rate, slight pericardial rub and pleura. The liver and spleen are not enlarged. Heart rate of 96 per minute., Blood pressure 130/90 mm Hg. Fluoroscopy: there is little fluid in the pleural cavity. Jabs: Lake 12 × 10 9 / l, e-18, ESR-21mm / h 1. List at least four diseases in which the above mentioned symptoms are observed; 2. Preliminary diagnosis: 3. Informative survey methods; 4. The tactics of the GP; __________________________________________________________________ 3. A patient 28 years of working all day in the cold. In the morning complaints of malaise, chills, weakness, pain in the right side of the chest with a deep breath, fever up to 38,4 º C. 3-day illness shortness of breath, cough with "rusty" sputum.On-but: a serious condition, cyanosis of the lips, blush on his right cheek. Aus-no: in the lower right corner of the right lung bronchial breathing, gentle crackles, pleural friction rub. At what stage is characterized by pathological auscultatory findings of the patient; Preliminary diagnosis: Identify the specific changes proposed by the KLA and radiological findings; Tactics GPs. __________________________________________________________________ 4. By patient, 50 years old. Admitted with complaints of paroxysmal cough, shortness of breath, wheezing, minor chest pain, general weakness. Recently, the above complaints have increased. History of the patient for 3 years suffering from chronic bronchitis. On-no: BH 30 min., Cyanosis of the lips, heart rate 100 beats per minute. Dullness to percussion on the right, and the decreased vesicular breathing. The liver performs at 3 cm from under the costal arch. X-rays on a fluid level III to the ribs.The ECG: sinus tachycardia. Informative survey methods; Preliminary diagnosis: The patient what type of respiratory failure is observed; The tactics of the GP; __________________________________________________________________ 5. Patient 32 years. Complaints of pain in the chest, worse when taking a deep breath, dry cough, fever. After treatment sulfanilamidnymi drugs did not improve. There was swelling and pain in the small joints. On examination, swelling of the small joints and limitation of movement. On the skin of a small rash. Auscultation auscultated weakened vesicular breathing on both sides. Heart rate 120 per min. Jabs: normochromic anemia, reticulocytosis, leukopenia, erythrocyte sedimentation rate 44 mm / h List the information the survey methods; Preliminary diagnosis: You are what connect to the exacerbation of the disease; The tactics of the GP; __________________________________________________________________ 6. Analysis of the pleural fluid count. 100 ml, not viscous, transparent, relative density, 1004, Protein -18 g / l; leyk. 1x10-2 / l bacteria-abs. 1. For what pleural fluid characteristic of this disease; 2.Even at what pathology observed (typical) given signs of pleural fluid; __________________________________________________________________ 7. Analysis of the pleural fluid count. 300 ml, turbid ud.ves.-1020 protein -32 g / l; sample Rivolta + + leyk. 2x10-3 / L -10, -10, 5-6 Acid Bacteria. 1. For what pleural fluid characteristic of these signs; 2. For what disease is characterized by the analysis; 3. List at least four group of diseases in which the cause pleurisy; ___________________________________________________________________ 8. A patient 26 years old, the bus driver. Addressed to the clinic to the GP with complaints of weakness, dry cough, aches and sore in the chest. Last night in the rain for two hours repairing the bus and heavily wet. He slept restlessly, in the morning woke up with a headache, fever up to 37,8 º. Objective: body temperature 37,5 º. Zev bloodshot. Tongue - moist and clear. Rhythmic pulse satisfactory filling and voltage, 88 beats per 1minute. Heart tones rhythmic, melodious. In the lungs: lung sounds percussion, auscultation of breath against the hard scattered dry rales. The abdomen was soft, painless on palpation. 1. List at least three diseases, which are above the complaint; 2. The most likely diagnosis; 3. List the typical 7 signs of the disease that are present in this patient; 4. Methods of the research. 5. Tactics GPs and treatment. __________________________________________________________________ 9. A patient 50 years old, in serious condition, he turned to the GP with complaints of fever, purulent, bloody sputum when you cough. Auscultation in the lungs: the right against the hard breathing moist finely sonorous rales, percussion: tympanitis. Heart sounds, rhythmic. HR 100 for 1 minute. Liver 1 cm On chest radiography: Right few cavities with thin layer. Jabs: HB - 110 g / L, red blood. - 3.6 × 10 12, Lake. - 18x 10 9 / L with a left shift. List three diseases for which there are the above complaint; The most likely diagnosis; List 6 are typical signs of the disease, which include this patient; Methods of the research. Tactics GPs and treatment. _________________________________________________________________ 10. A patient 24 years old, examined by GPs. Complaints of fever up to 39,6 º, chills, pain in the right side of the chest, shortness of breath, cough with detachable hard "rusty sputum" headaches. Objectively: the patient's condition serious, cyanosis of the lips, rosy cheeks, body temperature 39, 2 º.Rhythmic pulse, 110 beats v1minutu. Heart sounds, rhythmic. NPV of 30 times per minute. When light percussion at the back of the sixth rib and lower dull sound, auscultation at the site bronchial breathing. Abdomen is soft and painless. UAC: erit.-5 0x10 12 / l, Hb-89g / l cs - 0.9 lejk. - 17.0 × 10 9 / L, eosinophil-1% 9% p/ya- with / I -76% lymphs 10%, 4%, monocytes, SOE-35 mm / hour. Chest x-ray: Right below the 6th rib intense homogeneous darkening with clear margins merges with the dome diaphragm. 1. List at least four diseases that are characteristic of the above complaints; 2. The most likely diagnosis; 3. Plan Survey; 4. List the typical 9 signs of the disease that are present in this patient;
1. For the differential diagnosis of exudative pleurisy atelectasis and informative studies are: a) ultrasound b) Trial pleural puncture c) bronchography g) fibrobronchoscopy e) angiography e) computed tomography
2. Pleural friction rub: a) be heard more often in the height of inspiration b) auscultated for inhalation and exhalation c) weakens after coughing g) does not change after coughing e) can be felt by palpation e) uvelichevaetsya after coughing
3. For transsudate characterized by: a) The relative density of the pleural fluid is less than 1015 b) the curtailment of pleural fluid with prolonged standing c) The sample is negative Rivalta g) sample positive Rivalta d) the relative density of more than 1,020 pleural fluid
4. Exudate characterized by: a) The relative density of more than 1,015 pleural fluid b) in the pleural fluid content 3% protein and up c) The sample is positive Rivalta g) sample Rivalta negative d) the relative density of the pleural fluid is less than 1015 e) does not exist in the pleural fluid protein
5. Hemorrhagic exudate is typical: a) for pleurisy accompanying pulmonary infarction b) for the effusion on the background of nephrotic syndrome c) for tumor pleurisy g) for post-traumatic pleurisy e) for lupus pleuritis e) for chronic heart failure pleurisy
6. If at total lung field shading does not show the displacement of the mediastinum, the patient can be assumed: a) pulmonary atelectasis b) the total pneumonia c) pleural effusion g) plevrofibroz e) encysted pleurisy e) fibrosis
7. For tuberculous pleurisy is characterized by: a) seroplastic nature of exudate b) the nature of the hemorrhagic exudate c) turn the Mantoux test g) the predominance of neutrophils in the exudate e) the predominance of lymphocytes in the pleural fluid e) the predominance of eosinophils in the exudate
8. The two most common pathways of pyogenic organisms into the pleural area are: a) penetrating injuries of the chest b) surgery on the chest c) the penetration of the hotbeds of acute non-specific inflammation in the lung parenchyma per continuitatem g) breakthrough pulmonary abscess through the visceral pleura e) plevral puncture
9. For acute empyema is characterized by: a) acute onset b) symptoms of purulent intoxication c) shortness of breath d) the patient's condition is satisfactory d) the frequency of breathing 16-18 g) the heart rate is normal
10. The two most common symptoms of spontaneous pneumothorax are: a) anxiety, fear b) dry cough g), chest pain e) hemoptysis e) shortness of breath g) strengthening voice tremor
4.2.2. Graphic Organizer "Venn diagram."
used for comparison or matching iliprotivopostavleniya 2-3x aspects and show them both traits. Develops systems thinking, the ability to compare, compare, analyze and synthesis. Acquainted with the rules of construction of a Venn diagram. Individually / in pairs construct a Venn diagram and fill part of the non-overlapping circles (X) Are paired, compare and complete their charts. The intersection of circles make a list of those features that, in their opinion, are common to information 2 to 3 laps (xx / xxx).
1. Perform a visual inspection of patients with diseases that are accompanied by pain in the chest (with dry and exudative pleurisy). 2. Interpretation of the analyzes, the data of laboratory and instrumental studies, patients radiographs, ultrasound, thoracoscopy with diseases that are accompanied by pain in the chest. (Clinical and biochemical analyzes of blood coagulation, pleural fluid analysis, x-ray pictures of the chest, the results of lung function). 3. Prescription of drugs depending on the etiology of diseases that are accompanied with pain in the chest.
5. TYPES OF ASSESSMENT OF KNOWLEDGE, SKILLS AND ABILITIES Orally Writing The solution case studies Demonstration of practical skills mastered
5.1. Criteria for evaluation of knowledge and skill to practical skills of students.
Note: The basic level of knowledge and skills - a minimum of knowledge that provides the principle of "security" for the patient.
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