The Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy The department of internal diseases №3 of medical and pedagogical faculty

The Ministry of Health of the Republic of Uzbekistan

Tashkent Medical Academy

The department of internal diseases № 3 of medical and pedagogical faculty

 

 

 

 

 

 

 

APPROVED: Vice Rector for Academic Affairs, TMA, Professor Teshaev OR     «___________»____________ 2016 year

 

 

 

Discipline: INTERNAL DISEASES

 

6th course

 

 

Learning Technology

 

Cycle: PULMONOLOGY

Syndromes:

"Coughing up phlegm"

"Chest Pain"

"Shortness of breath, choking"

 

__________________________________________________________________

 

(Teaching guidelines for teachers and students

medical schools)

 

 

  

 

 

 

Tashkent-2016

KNOWLEDGE Requirements and skills in teaching students on the basis of the Decision problems with cough

 

Purpose: Teach students posindromalnomu addressing patients with a cough, and the principles of their management in primary health care as part of the qualifying characteristics of GPs

 

The main learning objectives:

 

        To teach the students solve the problem associated with the cough.

        Giving students timely diagnosis in the presence of the problems associated with cough.

        To teach students to differentiate the disease, accompanied by a cough.

        To improve the knowledge, skills and practical skills in solving problems of patients with cough (gathering information, identifying problems and physical examination, as well as the ability to reasonably prescribe laboratory and instrumental methods of research);

        To teach students to reasonably choose the tactics;

        To teach students to exercise reasonable medical and preventive measures and monitoring in SAP and SP.

 

1.2. When parsing the problem of patients the key moments of assessing students must be:

                         Ability to identify the underlying problem, which is reflected in the quality of life of patients.

                         Asking the ancillary issues of rational history.

                         Ability to identify the presence of risk factors.

                         The ability to transfer disease or condition which may cause the problem.

                         The ability to reasonably conduct physical examination.

                         Ability to use sound laboratory and laboratory studies in a hovercraft or a joint venture.

                         Ability to identify the need for additional research outside the SVP or joint venture.

                         Based on this information the ability to identify the root cause (diagnosis) of the problem.

                         The ability to identify tactics on the basis of the qualifying characteristics of GPs.

                         The ability to provide non-pharmacological advice.

                         The ability to identify drug treatment based on evidence-based medicine

                         The ability to identify preventive measures at the level of primary health care.

                         The ability to define the principles of clinical examination and rehabilitation of patients in a hovercraft or a joint venture.

 

What the student needs to know to solve the problems of patients with cough:

Number	The list of knowledge	The basic level
1	The list of diseases which occur with coughing	The student should know at least 10 of the most common diseases
2	A list of the most dangerous diseases that occur with coughing	The student should know at least 5 diseases
3	The list of conditions that require management in SAP or SP (1 category)	According to the characteristics of the GP qualifying
4	The list of states that require a specialist consultation or hospitalization (category 2)	According to the characteristics of the GP qualifying
5	A list of studies requiring in SAP or SP (3.1 category)	According to the characteristics of the GP qualifying
6	The list of research areas requiring outside SVP or SP (3-2 category)	According to the characteristics of the GP qualifying
7	Key points (criteria) diagnosis, occurring with a cough	The student must know the characteristics and manifestations of each disease, and the criteria for their diagnosis.
8	Symptoms of cardiac asthma or pulmonary edema	The student must list the symptoms
9	Symptoms of asthma	The student must list the symptoms
10	Symptoms of heart failure	The student must know the manifestation
11	Signs of respiratory distress	The student must know the manifestation
12	Symptoms of internal organ	The student should know the symptoms of
13	The principle of "traffic light"	The student should know levels of peak expiratory flow (PEF), depending on the color of the traffic light
14	Indicators of results of laboratory and instrumental investigations	the student should know: - Normal values, as well as their changes in pathology.
15	Therapeutic tactics	The student must know the methods and principles of treatment (including non-drug).
16	The principles of primary, secondary and tertiary prevention	The student should know the basic activities required for the primary, secondary and tertiary prevention
17	The principles of clinical examination and rehabilitation of patients in a hovercraft or OP (category 4)	The student must list the main activities for clinical examination and rehabilitation

 

What the student should be able to solve the problems of patients with cough:

 

Number	The list of skills	The basic level
1	Ask the patient and his relatives	      The student should be able to ask questions of management concise questions that really helps to set the probable diagnosis.       The student should be able to specifically identify and assess the patient's complaints.       The student must be able to analyze medical history: the beginning of the disease, the first symptoms, the causal relationship and the dynamics of their development.       The student must be able to analyze the history of life: the identification of risk factors, the health of parents and close relatives.
2	Identify risk factors	The student must be able to identify the managed and unmanaged risk factors such as on questioning the patient, so on the basis of an objective approach
3	Calculate the index weight / body	The student must be able to identify signs: - Underweight - Increased weight.
4	Measure blood pressure.	The student should be able to tonometry with the incremental principle.
5	Perform visual inspection of the skin	The student must be able to detect the presence of: Pale- - Cyanosis - The presence of lesions
6	Inspection of the throat	The student should be able to inspect the throat with the principle of step and identify the signs of angina.
7	Inspect and palpate the chest	the student should be able to: - To evaluate the excursion of the chest - To evaluate voice trembling - To estimate the elasticity of the chest - To identify strains
8	Conduct percussion respiratory	the student should be able to: a change in pulmonary sound and interpret them
9	To conduct auscultation of the respiratory	the student should be able to: assess bronchial and vesicular breathing, as well as the presence of abnormal noise or wheezing, interpret them.
10	To conduct palpation of the heart	The student must be able to identify: - Cardiac impulse - Systolic and diastolic tremor The student must be able to assess the apical impulse.
11	Conduct percussion heart	The student must be able to identify: - Boundaries of relative and absolute dullness of heart - The boundaries of the vascular bundle - The diameter of the heart Configuration and the waist of the heart. The student must be able to identify: - Signs of hypertrophy of the heart - Configuration of the mitral -Aortic configuration
12	Conduct a cardiac auscultation	The student must be able to identify: - Easing I and II sound - I gain tones on top - Accent II tone of the aorta or pulmonary artery - Systolic and diastolic murmur, and to identify their epicenter To be able to differentiate functional from organic heart murmur. - Noise pericardial friction
13	Inspect the limb	The student should see the limbs and body, and to be able to find: - Local or generalized edema. The fingers must be able to exert pressure on the back of the foot to discover: - There is a hole or not.
14	Perform a visual inspection of bones and joints	The student should be able to find: - The presence of articular syndrome
15	Examine the thyroid gland.	The student should be able to inspect and palpate the thyroid gland and identify signs of increase, and depending on the size of the thyroid gland to distinguish the degree of goiter
16	Conduct a peak flow meter	The student should be able to hold the peak flow meter, taking into account the principle of step
17	Interpret the results of peak flow	The student must: - Know how to use tables and charts PSV normal values ​​based on gender, age and height of the patient. - Be able to calculate the percentage of predicted PEF values ​​depending on gender, age and height of the patient. - Be able to analyze and predict the results
18	Conduct ophthalmoscopy	The student should be able to ophthalmoscopy with the principle of incremental viewing fundus
19	Interpret clinical, instrumental and biochemical analyzes	The student must be able to detect a shift from the norm
2	Interpret the X-ray picture of light	The student must be able to identify signs: - Pneumonia - Pneumothorax - Pleurisy - Lung cancer and tuberculosis - Chronic Bronchitis - PE
21	Remove the ECG and decrypt it	The student should be able to record the ECG with the incremental principle. The student must be able to decipher the results of the ECG and identify signs: - Hypertrophy of the heart. -Rhythm disturbances
22	Differentiate the disease, accompanied with cough	The student must be able to differentiate the disease on the basis of the distinctive features (history, physical examination, laboratory and instrumental investigations). The student must be able to differentiate asthma from cardiac asthma on the basis of objective data. The student must be able to differentiate NC from respiratory failure on the basis of objective data.
23	Post a non-drug advice	the student should be able to: - Educate patients on self-monitoring - Advise on diet - Advise on healthy lifestyles
24	To provide pre-hospital care	The student must be able to provide pre-hospital care in a fit of asthma, spontaneous pneumothorax, cardiac asthma or pulmonary edema and myocardial infarction.
25	To hold the pleural puncture	The student must be able to carry out pleural puncture technique for spontaneous pneumothorax.
26	Rational use of medicines in the treatment of diseases that occur with coughing	The student should be able to choose drugs with proven efficacy. When selecting a drug student should be able to evaluate: Efficiency safety - Eligibility Efficiency.
27	Conduct monitoring and surveillance of patients	The student must be able to carry out monitoring and control: FBC - The general analysis of sputum - X-ray - Peak flow

 


Practical class number 1

Theme: "Cough with expectoration. Diseases that occur cereals Lemma.The most dangerous diseases that occur with coughing. Differential diagnosis in the equity segment of packaging and lung lesions.Lobar pneumonia, infiltrative pulmonary tuberculosis, pulmonary infarction. Community-acquired and nosocomial pneumonia. Tactics GPs. Principles of observation of dispensary, control and rehabilitation in a hovercraft or a joint venture. The principles of prevention.Definition of disability. Principles of St. odavaniya topics »

 

1.        Learning Technology

Study time: 6:00
The structure of the training session	1.     Training themed office. 2.     Cabinet ECG 3.     Tutorials, phantoms, models, handouts, a collection of case studies and tests 4.TV, video equipment, multimedia 5.     Hospital wards
The purpose of the training session: Getting GPs on timely diagnosis and differential diagnosis of diseases associated with cough.
Pedagogical objectives: 1.     Teach GP diagnosis - equity and segmental lesions of the lungs, the clinical course depending on the etiology and on the stage. 2.     GPs teach differential diagnosis of diseases in which there is equity and segmental lung disease. 3.     GPs familiarize with the list of communicable and non-communicable diseases associated with equity and segmental pulmonary disease and is being treated in the FCP (GWP) or specialized hospitals. 4.Discuss questions about tactics in the qualifying characteristics of GPs 5.     Discuss the principles of treatment (medication and non-medication). 6.     Discuss the principles of management, supervision and monitoring of patients in a hovercraft or a joint venture. 7.     Discuss the principles of primary, secondary and tertiary prevention in these diseases.	Learning outcomes: GPs should be aware of: 1.        Clinical manifestations of lobar pneumonia, infiltrative tuberculosis, pulmonary infarction (especially their flow). 2.        The differential diagnosis of these. 3.        Tactics GPs. 4.        Principles of follow-up and monitoring of patients in a hovercraft or a joint venture. 5.       The principles of primary, secondary and tertiary prevention in these diseases.   GPs should be able to: 1.        Analyze the data and history of complaints for the diagnosis of lobar pneumonia, infiltrative tuberculosis, pulmonary infarction. 2.        Diagnose, differentiated by clinical, laboratory studies, radiographs of lobar pneumonia, infiltrative tuberculosis, pulmonary infarction. 3.        Advise on non-drug therapies. 4.        To monitor in a hovercraft or a joint venture.
Teaching Methods	the method of "tour of the gallery." demonstration, entertainment experience, discussion, conversation, decision tests and case studies
Forms of organization of learning activities	Individual work, group work, team, classroom, extracurricular.
Learning Tools	Hand-learning materials viziualnye materials, videos, models, graphic organizers, sputum smears, sets of medical records, tables, stands, kits radiographs.
Methods and feedback means	Quiz, test, presentation of the results of the learning task, filling histories, performing practical skill "professional debriefing"

 

 

Flow chart classes

"Cough with expectoration. Diseases that occur cereals Lemma.The most dangerous diseases that occur with coughing. Differential diagnosis in the equity segment of packaging and lung lesions.Lobar pneumonia, infiltrative pulmonary tuberculosis, pulmonary infarction. Community-acquired and nosocomial pneumonia. Tactics GPs. Principles of observation of dispensary, control and rehabilitation in a hovercraft or a joint venture. The principles of prevention.Definition of disability. Principles of St. odavaniya topics »

Number	Stages of the practice session	Form classes Location	Duration classes 225
1	Chapeau (justification themes)		10
2	The discussion on the practical lessons with the use of new educational technologies (method "tour of the gallery"), as well as demonstration material (case histories, charts, posters, x-ray), define the initial level.	The survey, discussion      Classroom, the Chamber	40
3	Conclusion discussion		10
4	Definition of tasks to perform the practical part - professional questioning. Explanation of the provisions and recommendations for the job by filling histories.	Discussion	2
5	Mastering the practical part of the training under the guidance of a teacher.	Prof. questioning.  A conversation with patients and honey filling cards, situational problems.   Thematic inspection of patients in the wards	2
6	Interpretation of the survey data of patients, complaints, inspection, palpation, percussion, auscultation of patients, as well as research OAM KLA, radiographs, and a general analysis of the tank. sputum culture and biochemical analysis and diagnosis	Medical history, laboratory data situational problems	25
7	Discussion of theoretical and practical knowledge of the students, securing the material to determine the level of assimilation of knowledge assessment.	Oral questioning, tests, discussion, identification of practical skills   Classroom	75
8	Defining output on practical sessions on a 100-point rating system and ad evaluations. Homework next practice session (a collection of questions).	Information, questions for homework. Classroom	25

 

 

2. Motivation

The majority of patients with cough seek medical help. In this effort to ituatsii general practitioner (GP) is directed to the diagnosis of cough due to various diseases.In case of cough GPs should diagnose the disease, and to identify the reasons behind the disease, to provide medical care and clarifications locations of this group ppg nyh.

 

3. Interdisciplinary communication and Intra

Since cough occurs in diseases of the heart and blood vessels, nervous system, systemic connective tissue diseases, GPs have to face to work with cardiologists, neurologists, rheumatologists. The results obtained in the course of training knowledge will be used during the passage of the GP - internal medicine and other clinical disciplines.

 

4. The content of classes

4.1. Theoretical part

Cough - one of the complaints with which patients go to a GP doctor.Cough - a protective reaction of the body to remove foreign substances, exudate, dust, from the upper respiratory tract and is a psychogenic origin and is the most common symptom of diseases of the lower respiratory tract.

Cough - is a complicated reflex act and is characterized by a rapid increase in intrathoracic pressure.

The cough is often a symptom of pathological accompanying lung disease.  The cough reflex begins with the vagus nerve.  Tickling receptors pleura or airway cough is transmitted to the center in the medulla oblongata.  There polisinopticheskie way through the reticular system is observed coordinated response bronchus, larynx, chest and diaphragm.  Pressure thorax increases Kukrakkafasibosimi 140 mm. Sim.ust. etadi.Air flow rate increases by 20-30 times in the major bronchi on 30-40m/sek, speed of receiving up to 12 l / s. The cough reflex is under the influence of the cerebral cortex in certain diseases of the lungs coughs a specific symptom. So when interviewing patients should pay attention to the time of occurrence of cough, the duration and nature of the sputum.  

Pneumonia - an acute infectious and inflammatory disease mainly bacterial etiology, involving the respiratory inflammation of the lungs, alveolar exudation mandatory that spreads to adjacent bronchi, vessels, pleura.

Social and medical significance of pneumonia: the incidence is 10-15/1000 per year;

Duration of pneumonia:

        in mild - 2-3 weeks;

        at moderate flow - 4-5 weeks;

        if severe - 6-8 weeks;

­ CLASSIFICATION OF PNEUMONIA (1995)

1. According to the etiology:

        bacterial,

        mycoplasma,

        Chlamydia,

        viral,

        fungal,

        parasitic,

        mixed etiology,

        unknown etiology

        Among the bacterial flora is dominated by:

        ­ Gram +: Streptococcus pneumoniae, Staphylococcus aureus, pus-producing group A streptococcus, enterococcus, etc.;

        ­ anaerobic Gram +: peptokokki, peptostreptokokki etal.;

        ­ Gram: pneumobaccillus (Klebsiella pneumoniae), Escherichia coli, Pseudomonas aeruginosae, Legionella (intracellular), Proteus, etc.;

        anaerobic Gram: Bacteroides, fuzobakterii, Branchamella catarrhalis, Moraxella catarrhalis.

2. Under the terms of occurrence:

        community-acquired,

        hospital (48-72 hours after admission)

        atypical,

        aspiration,

        in immunocompromised patients,

        neutropenic patients.

Advantageous community-acquired pneumonia pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Legionella; hospital - Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosae, Proteus, Bacteroides. Distinguish ventilator-associated pneumonia - on mechanical ventilation (more St.aureus, etc.).

3. Localization and extent:

-right, left, bilateral, total, lobar, segmental, central ("basal").

4. By severity:

        severe course;

        moderate flow;

        mild course.

5. By the presence of complications (pulmonary and extrapulmonary).

6. The phase of the disease (high, resolution, convalescence, prolonged duration).

The severity of pneumonia

Symptom	Severity
	Easy	Average	Severe
BH	not exceeding 25	30	40 or more
PS	less than 90	100	above 100
TO	^to 38	to 39 ^of the	^About 40 and up
Supervenosity	no cyanosis	blurred cyanosis	marked cyanosis
NC ^*	No	Unsharp	distinct
The vastness of the destruction	1-2 segments	1-2 segments on both sides or the entire share	more than one share, total; polysegmental

^*) - Circulatory failure

Examples of events:

        Pulmonary:

        coughing up blood;

        parapneumonic effusion;

        bronchial obstruction syndrome;

        acute respiratory failure;

        From the CCC (from extrapulmonary)

        kollaptoidnoe state (especially standing);

        acute pulmonary heart;

        DIC;

        shock;

        anemia.

Prolonged pneumonia - an acute infectious inflammatory disease of the lungs in which the pneumonic infiltration is not permitted at the usual time (4 weeks), and slower for 5-8 weeks, and is usually finished, recovery.

SARS - is pneumonia, which is caused by microorganisms will multiply intracellularly: Legionella, Chlamydia, Mycoplasma.These pneumonia occur without typical clinical and radiological (infiltrative) displays, for the pathogenesis - mainly secondary, difficult to treat with antibiotics penicillin and cephalosporin.

CLINIC

The typical syndromes:

        syndrome of acute intoxication (fatigue, loss of appetite, headache, myalgia, shortness of breath, palpitations, pallor and drop in blood pressure, disorders of consciousness);

        syndrome, inflammation of lung tissue (local bronchitis, lung tissue sealing, the involvement of the pleura);

        common clinical syndrome, inflammatory manifestations (fever, chills, severe night sweats);

        changes in acute phase reactant (neutrophilic leukocytosis with a left shift, accelerated ESR, hanging level of α _2-globulin more than 10%, the occurrence of CRP).

The main radiological manifestations:

patchy shadows caused by exudation of fluid in the alveoli, the small size (12-15 mm), rounded, may merge (focal-drain shadow);

In form:

round (with clear margins);

cloud-like (with indistinct contours);

in the form of Lobito (equity);

as peristsissurita (from interlobar gap outline a clear, from the parenchyma - fuzzy).

Secondary radiographic manifestations

syndrome of pathological changes in lung pattern (hardening of the interstitial tissue, its modification, enhancement, enrichment, distortion, blurring);

expansion of the lung root on the affected side (2-4 intercostal space);

Swollen lymph nodes (although usually it's not);

reaction of the pleura (thickening, adhesions, Mooring, encysted parapneumonic pleural effusion).

The first 2 days are only visible on X-ray changes in lung pattern (vessels), and the site of infection occurs in 2-3 days, stored 5-7-10 days, after which there are only changes in pulmonary pattern, size of the root, gradually emerging pulmonary fibrosis, pulmonary fibrosis, carnification (organization of fibrinous exudate in the alveoli), pleural overlay.

Depending on the etiology:

lobar and mnogodolevaya infection - usually Streptococcus pneumoniae, Legionella less, anaerobes;

lobular and focally-drain - Streptococcus pneumoniae, Staphylococcus aureus, Legionella;

miliary - fungi, mycobacterium tuberculosis;

peribronchial multiple abscesses - aureus;

one round abscess in the upper lobe - pneumobaccillus;

to etiological research is desirable to produce sputum, and in severe pneumonia - blood cultures for sterility.

Differential diagnosis:

acute bronchitis (chronic or worsening);

exudative pleurisy other etiologies;

tuberculosis of the lungs;

lung cancer, or (more often) metastases in lungs

pulmonary infarction;

pulmonary eosinophilic infiltration;

pulmonary atelectasis;

congestive changes.

Diagnostics: CT biopsy.

GP tactics - direct the patient to the hospital.

Basic principles of treatment of acute pneumonia

Selection of antibiotics is directly related to the type of pathogen establishment and refinement of its sensitivity.

I. Pneumococci.

Prior to 1970 an ideal drug for the treatment of penicillin was considered.However, were soon Bldg e Lena pneumococcal strains resistant to penicillin and cephalosporins the vast majority.The main mechanism spine resistant to beta-lactam antibiotics - Productivity bacterial beta-lactamases, beta-lactam destroying ring.

In this connection, in recent years, become widely used as inhibitors of beta-lactamase - sul bac and clavulanic acid.They come in combination with ampicillin and amoxicillin. Mbinatsiya to ampicillin with sulbactam - unazin, 1.5-3 g per day for 3-4 hours.The combination of clavulanic acid with amokitsillinom - amoxicillin keypad.

Second-line drugs - cephalosporins

First generation: cefazolin (Kefzol) to 4-6 g per os cephalexin, 1-2 grams per day.These prep arats highly active against staphylococci, streptococci, Escherichia coli, Klebsiella, destroyed most of the beta-lactamase.

The second generation: cefaclor (tseklor) - 750 mg 2 times a day, cefuroxime (ziinat) - 500 mg 2 times a day. These drugs are also highly active against Haemophilus influenzae, more resistant to beta-lactamases.

Third generation: klaforan - 3-6 grams per day; dardum (tsefaperazon) - 2-4 grams per day is 2 times intravenously; Fortum - 3 grams a day for 3 doses, only parenterally, Rocephin (ceftriaxone) - 1-2 g day (single dose) intravenously or intramuscularly.

The drug is the third generation of sulbactam +: sulperadon (tsefaperazen) - 2-4 grams per day in 2 divided doses intravenously or intramuscularly.

Third-line - macrolide antibiotics: erythromycin - 200 mg 2-3 times a day intravenously (up to 1 g per day), per os 250-500 mg four times a day, roxithromycin (rulid) - 150 mg 2 times a day, clarithromycin - 250 - 500 mg 2 times a day.

II. Staphylococci: large doses of penicillin - up to 20 million units, semi-synthetic penicillins (oxacillin, methicillin), second row: lincomycin - 500 mg 3 times a day, aminoglycosides: gentamicin - 80 mg 3 times a day, kanamycin - 500 mg 3 times day.

III. Escherichia coli, Pseudomonas aeruginosa, Proteus (nosocomial infection) semi-synthetic penicillins, aminoglycosides, chloramphenicol and 1 g per day.

IV. Klebsiella (pneumobaccillus) aminoglycosides in combination with chloramphenicol or tetracycline (doksatsiklina hydrochloride) prolonged scheme - the first day, 200 mg (100 mg two times a day), then 100 mg 1 time per day for 5-10 days.

V. Chlamydia, Legionella, Mycoplasma: macrolides (erythromycin, rulid, clarithromycin), tetracyclines (doksatsiklina hydrochloride).

VI. Anaerobic: penicillin, lincomycin (500 mg 3-4 times a day intravenously to 600 mg per day in 250 ml of physiological saline solution 2-3 times a day).

Fluoroquinolones.Drugs in this group can be related to antibiotics. Along with cephalosporins are widely used in the treatment of bact e torial infections.Fluoroquinolones have an advantage over many ant ibiotikami: well into the cells to be active against gram positive and gram negative, anaerobic bacteria, they are sensitive Haemophilus influenzae, Streptococcus, Staphylococcus.

Used clinically: ciprofloxacin (tsiprolet, Tsiprobay) 250-500 mg 2 times a day for 7-10 days, 200 mg intravenously 2 times per day for 1-2 weeks, ofloxacin (tarevid) 200-400 mg 2 times per day (more active against S. aureus).

VII. Fungi: amphotericin B (daily dose - 250 U / kg intravenously every other day or 2 times a week for 4-8 weeks).

VIII. Virus - interferon.

Infiltrative pulmonary tuberculosis combines a variety of patterns of inflammatory reaction processes presented a hotbed of inflammations are larger than 10 mm in diameter, are prone to acute flow and rapid progression.It is characterized by the development of a fresh round of singed or aggravated an old encapsulated hearth, remaining after the treatment of TB scars.Symptoms of the disease n e pronounced, scanty and is mainly determined by the size and nature of the perifocal infiltration infiltration.In terms of diagnosis and diagnosis n stop focusing on the reaction to tuberculin, the detection in the sputum of the Office of unsuccessful therapy ABILITY broad-spectrum antibiotics.Appointment of a combination of three or four anti-TB drugs, the accession of corticosteroids in the treatment of light sensitivity to a positive effect.

              Pulmonary infarction - the main complications of the disease or a manifestation of the latter, if the patient is in the recent past had surgery or an injury, thromboembolic events in one of the branches of the pulmonary artery embolism is more common in patients with hypertension, myocardial infarction, thrombophlebitis, with heart defects, with atrial fibrillation , with a long reception tseptivov contraception.Branches of the pulmonary artery thrombosis observed in atherosclerotic lesions of her degree n ki, slowing blood flow in the pulmonary circulation, disorders of coagulation and blood antisvertyvayuschey systems.Clinical symptoms are determined by the caliber of Ord at porn vessel.Embolism large branches manifested sudden sharp pain in the chest, shortness of breath, tachycardia, cyanosis, and signs of collapse Ave.24-48 hours is formed pulmonary infarction, there are scant krovoha p Kanye, fever, jaundice of the sclera.Percussion sound slightly blunted, and listened melkopuzyrch tye wheezing, often pleural friction rub.Pleural friction rub and serosanguineous ekss udat may appear in a satisfactory condition of the patient.

X-ray method allows detection of pulmonary infarction blackout and a decrease of the volume of one of the segments, most basal-back.Heart attacks are more often localized in the lungs or train their shares.X-ray symptom: a triangular shadow, facing the top to rnyu, oval or round shape.

Diagnosis is difficult since the symptoms are similar to the symptoms of lobar pneumonia, myocardial infarction. In contrast to lobar pneumonia, pain in the side for easy and n infarction appears earlier chills and fever, and coughing up blood - after it.Take into account the differential diagnosis yes nnye ECG.

 

USE OF ROLE PLAY

The approximate content of role-playing games:

The patient 33 years old, there is a cough with "rusty sputum" pain in the right side of the chest and high body temperature.According to the patient, sick 4 days ago after hypothermia, started sharply with the increase in body temperature to 39,8 ° C and cough. First was a dry cough, and then 2 days later was released bloody "rusty" sputum.

OBJECTIVE: pale skin, blush cheeks. Heart sounds, respiratory rate 34 per minute. The right half of the chest behind in the act of breathing. Palpable: enhanced voice tremor on the right bottom. Percussion: the right and back to the lower parts of a dull sound. Auscultation: Right in the lower bronchial breathing. Abdominal pathology were found. Body Temperature 38,8 ° C