A procedure for extracorporeal continuous correction of hemostasis was performed (09/07/2017)

HEREDITARY – father – chronic viral hepatitis C

BAD HABITS - from the words - since the age of 18, the patient has been drinking dry white wine 2 times a week. There was abuse in August alcoholic drinks: 6 glasses of dry white wine daily. I do not smoke. Doesn't use drugs.

OBJECTIVELY.

Weight – 78 kg Height – 188cm BMI = 22.3 kg/m2

General state relatively satisfactory. Consciousness is clear. Position active. The physique is correct. The type of constitution is normosthenic. Increased nutrition. The skin is icteric, insolated, the sclera is yellow. Mucous membranes with normal moisture. The shape of the neck is normal, its contours are smooth. On the anterior surface of the neck in the area of ​​the right carotid artery there is a scar without signs of inflammation measuring 2x2 cm. The consequences are visualized on the upper shoulder girdle sunburn in the form of pigmented confluent spots in the shoulder area and between the shoulder blades. Thyroid not enlarged; upon palpation its structure is heterogeneous. There is no swelling. Palpation of the paravertebral zone and percussion of the spinous processes of the spine are painless. Full range of movements in the joints and spine.

THE CARDIOVASCULAR SYSTEM. The cardiac impulse, protrusions in the precordial region, retrosternal and epigastric pulsations are not visually detected. Swelling of the cervical (jugular) veins, expansion of the saphenous veins of the trunk and extremities, as well as visible pulsation of the carotid and peripheral arteries are absent. Blood pressure – 140 and 90 mm Hg. Art. Pulse 78 beats per minute, satisfactory filling, normal tension, the vascular wall outside the pulse wave is not palpable. The boundaries of relative cardiac dullness: right - along the right edge of the sternum in the VI m/r, upper - at the level of the III rib along the left parasternal line, left - along the left midclavicular line. The number of heartbeats corresponds to the pulse. Heart sounds are rhythmic and clear. There are no pathological noises.

RESPIRATORY SYSTEM. The chest is of the correct shape. The supraclavicular and subclavian fossae are pronounced and identical on both sides. The intercostal spaces are not widened. The respiratory rate is 16 per minute, the breathing movements are rhythmic, of medium depth, both halves chest evenly participate in the act of breathing. When auscultating over the lungs, vesicular breathing is heard. No wheezing.

ORGANS OF THE ABDOMINAL CAVITY. The tongue is moist, coated with a yellow coating, and there are teeth marks along the edges of the tongue. The stomach is swollen. On palpation, the abdomen is soft, moderately painful in the epigastric and left iliac regions. The liver protrudes from under the edge of the costal arch by 2 cm, the edge of the liver is smooth, dense, painless. The spleen is palpable in the supine position.

GINOROGENITAL SYSTEM. The lumbar region was not changed upon examination. The kidneys are not palpable in standing and supine positions. Tapping the lumbar region is painless on both sides.

Based on complaints: to severe general weakness, yellowing of the skin and sclera; itching of the skin History data: While on vacation in Turkey, the patient, according to his words, drank 5-6 glasses of dry white wine daily. On the 5th day of stay, he noted the appearance of yellowness of the skin and darkening of the urine, after which he stopped drinking alcohol (according to his words)

On the 8th day there was a short-term loss of consciousness (there were no convulsions). Upon arrival in Russia, Murmansk, due to deterioration of the condition in the form of increased jaundice of the skin, he applied for medical care in the State Budgetary Healthcare Institution of Municipal Medical Institution "Sevryba" Department of Pulmonology in Murmansk, where the diagnosis was made: Main: Chronic toxic hepatitis, exacerbation. Concomitant diseases: Gastroesophageal reflux disease. Reflux esophagitis. Superficial gastroduodenitis. Biliary dyskinesia. Chronic cholecystitis. Chronic pancreatitis, remission phase. Iron deficiency anemia of moderate severity.

In the hospital, there was an increase in body temperature to 40C. As a result of treatment, the temperature returned to normal.

Over the course of six months, he noted a decrease in body weight of 20 kg, of which over the last 2 months he lost 10 kg.

Diagnostic and therapeutic measures were carried out:

Clinical blood test. Hemoglobin – 114 – 85 g/l, Leukocytes 10.4 – 7.5 10^9/l

Blood chemistry. Glucose – 10.5 – 12.8 – 4.8, Total/direct bilirubin – 1172.4/682.4 – 734.2/481.0 – 457.2/321.5 – 262.37/227.47 , AST - 323.8 - 350.47, ALT - 105.9 - 75.8 - 289.54, GGT - 4836.3 - 2124.35, ALP - 1530.2 - 1251.75

Fibrogastroduodenoscopy from 08/31/2017. : No signs of varicose veins of the esophagus were detected.

Ultrasound examination of organs abdominal cavity from 09/01/2017: Conclusion: Hepatomegaly, diffuse-dystrophic changes in the liver parenchyma, spleen. Signs of toxic hepatitis. Indirect ultrasound signs of liver cirrhosis. Hypotension of the gallbladder. Dyskinesia of the bile ducts. Chronic cholecystitis. Stagnant gallbladder. Chronic pancreatitis with signs of exacerbation. Phenomena of nephropathy. Kidney microliths. Bilateral nephroptosis.

The procedure for extracorporeal continuous correction of hemostasis from 09/07/2017 to 09/08/2017.

Treatment: Infusion therapy, Kvamatel, Heptral, Lasix, Vitamin B1, Vitamin B6, Vitamin B12, omeprazole, veroshpiron, cefazolin, prednisolone, heptor.

Consulted by a professor at the TUV-2 Department of VMedA - inpatient treatment in the gastroenterology department was recommended.

He entered the department of TUV-2 of the Military Medical Academy as planned for the purpose of further diagnosis and correction of the treatment regimen.

A preliminary diagnosis can be made:

Basic: Acute toxic hepatitis, highly active

Complication: Parenchymal jaundice. Anemia of mixed origin, mild severity.

Related: Gastroesophageal reflux disease, Reflux esophagitis stage A. GSD.Biliary sludge.

In respect of differential diagnosis must be excluded: autoimmune liver diseases, viral hepatitis, cholelithiasis, liver cirrhosis.

Main directions of examination: general blood and urine test, biochemical blood test (total protein, total bilirubin fraction, glucose, urea, creatinine, ALT, AST), coagulogram, immunoglobulins A, M, G, D-dimers, coprogram, ECG, abdominal ultrasound .

Main directions of therapy: regimen, diet, drug therapy: antacids, secretolytics, antispasmodics (for details, see the prescription sheet).

Purpose of hospitalization: relief of complaints, verification of diagnosis.

The patient agrees with the prescribed examination and treatment and has no complaints.

The planned treatment period is 14 days.

Head of the department Sharap O.S.

Clinical resident Ismailova M.E.

The main causes of injuries are road accidents (40%), falls from great heights (30%), various types of injuries (10%). Each injury is fraught with dozens of complications, including death, for example, in the case of sepsis. Some complications become apparent immediately, while others are not immediately apparent. To avoid serious consequences after injury, it is very important to properly conduct the rehabilitation period.

Stages of medical rehabilitation after injury

Unfortunately, none of us are immune from injury. The body can cope with some of them easily, while others require long-term treatment and restoration of lost functions. This primarily applies to complex fractures, injuries to the head, limbs, joints, menisci and ligaments. The injured part of the body is usually left without movement for a long time, so swelling occurs, blood circulation is impaired, and muscles atrophy. And this, in turn, causes a general weakening of the body and can provoke the emergence of new diseases. This is why it is so important to take the recovery period seriously.

Rehabilitation after fractures and injuries should follow an individual program, but in general it consists of the following stages:

• Elimination of vascular changes and edema. These phenomena, alas, are inevitable with long-term immobility of the limbs or the entire body.
• Increased elasticity and muscle tone. Before going directly to motor activity, you need to make sure that the muscles are ready for this, otherwise returning to your usual lifestyle may become too painful.
• Restoration of motor functions. The process should be progressive in nature and not involve excessive physical exertion. This will avoid sprains and physiological stress.
• Strengthening the general condition of the body - maintaining a daily routine and nutrition, staying in the fresh air. These recommendations must be followed throughout all stages of rehabilitation, since the rate of recovery largely depends on this.

Abroad, medical rehabilitation began to develop in the middle of the 20th century, when the need arose to restore and adapt to the life of participants in the Second World War. Later, this direction “took” the elderly, the disabled, and patients who had suffered serious illnesses and injuries under its wing.
The first rehabilitation clinic in Russia appeared in 1976. It was a specialized drug treatment rehabilitation center. Since then, this area of ​​medicine has been successfully developing in our country, developing its own methods and taking into account foreign experience.

Rehabilitation therapy methods

Physical rehabilitation occupies the main place in restorative medicine. It involves the complex use of both physical exercises and influences, as well as natural factors. This type of rehabilitation is aimed at restoring the functions of damaged organs, adaptation after injuries, and involvement in a normal lifestyle. Let's take a closer look at the methods of physical rehabilitation therapy:

• Massage - one of the most common methods of rehabilitation after injuries. Most often used for strokes, fractures, osteochondrosis. Therapeutic massage involves stroking, rubbing and kneading individual parts or the entire body. It stimulates blood circulation, relieves swelling, activates muscles and is an excellent preparation for physical therapy. A course of therapeutic massage usually includes 10 sessions; it is recommended to conduct them daily or every other day.
• Therapeutic exercise (physical therapy) is a specially designed set of physical exercises performed under the supervision of a specialist. They help eliminate degenerative changes in tissues and organs and help cope with atrophy. Exercise therapy helps normalize metabolism, improves the functioning of the cardiovascular system, strengthens muscles and, in general, “calms” the nervous system and improves mood. It is important not to overdo it: you should exercise according to the program developed by your doctor.
• Mechanotherapy is an addition to exercise therapy - these are the same exercises, but they are performed by the patient not independently, but with the help of special devices (designs Armeo, Locomat, Pablo, “Gyrotonic”). This allows you to improve the mobility of joints and muscles, cope with atrophic and degenerative processes, and restore functions lost as a result of injuries. The exercises should be performed under the supervision of a specialist. Only he can correctly install and fix the body segment on the structure, select the correct load and correctly assess the pace of the movements performed.
• Physiotherapy - this is restoration using physical factors: heat, magnetic radiation, electric current, light, air and others. The method involves the use of special instruments and apparatus.
• When motor activity is impaired, electrical stimulation, that is, current, is used. Thermal methods, such as paraffin baths, are used in recovery from spinal injuries. Laser therapy helps eliminate pain and swelling, and magnetic therapy helps improve the general condition of the body. These procedures are painless, but some of them have a number of contraindications, so physiotherapeutic treatment is selected individually.
• Reflexology - this method involves influencing biologically active points on the patient’s body. The trend originated several thousand years ago in the East and is now popular all over the world. Reflexology has several techniques: acupuncture (acupuncture), treatment with leeches (hirudotherapy), impact on the points of the ears (auriculotherapy), acupressure, stone massage (snow therapy), cupping massage (vacuum therapy). The essence of reflexology is to mobilize the body’s internal resources and involve them in Active participation in the healing process.
• Diet therapy - organization of nutrition using certain products for medicinal purposes. Thus, in case of fractures, the process of bone fusion is facilitated by collagen. It is found in aspic, jellied fish and poultry dishes. Calcium is needed to form bone tissue. A large amount of it is present in dairy products, especially low-fat cottage cheese. And vitamin D3 promotes the absorption of calcium; there is a lot of it in fish oil, caviar, sesame, egg yolk, nuts. And, of course, it is useful to eat fresh vegetables and fruits - they contain a lot of vitamins and fiber. But it’s better to forget about semi-finished products containing preservatives, alcohol and carbonated drinks: they cause great harm to the body, and not only during the rehabilitation period.

A special method of therapy after injuries is occupational therapy- a branch of medicine aimed at restoring and maintaining necessary life skills. The term literally translates as “treatment through work, employment” (ergon (Latin) - work; therapia (Greek) - treatment). After injuries and fractures and associated immobility, the patient may lose basic self-care skills. He needs to relearn how to dress, put on shoes, hold cutlery, and maintain personal hygiene. Often a person who has suffered trauma also needs social adaptation. In this he is supported by an occupational therapist who helps him re-learn fine motor skills, develop coordination, and adapt to Everyday life. The doctor may ask the patient to draw a picture or tie shoelaces, and, based on these mini-tests, will determine what exactly the person needs to help with, what movements need to be mastered. This method rehabilitation has been known in the West for more than 60 years. But in our country it became widespread relatively recently.

Each of the methods described above is used taking into account the nature and characteristics of the injury. We will talk about this further.

Features of rehabilitation after injuries of various types

Spinal injuries

They can be obtained as a result of bruises, falls, compression and other impacts. This is one of the most dangerous species mechanical damage, as it can lead to extremely serious consequences: disruption of the spinal cord pathways. The latter entails immobility and loss of sensitivity.

The rehabilitation program and terms depend on the severity of the injury, as well as on the individual characteristics of the patient.

The initial stage of rehabilitation should be carried out in the first days after the injury. First of all, the patient must be helped to take the correct position on the bed; the occurrence of bedsores and congestion in the lungs should be prevented. Patients who have sustained a spinal injury are also immediately prescribed breathing exercises and dietary nutrition.

At the third stage, the set of exercises changes: swimming in the pool can be added to physical therapy, physiotherapy and mechanotherapy. To restore lost skills, classes are held with an occupational therapist.

Traumatic brain injuries

The duration of rehabilitation and the complex of rehabilitation therapy for such injuries depend on the severity of the injury. For mild traumatic brain injuries - subject to compliance with the regimen, proper nutrition and physiotherapeutic treatment - recovery usually occurs within a month and does not require additional rehabilitation measures.

As for severe and moderate traumatic brain injuries, they can cause difficulty in movement, and it becomes difficult for patients to care for themselves. Speech disturbances and decreased vision may occur. Massage, exercise therapy and physiotherapy will be effective in the first stages of rehabilitation.

Musculoskeletal injuries

This type of injury includes fractures, cracks, joint injuries, dislocations, muscle and tendon ruptures, and sprains. During the early rehabilitation period, patients are individually prescribed physiotherapy to help get rid of edema, exercise therapy and mechanotherapy. Therapeutic massage will also be beneficial.

As we have seen, rehabilitation after injuries and fractures is a complex process. It consists of a set of rehabilitation therapy methods. Only a specialist can create an individual program.

Rehabilitation after injuries, or Why is surgical treatment not enough?

In most cases, after suffering an illness or undergoing surgery, patients should know about an important stage - recovery (rehabilitation) after injuries and/or fractures. After all, prolonged immobility of a damaged or diseased part of the body, lack of usual loads, vascular and other changes lead to muscle atrophy and limited joint mobility. The success of treatment after injuries depends more than half not only on the quality of the operation performed, but also on competently conducted post-traumatic rehabilitation. A healed fracture or reduced dislocation does not always mean recovery.

It often happens that, for example, the healing of a fracture has occurred, but the function of the limb is absent. And here a wide variety of types of rehabilitation after injuries come to our aid. The main type of such rehabilitation is passive mechanotherapy (SRM) using, which is possible in the earliest stages.

Rehabilitation after injuries. What is it like?

Among the main types of rehabilitation after injuries are physical therapy (PT), massage, mechanotherapy and physiotherapy.

Physical therapy is a set of physical exercises that helps develop damaged parts of the body. Physical exercise prevent the development of atrophy and degenerative changes in tissues and organs. You can read more about physical therapy (physical therapy) here.

Mechanotherapy is used to develop muscle strength, improve coordination of movements and form the correct motor stereotype. One of the types of mechanotherapy is CPM therapy - modern method treatment of injuries, allowing you to restore mobility to the joints through “passive action”.

Next, the patient should be asked to tell about all past illnesses, injuries and surgical operations. This will help rule out some diseases. For example, if in the past the patient had an appendectomy (surgical removal of the appendix), then pain in the lower right abdomen cannot be a manifestation of acute appendicitis. On the other hand, knowledge of previous illnesses helps to detect a relapse. If the patient has been hospitalized in the past for a peptic ulcer duodenum, and now he complains of a burning pain in the upper abdomen, which subsides after taking antacids and milk, then we can conclude with almost complete certainty that this pain is due to an exacerbation of a peptic ulcer. You should remember about those diseases that were diagnosed in this patient earlier, for example, diabetes mellitus and hypertension, since they can worsen as a result of a new disease and can also cause its complications. You need to find out from the patient whether he is allergic to any medications and whether he felt ill from any medications.

Page 75

Overview of body systems

In cases where the diagnosis is unclear or incomplete and there is time, a general overview of the various body systems and a search for relevant symptoms may be helpful.

Head - Past injuries (wounds), severe headaches.

Eyes - Blurred vision, double vision, yellow sclera (white part of the eyeball), pain when looking at the light.

Ears - Hearing loss, severe dizziness, pain or discharge from the ear canal.

Nose - Bleeding, runny or stuffy nose.

Mouth - Ulcers, pain, difficulty swallowing.

Neck - Muscle stiffness, swollen lymph nodes, soreness.

Respiratory system- Cough and sputum character, cough with blood, chest pain when breathing, shortness of breath.

Cardiovascular system - Pain behind the sternum, swelling of both legs, shortness of breath when physical activity and during sleep, palpitations, previous high blood pressure, heart attack, previous rheumatism.

Digestive system - Poor appetite, indigestion, nausea, vomiting, diarrhea, constipation, jaundice, abdominal pain, blood in stool or vomit.

Genitourinary system - Pain when urinating, lower back pain, frequent urination, painful urge to urinate, blood or pus in the urine, discharge from the penis.

Nervous system - Paralysis or severe weakness of the muscles of any part of the body (arms or legs), convulsions or seizures.

Family and social history - You need to find out from the patient whether other members of his family were sick diabetes mellitus, tuberculosis, heart disease, cancer or other diseases, signs of which may be observed in the patient himself.

Find out from the patient whether he smokes and drinks a lot. If you suspect chronic alcoholism, you should find out the date of your last intake of alcohol, since delirium tremens can occur 5-7 days after a person stops drinking.

Page 76

Physical examination

This is the second important part of the examination of the patient. By this time, some observations should be made, for example, assessing the nature of the patient’s speech, his general appearance and mental state. Then it is necessary to use a different information collection system based on identifying certain signs of the disease.

To perform a physical examination, you should have a stopwatch or watch with a second hand, a blood pressure machine, a stethoscope, and a thermometer; the examination must be carried out in a quiet room.

Respiration pulse and temperature

What is your breathing rate? What is your heart rate? What is your body temperature?

General form

Pay attention to the patient's body position and facial expression. Is the patient restless, is his posture unusual? Pay attention to how he moves and reacts to your questions.

Note the location of the rash or ulcers. What color is the rash, small or large? Are the elements of the rash located separately from each other or merged together? Do they itch? Are they raised or flat? Does your skin feel hot and dry or cold and damp? What is your skin color? Are there any signs of jaundice (yellow discoloration)? Is the color of the lips and nail beds bluish or pale white?

Are there signs of injury, such as a cut, abrasion, or swelling?

Are there signs of jaundice or inflammation of the sclera (the white part of the eyeball)? (It is best to look for signs of jaundice in sunlight; in artificial light, many healthy people have a yellowish tint to their sclera.)

Look for bleeding from the external auditory canal, especially if the patient has received a blow to the head or there is reason to suspect such a blow.

See if the patient has bleeding or unusual nasal discharge.

Mouth and throat

Is there swelling and redness of the gums? What are the colors and movements of the tongue, is there anything unusual about them? Is there unusual redness, swelling, or sores in the throat? Pay attention to how the patient swallows. Is swallowing difficult? Is there any unusual odor from your mouth?

Ask the patient to lie on their back and place your hand under their head. Ask the patient to relax, while you should easily lift his head, and the neck should bend so that the chin touches the chest. Pay attention to whether the patient has unusual tension in the neck muscles and whether he experiences discomfort when raising his legs to a lying position with his knees straight. Check to see if the glands on the sides of the neck are enlarged. Pay attention to whether they are painful to the touch, mobile, soft or hard.

Page 77

Rib cage

Pay attention to how the patient breathes, whether he experiences pain and whether both halves of the chest move equally. Is the patient forced to sit to ease breathing? Using a stethoscope, it is necessary to listen to the chest from the front and back and compare both halves of it (see Fig. 125, p. 222 and Table 6, pp. 224-227).

Pay attention to the contours of the abdomen. Is it symmetrical? Ask the patient about the origin of any existing scars. Such scars may be the result of previous operations and exclude gallbladder disease or inflammation of the appendix, since they have already been removed. Feel your stomach, paying attention to any tender areas and whether it is soft or tight. (See Fig. 122, p. 202 and Table 5, pp. 198-201.)

Genitals

See if there are ulcers, as with syphilis; try not to touch them. Is there any discharge from the penis? Is there swelling and tenderness of the testicles? Are there enlarged glands (lymph nodes) or a hernia in the groin?

Arms and legs

Check the mobility and strength of the muscles in all parts of the arms and legs. Is there paralysis or muscle weakness? (For example, if the patient cannot move his leg, then you need to find out whether this is due to pain or is it true paralysis, in which there is usually no pain.) Is there swelling and tenderness? What is the condition of the second arm or leg?

Is there pain or deformity? It is necessary to check whether the kidney area is painful, for which you need to lightly hit it with your fist. This area is located on the side of the spine, between the top edge of the pelvic bone and the last rib.

Nervous system

Does the patient have excessive concern about his illness? Pay attention to the patient's mental state. Is his behavior rational, is there anything unusual about it? Can he give today's date and do simple arithmetic?

Page 78

Are his movements coordinated and what is his gait like?

Ask the patient to take a few steps and take an object from the table or chair with each hand. If the patient is too weak to walk, watch how he moves, turns, and picks up objects in bed.

Symptoms

The previous section of this chapter discussed how to collect information about a patient's condition. The approach used for this consists of interviewing the patient (to clarify his complaints and sensations), as well as a physical examination, which does not require the direct participation of the patient, the purpose of which is to identify symptoms. The examination of the patient should begin with the head and end with the legs.

In order for any reasonable conclusions to be drawn based on all the collected information, it must be sorted and organized in a certain way. Related data should be classified into the same category. The recommended way to organize information when consulting with a doctor over the radio is described in Chapter 14, section "External Help", p. 341.

Formulation of conclusions

Write down the patient's main complaints, note the body systems that may be affected, and ask additional questions regarding these symptoms. You can repeat the physical examination and note the body systems in which abnormalities are found. If necessary, ask the patient additional questions or re-examine certain areas of the body. This will help clarify the observations you made. Often, by elimination, it is possible to settle on several possible diagnoses. After this, turn to those chapters of this book that describe probable diseases or conditions, and decide which of them most closely matches all the symptoms observed in the patient. After reading the material in these chapters, you may come to the conclusion that it is necessary to conduct additional tests or obtain answers to additional questions from the patient.

At this stage, even if you fail to make a definitive diagnosis, you will know enough about the patient to consult a doctor by radio.

It is necessary to carefully examine secretions such as vomit, feces, sputum and urine, paying attention to their unusual color, consistency and especially the presence of blood. Blood in stool may be bright red, dark brown, or black. Blood in urine is usually red, but often blood can only be detected after the urine has been sitting for several hours. A patient with jaundice usually has dark yellow urine. To confirm the presence of jaundice, urine should be poured into a small bottle and shaken vigorously. If jaundice is present, the foam will be yellow when it is normally white. You can compare the urine of a patient with the urine of a healthy person.

There are two things to remember important points: firstly, in case of doubt, always compare the patient’s condition with the condition of a healthy person; compare symmetrical organs in the same patient, for example, the right ear with the left, the right eye with the left, etc. Secondly, continue to monitor the patient’s condition and re-examine him, this will allow you to detect previously undetected symptoms of the disease. Avoid making quick decisions or making a diagnosis! A hasty decision may turn out to be false!

Page 79

Simulation

Simulation is when a person pretends to be sick in order not to work or for other personal reasons. The malingerer either has no signs of illness at all, or he tries to portray them as more severe than they actually are. If you suspect malingering, carefully collect a medical history and carefully examine the patient, in particular, measure his temperature and count his pulse.

Treatment

If you are not absolutely sure of the diagnosis, tell the patient about your doubts and leave the decision to the doctor. Before the doctor arrives, the patient must strictly observe bed rest, be given light food and monitor the regularity of urination and bowel movements. The patient should not smoke or drink alcohol.

Page 80

Chapter 4.

Help for victims

Sterilization

General rules wound treatment

Internal damage

Head injuries

Eye injuries

Ear damage

Damage to the nose

Damage to the mouth and teeth

Sprains

Applying dressings

This chapter covers the post-first aid treatment of victims taken to the ship's hospital or to their own cabin, with the goal of permanently healing injuries sustained on board the ship.

Sterilization

To prevent infection of wounds, burns and other injuries, all dressings and instruments must be sterile.

Dressing materials must be pre-packaged and sterilized.

There are two ways to sterilize instruments:

Tools and materials can be pre-packaged and sterilized in the factory. They are intended for one-time use and are very convenient to use.

Instruments intended for repeated use are sterilized by boiling for at least 20 minutes. The end of the instrument that touches the patient’s body must not be touched before use; the instrument should only be grasped by the handle.

The person providing assistance to the wounded must also take measures aimed at preventing infection:

Roll up your sleeves;

Wash your hands, wrists and forearms thoroughly, first with soap under running water and then with a 1% cetrimide solution.

He does not remember infectious diseases in childhood (“I was sick like everyone else”).

Denies sexually transmitted diseases, tuberculosis, Botkin's disease.

Allergological history.

Intolerance to drugs, household chemicals, food products not found. Blood transfusion history without features. No blood transfusion was performed.

Epidemiological history

Since 1995, he has not traveled outside the city of Samara; there has been no contact with infectious or febrile patients over the past six months.

Family history

My parents died a long time ago from diseases of the cardiovascular system (mother at 73 years old, father at 83 years old). My sister is healthy. Denies tuberculosis, mental, venereal, and oncological diseases in the family.

Data from physical and instrumental research methods.

External research.

The general condition is of moderate severity, forced position: orthopnea, clear consciousness, normal facial expression, correct physique, body temperature 36.6 o C, weight - 81 kg, height - 175 cm. Skin covering pale pink color, clean. Leather-elastic, normal moisture content. Visible mucous membranes pale, clean. Subcutaneous fat developed satisfactorily. Pastosity of the skin of the legs is noted. The lymph nodes (submandibular, occipital, postauricular, lateral lymph nodes of the neck, supraclavicular, subclavian, axillary, ulnar) are not enlarged on palpation.

Degree of development muscles medium, muscles are painless on palpation. Bones developed normally, no deformations or periostitis were detected, painless on palpation and tapping. Joints normal configuration. Movements in the joints (active and passive) are free, painless, without crunching or fluctuations.

Nervous system.

It makes contact easily. The cranial nerves are not changed. The speech is clear. There are no paresis of facial muscles. The gait is normal. Coordination of movements is not impaired. Stable in the Romberg position. There are no hyperkinesis. Skin and tendon reflexes are symmetrical. There are no pathological reflexes. No sensory disturbances were detected. Meningeal symptoms are absent. Dermographism pink.

Respiratory system.

The voice is normal. The chest has the shape of a truncated cone, is symmetrical, and is involved in the act of breathing. The width of the intercostal spaces is 2 cm. The shoulder blades fit normally to the chest. Breathing is rhythmic, 24 per minute. No pathology was detected on palpation of the chest. Vocal tremors are the same in symmetrical areas. With comparative percussion, a boxy tint of the percussion tone is noted.

Topographic percussion data:

Mobility of the pulmonary edge along the midclavicular line on the right and left is 3 cm.

Auscultation of the lungs - hard vesicular breathing, isolated wheezing wheezing is noted. No pleural friction or splashing noise was detected. Bronchophony is the same on both sides, enhanced in all pulmonary fields.

Circulatory organs

No visible changes in the heart were detected. The left ventricular impulse is palpated in the 5th intercostal space 1 cm outward from the left midclavicular line, of medium strength, with an area of ​​2 fingers, resistant, positive. The right ventricular impulse is not palpable. Cardiac tremors are not detected.

Limits of relative cardiac dullness:

Right border at 4 m/r - 0.5 cm outward from the edge of the sternum.

Upper limit– runs along the parasternal line at the level of the lower edge of the 3rd rib.

Left border– passes 5 m/r 1 cm outward from the midclavicular line.

Vascular bundle width– 4.5 cm, does not extend beyond the sternum.

Heart sounds are dull, the volume of each tone changes chaotically from systole to systole: the shorter the diastole, the quieter the sonority of the tones. No noise was detected. The heart rhythm is incorrect, the heart rate is 75 per minute.

No visible pulsation of the carotid arteries was detected. Pulse irregular, not the same in both arms; filling and tension varied throughout the study, frequency – 67 per minute, irregular rhythm, pulse deficit – 8 per minute.

Swelling of the neck veins, their pulsation, and the “spinning top” noise were not detected. Blood pressure – 130 and 80 mm Hg. Art.

Digestive organs.

The oral cavity has been sanitized. The tongue is moist, clean, without visible coating.

The abdomen is rounded, symmetrical, and is involved in the act of breathing. Flatulence, dilated saphenous veins, hernial protrusions, visible peristalsis were not detected. The navel is retracted, the abdominal muscles are not tense.

On superficial palpation it is soft and painless. Mendel's and Shchetkin-Blumberg's symptoms are negative.

With deep palpation: sigmoid colon palpated in the form of a smooth, elastic, movable cylinder, 3 cm in diameter; cecum - in the form of a smooth, painless, slightly displaceable cylinder, 3 cm thick, ascending, transverse, descending colon, greater curvature of the stomach and pylorus- without features.

The lower border of the stomach (by auscultopercussion) is 3 cm above the navel. Free fluid in the abdominal cavity is not determined by percussion.

Auscultation reveals quiet peristalsis.

Hepato-lienal system.

The lower edge of the liver protrudes beyond the edge of the costal arch by 1.5 cm, the edge of the liver is round, smooth, painless, elastic.

Liver dimensions according to Kurlov:

The first straight line is 12 cm, the second straight line is 10 cm, the third oblique is 8 cm.

The gallbladder is not palpable.

The spleen is not palpable in the patient's supine or lateral position.

Upon percussion, the dimensions of the spleen are:

q Length – 8 cm

q Diameter – 7 cm

Urinary organs.

No visible changes were detected. The kidneys are not palpable. Ureteral points are painless. The symptom of tapping on both sides is negative. The bladder is empty and not palpable.

Endocrine system.

The thyroid gland upon palpation is of normal size, elastic consistency, the isthmus is mobile, painless with a diameter of 4 mm.

There are no ocular symptoms of hyperthyroidism.

Secondary sexual characteristics correspond to gender and age.

Preliminary diagnosis:

IHD. Progressive angina pectoris. Paroxysmal atrial fibrillation, normosystolic form. NIIb. Chronic catarrhal obstructive bronchitis in remission. Emphysema. Diffuse pneumosclerosis. DN II.

Appointment sheet.

FULL NAME. sick : Maksimov Yu.M. Ward № 201

Appointment date	Purpose	Cancellation date	Surveys.
21.12.98 19.02.17 19.02.17	1. Bed rest 2. Table 10. 3. Rp.: Tab. Nitroglicerini 0.0005 D.S. One tablet for pain after 15 minutes under the tongue. 4. Rp.: “Tab. Sustac forte” D.S. 1 tablet 3 times a day. 5. Rp.: Tab. Anaprilini 0.04 D.S. 1 tablet 3 times a day. 6. Rp.: Digoxini 0.00025 D.S. On day 1, 1 tablet - 4 times a day, on subsequent days, 1 tablet per day under pulse control. 7. Rp.: Sol. Glucosi 5% - 200 ml Insulini 2 ED Panangini 10 ml D.S. Administer intravenously once a day. 8. Rp.: Tab. Riboxini 0.2 D.S. 1 tablet 3 times a day. 9. Rp.: Lasix 2 ml D.S. Administer intravenously, in a stream. 10. Oxygen inhaled through Bobrov’s apparatus for increased shortness of breath.		1. General analysis blood. 2. General urine analysis. 3. X-ray of the chest organs in a direct projection. 4. Feces for helminth eggs 5. ECG. 6. Biochemical blood test: total protein, fractions; qbilirubin, fractions; qcholesterol, b - lipoproteins; qurea, creatinine, residual nitrogen; qK + , Na + , Ca 2+ ; qPlasma glucose; qPlasma enzymes: LDH 1.2, CPK MB, AlAT, AST 7. Echocardiography 8. General sputum analysis. 9. Culture of sputum for BC. 10. X-ray of the chest organs in a direct projection. 11.Consultations with an ophthalmologist and angiosurgeon.

Curator, subordinator A. Supilnikov