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3.1.6. Clinical examples.

1. With the patient I eat 72 years, was in clinic gospitapnoj therapies SPbGMU of a name of academician I.P.Pavlova from 19.11.2002 on 117.12. 2002, i/b № 18860.

Has arrived with complaints to a dyspnea with difficulty of an inspiration and an exhalation at a usual exercise stress; tussis with moderate quantity trudnootyo

deljaemoj sputums of green colour; periodic short-term szhiyomajushchie pains behind a breast bone, arising at an exercise stress, kupiyorujushchiesja Sodium nitritums.

Considers itself as the patient since 2000 (from age of 70 years). From now on began more than 3 times a year to be ill with catarrhal diseases, which soproyovozhdalis long tussis with from/circulation moderate quantity grey-yellow, sometimes a green sputum, a dyspnea (at first at expressed fiziyocheskoj to a load, further tolerance to an exercise stress sniziyolas, the dyspnea began to disturb at usual activity), periodically with a fervescence. It was treated independently, to doctors obrashchalyosja it is rare. In 2001 during the next exacerbation oratnleja to the therapist but a residence, the chronic bronchitis, the naziachen-course of antibacterial, broncholitic therapy expectorating prepayoraty have been diagnosed. Against the given therapy felt improvement of state of health. Last deterioration of state of health has arisen about two weeks ago after pereohlayozhdenija, has arrived urgently in connection with an accruing dyspnea.

Smokes from 25 years on 40 cigarettes in day. During a life worked voditeyolem. A household, pollen, epidermal, alimentary sensibilization otriyotsaet; the intolerance of medicinal preparations denies.

Accompanying diseases: 1. An ischemic heart disease: an angina of exertion of the first

f. kl.

At entering in data of objective survey attracted attention: the moderate severity level condition, CHDD 18, is percussion - koroyobochnyj a sound without a local obtusion, auskultativno - weakened zheyostkoe breath, is spent to all departments, individual dry rhonchuses in the bottom departments of lungs at the forced exhalation.

In clinical and biochemical analyses of blood without deviations from norm. A potassium of 4,5 mmol/l. A hydrocortisone of blood of 356 nanometers/l.

In the cytologic analysis of a sputum presence expressed vospaliyotelnogo process (pejtrofily 37 %, macrophages of 20 %), small eozinofi-lpja (14 %), a cellular detritis in a considerable quantity.

Gas structure of blood: рН-7,38; Ра02-69,2; РаС02-42,5.

On an electrocardiogram series registered a sinoatrial rate, incomplete blockade of the right leg of a ventriculonector, a load on the right auricle, which umenshiyolas against therapy.

X-ray inspection of organs of a thorax. InfiltYOratsii in a pulmonary tissue it is not defined. The pulmonary drawing is strengthened for the account nnterstntsialnogo a component on type peribronho-perivaskuljarnyh in the bottom departments of both lungs. Roots of lungs strukturny, are not dilated. The diaphragm is low located, yrniouiena, deformed pleural shvartami. The warm shade in sizes is not enlarged.

Computer tomography (KT) lungs: Lightness of a pulmonary tissue is diffusively raised in all departments of lungs for the account panatsinarnoj and tsentri-lobuljarnoj emphysemas., the top shares of both lungs are presented mnozhestyovennymi by bullas of various diameter to 2,0 sm in diameter, between kotoryyomi thin septums are taped.

Prilezhashchaja the pulmonary tissue is drawn in by bullas from both parties, on the right 2,5 on 3 sm in diameter. In naddiafragmal th departments of lungs from both parties of a bulla fine and not numerous. proyosvety tracheas, the main things, lobar bronchuses are not changed. Walls segmentary and subsegmental bronchuses utolshcheny, their lumens are not dilated, not deyoformirovany. The diaphragm is low located, uploshchena. The conclusion: KT data are characteristic for implications of chronic obstructive illness of lungs, a violent emphysema of both lungs.

Research of function of external breath. Appreciable obstructive disturbances (OFV) after beroteka 46,7 % from due) are taped. ObYOstruktsija it is irreversible (gain OFVgZ, 33 % from reference values). Bron-hospazm it is not taped.

Research diffuzionnoj abilities of lungs: are taped znachiyotelnye disturbances diffuzionnoj abilities of lungs for schetsiizhenija a membranous component and obema bloods in pulmonary capillaries.

Spent therapy: intravenous introduction of a polarising solution, an Euphyllinum, dexamethasone of 8 mg. A day within 8 days, ciprofloxacin of 200,0 mg. A day within 7 days; ingaljatsnonno berodual on 2 inspirations 4 times a day, beklodzhet on 2 inspirations 4 times a day, expectorating, mukoliticheskis agents: Sodium nitritums prlongirovannogo actions.

Against spent therapy the state of health has improved, implications of respiratory insufficiency have clinically decreased. Dynamics of laboratory-tool indicators is noted polozhiyotelnaja: the quantity of neutrophils in a sputum has decreased to 28 %, was enlarged ОФВ1 after beroteka to 63,4 % from due, the gain gain ОФВ1 became 11,61 % from initial znayocheny.

In a satisfactory condition of the patient it is written out on podderzhivajuyoshchej therapies: bero; *уал on 2 inspirations 4 times a day, beklodzhet on 2 inspirations 4 times a day.

2. Manumission N, 57 years, was in clinic of hospital therapy SPbGMU of a name of academician I.P.Pavlova from 25.11.2002 till. 2002, i/b № 19337.

Has arrived with complaints to a dyspnea with difficulty of an inspiration and an exhalation at the minimum exercise stress, conversation; tussis with moderated kolicheyostvom trudnootdeljaemoj sputums of grey-yellow colour; rising temperayotury bodies to 37, ZS; accruing delicacy.

Considers itself as the patient since 1987 (from age of 42 years). From now on began be ill often catarrhal diseases (2 and more times a year) which were accompanied by long tussis with othozhdeniem moderate quantity grey-yellow, sometimes a green sputum, a dyspnea (at first at the expressed exercise stress, further tolerance to an exercise stress has decreased, the dyspnea began to disturb at the minimum activity), perioyodichsski with a fervescence. It was treated independently, to doctors addressed seldom. In 1997 during the next exacerbation was diagnoyostirovan chronic obstruktiviyj a bronchitis, therapy berots, by Becotidum 400мкг a day is prescribed. Therapy accepted not regularly. With 1998 on 2002 ten times it was hospitalised in different hospitals of of St.-Petersburg where received treatment by intravenous glucocorticoids, me-tilksantinami, the antibacterial preparations expectorating, muko-liticheskimi by agents. Against the given therapy felt improvement samoyochuvstvija only for the short period. Last deterioration of state of health has arisen after a frigorism, has arrived urgently.

Smokes from 33 years till 20-40 cigarettes in day. During a life worked svaryoshchikom, the house painter (painting of submarines). Household, pollen, epi-dermalnuju, an alimentary sensibilization denies; the intolerance lekarstyovennyh preparations denies.

Accompanying diseases: 1. An ischemic heart disease: an angina of exertion of the first f. kl. An atherosclerotic cardiosclerosis: paroksizmaliaja the form mertsayotelnoj arrhythmias, ekstrasistolija, paroksizmaliaja a tachycardia. A heart failure AT a stage, III f. kl. 2. The Peptic ulcer in a remission stage. Rubtsovo-ulcer deformation of a bulb of a duodenum.

At entering in data of objective survey attracted attention: a moderate severity level condition, a Crocq's disease, arrhythmic pulse (the CARDIAC CONTRACTIONS RATE = to pulse 88 ud. In minute), CHDD 22, it is percussion - a bandbox sound without a local obtusion, auskultativno - weakened rigid dyhayonie, it is spent to all departments, individual dry rhonchuses in the bottom departments of lungs at the forced exhalation.

In clinical and biochemical analyses of blood without deviations from norm. A potassium of 4,7 mmol/l. A hydrocortisone of blood 29 it/l, 11-Construction Department of blood 7,2 mkt %.

In the cytologic analysis of a sputum presence expressed vospaliyotelnogo process (neutrophils of 50 %), small eozinofnlija (13 %), kleyotochnyj a detritis in a considerable quantity.

Gas structure of blood: рН-7,48; Ра02-82,5; РаС02-32,5; Sat. 02-96,5; to­tal С02-24,2.

On an electrocardiogram series registered a sinoatrial rate, disturbance vnutrizhe-ludochkovoj conductions, a left ventricle hypertrophy, augmentation leyovogo auricles, deterioration of a coronary circulation in the field of a lateral wall of a left ventricle.

X-ray inspection of organs of a thorax. In the bottom departments of both lungs intensifying of a pulmonary drawing for the account nn-terstitsialyjugo a component is defined: in S 9.10 left lungs in a kind peribronho-perivaskuljarnyh changes, in S 8левого a lung and in the bottom shares of the right lung in the form of many underlined walls of bronchuses. Roots of lungs strukyoturny, are not dilated. The diaphragm is low located, uploshchena. A warm shade of the small sizes. The conclusion: it is impossible to exclude presence tsilindyoricheskih bronchiectasias in the bottom share of the left lung.

Computer tomography (KT) lungs: diffusively in both lungs otyomechaetsja the expressed violent reorganisation, with sharp reduction stro-malnyh parenchyma elements. Bullas from 1 see to 5,5 see in diameter. proyozrachnost a pulmonary tissue it is sharply raised. In a mediastinum the enlarged lymphonoduses are not defined. Mediastinum organs occupy usual poloyozhenie. Moderately expressed augmentation of diameter of a trunk leyogochnoj an artery and its branches, as implication of a pulmonary hypertensia becomes perceptible. The lumen of a trachea, the main things, lobar bronchuses is not changed. The conclusion: KT data hayorakterny for implications of chronic obstructive illness of lungs, bul-leznoj emphysemas.

Research of function of external breath. Are taped sharp smeshanyonye disturbances: sharp restriktivnye (ZHEL 49,0 % from due), sharp about-struktivnye disturbances (ОФВ1 after beroteka 31,3 % from due). Bron-hospazm moderately expressed (gain ОФВГ10,94 of %; МОС50-25,93 % from reference values).

Research diffuzionnoj abilities of lungs: the general capacity legyokih is not broken, however the structure se is redistributed at the expense of sharp uveyolichenija residual volume (ООЛ-251,2 % from due). Sharp disturbances diffuzionnoj abilities of lungs most likely as a result of reduction of the area of gas exchange.

Spent therapy: intravenous introduction of a polarising solution, an Euphyllinum, dexamethasone of 12 mg. A day within 12 days, tsiprofloksatsi th 200,0 mg. A day within 7 days; inhalationly berodual on 2 inspirations 4 times a day, beklodzhet on 2 inspirations 4 times a day, expectorating, mukoliti-cheskie agents: Sodium nitritums prlongirovannogo actions.

Against spent therapy the state of health has improved, implications of respiratory insufficiency have clinically decreased.

However 05.12.2002 again narosla a dyspnea, has appeared pershenie in nosoyoglotke, tussis that has been regarded as implication of an acute respi-ratorno-virus infection has amplified. In communication, with what to therapy have been added vitayominy, antiviral preparations, kislorodoterapija, therapy is renewed iifu-zioinaja.

Despite spent therapy, the phenomena respiratory nedostatochyonosti accrued. 06.12.2002 has been translated in intensive care unit where the repeated X-ray inspection of organs of a thorax is executed, infiltratavnye changes distinctly have not been defined. In kliyonicheskom the analysis of blood 09.12.2002 neutrocytosis with shift to juvenile forms. On an electrocardiogram there was a tachycardia with transition in a consequence in supraventriku-ljarnuju a tachycardia. In the biochemical analysis of blood it has been taped povyyoshenie LLT to 0,62 E/l, ACT to 0,58 E/l, LDG to 427,1 E/l, KFK to 798,9 E/l. Troponinovyj the test was negative. It is executed fibrobronhoskopija 10.12.2002 where the is purulent-mucous endobronchitis is taped, the traheo-bronchial dyskinesia of the third degree, is spent sanation (tsefabolom) a bronchial tree. Despite treatment by antibiotics, bronholitika, gljukokortikomdami, anticoagulants, potassium preparations, diuretic

mi, antagonists of calcium, kislorodoterapiju, a condition of the patient ostavayolos serious, respiratory insufficiency did not decrease. 10.12.2002 the arterial hypotension has developed, the collapse, apnoe, sinusovaja a sconce-dikardija, rare idioventrikuljarnyj a rhythm has developed, an asystolia spent reaniyomatsionnye of action was not the death the Clinical posthumous diagnosis is effective, verified:

The basic diagnosis: Chronic obstructive illness of lungs, tjazheyoloe a current, in an exacerbation phase. A bilaterial violent emphysema of lungs. Traheobronhialnaja a dyskinesia of the third degree. An acute rsspiratorno-virus infection. An intrahospital pneumonia in the bottom share of the right lung (?).

Complications of the basic diagnosis: the Pneumofibrosis. A thromboembolism melyokih branches of pulmonary arteries (?). Respiratory insufficiency of the third steyopeni.

The accompanying diagnosis: an ischemic heart disease: an angina of exertion of the first f. kl. An atherosclerotic cardiosclerosis: paroksizmalnaja the ciliary arrhythmia form, ekstrasistolija, a Bouveret's disease. Warm nedostayotochnost AT a stage, III f. kl. 2. The Peptic ulcer in a remission stage. Rubtso-in-ulcer deformation of a bulb of a duodenum.

Cause of death: Accruing respiratory and cardiovascular neyodostatochnost. An intoxication.

In connection with refusal of relatives of opening, it was not spent.

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Scientific source Yefimova Olga Aleksandrovna. ESTIMATION of EFFICIENCY of TREATMENT GLJUKOKORTIKOSTEROIDNYMI PREPARATIONS of LUNGS SICK of CHRONIC OBSTRUCTIVE ILLNESS. The DISSERTATION on competition of a scientific degree of the candidate of medical sciences. St.-Petersburg - 2007. 2007

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  3. a clinical example
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  11. the Table of contents
  12. Introduction a problem Urgency
  13. the MAINTENANCE
  14. 3.1.6. Clinical examples.
  15. THE MAINTENANCE